Rate Review Request  

  
 
 
Pharmacy providers should use this form to report changes in drug pricing.

For a downloadable Acrobat PDF version of this document click here.

 
Pharmacy Provider Information   
Pharmacy Name  
Medicaid Provider Number  
City   State
Phone  
[##########]		 E-Mail
 
Drug Information   
Drug Name 
National Drug Code (NDC)  
[###########]

Provider Cost Information

Is this a recent change in reimbursement?
Cost Per Package $ 
Are you able to purchase alternate NDCs?
Package Size
Are there availability issues?
Date of Purchase
[MM/DD/YYYY]
Has there been a recent increase in acquisition cost?
Claim Information  
Dispense Date
[MM/DD/YYYY]		  
Quantity Dispensed  
Total Medicaid Reimbursement for Claim
(including disp. fee)		 $ 
Medicaid Co-pay due from recipient $ 
 
Comments:
 
NOTE:   You must fax to (317) 571-8481 (Attention: Pharmacy Unit) or e-mail to orpharmacy@mslc.com copies of your purchase records that illustrate your costs.
Once complete information is received, we will evaluate your inquiry and respond within 24 hours. For questions or to check the status of an inquiry, please contact us by email at orpharmacy@mslc.com or by phone at 800-591-1183.
 
Person Submitting This Request  
 
 
 
Myers and Stauffer LC