West Virginia Rate Review Request Form

West Virginia: Estimated 340B Ceiling Price Request for Medicaid Reimbursement Review

ESTIMATED 340B CEILING PRICE

Pharmacy providers should use this form to report an issue with 340B ceiling price. NOTE: ALL FIELDS MUST BE COMPLETED FOR PROPER SUBMISSION OF THIS FORM. PLEASE DO NOT INCLUDE ANY PERSONAL HEALTH INFORMATION (PHI) WITH SUBMITTED FORM OR INVOICE.

Submitter's Name:(Required)

First Last

Pharmacy Name:(Required)

NPI:(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

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)

Comments:

Please fax or email the completed form along with your purchase record or invoice supporting acquisition cost. Myers and Stauffer West Virginia Help Desk Fax: 317-571-8481 Email: wvpharmacy@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 wvpharmacy@mslc.com or by phone at 800-591-1183.

CAPTCHA