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Pharmacy providers should use this form to report problems purchasing drugs at prices equivalent to or less than established State Maximum Allowable Cost (State MAC) reimbursement rates.

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
Cost Per Package $ 
Are you able to purchase alternate NDCs?
Package Size
Are there availability issues?
Date of Purchase
Has there been a recent increase in acquisition cost?
Claim Information
Dispense Date [MM/DD/YYYY]
Quantity Dispensed
Total Reimbursement for Claim $ 
 
Comments:
  
NOTE:   You must send copies of drug purchase records to illustrate your cost information. Records can be sent via fax to (317) 571-8481 ATTN: Pharmacy Help Desk or via email to pharmacy@mslc.com (Please put the pharmacy name and ‘Drug Purchase Record attachment’ in the Subject line).
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 pharmacy@mslc.com or by phone at 800-591-1183.
 
Person Submitting This Request  
 
 
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