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Utah
Utah Department of Health and Human Services
Pharmacy Online Rate Review Request
Back to main
Utah pharmacy
page.
Utah: Average Acquisition Cost Program (AAC) Request for Medicaid Reimbursement Review
Pharmacy Provider Information:
Pharmacy providers should use this form to submit AAC pricing inquiries. All fields must be complete for proper submission of this form. Please do not include any personal health information (PHI) with submitted form or invoice. For a downloadable Acrobat PDF version of this document, see the AAC Rate Review section on the main Utah pharmacy page.
Pharmacy Name:
(Required)
NPI:
(Required)
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Phone:
(Required)
Email:
(Required)
Drug Information:
Please enter information for one (1) drug per submission form
Drug Name and Strength:
(Required)
National Drug Code (NDC):
(Required)
Provider Cost Information:
Cost Per Package:
(Required)
Package Size:
(Required)
Date of Purchase:
(Required)
Claim Information:
PBM / Payer Name:
(Required)
Dispense Date:
(Required)
Quantity Dispensed:
(Required)
Dispensing Fee:
(Required)
Total Reimbursement for Claim:
(Required)
(Including dispensing fee)
Medicaid Co-Pay Due From Recipient:
(Required)
Additional Drug Information:
Is this a recent change in reimbursement?
(Required)
Yes
No
Is this a recent increase in acquisition cost?
(Required)
Yes
No
If yes, what was your aquisition cost prior to cost increase?
(Required)
Is there an availability issue?
(Required)
Yes
No
If yes, reason for the issue?
(Required)
Are you able to purchase alternate NDCs?
(Required)
Yes
No
If yes, please send a copy or screen shot of your alternate NDC information including acquisition cost.
(Required)
Max. file size: 1 MB.
Comments:
Please fax or email the completed form along with your purchase record or invoice supporting acquisition cost and alternate NDC information to: Myers and Stauffer Utah Help Desk: Fax: 317-571-8481, Email: utpharmacy@mslc.com. Forms submitted without purchase record or invoice supporting your acquisition cost will not be considered for review. Once complete information is received, we will evaluate your inquiry and respond within 48 business hours. For questions or to check the status of an inquiry please contact us by email at utpharmacy@mslc.com or by phone at 800-591-1183.
Submitter's Name:
(Required)
First
Last
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