DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Medicaid Services Wis. Admin. Code §§ DHS 107.10(2), 152.06(3)(h), 153.06(3)(g), 154.06(3)(g) F-00030 (04/2017) FORWARDHEALTH STATE AND SPECIALTY MAXIMUM ALLOWED COST DRUG PRICING REVIEW REQUEST Instructions: The use of this form is mandatory to request the review of state Maximum Allowed Cost (MAC) pricing in the ForwardHealth drug index. Pharmacists are required to submit documentation to substantiate their actual acquisition cost (AAC) and sign the certifying statement below. The pharmacy must submit an invoice having a product date of purchase within 60 days of submitting the request. Refer to the State and Specialty Maximum Allowed Cost Drug Pricing Review Request Completion Instructions, F-00030A, for more information. Requests for pricing review will not be accepted for Wholesale Acquisition Cost, National Average Drug Acquisition Cost (NADAC), or ceiling price rates on file for a National Drug Code (NDC). National Average Drug Acquisition Cost review requests are submitted via the following: Telephone (toll-free): 855-457-5264 Email: Fax: 844-860-0236 The completed form may be returned to the Drug Authorization and Policy Override Center via fax at 608-250-0246 or by mail at the following address: ForwardHealth Drug Authorization and 313 Blettner Blvd Madison WI 53784 SECTION I PHARMACY INFORMATION – 1. Name Pharmacy – 2. National Provider Identifier 3. Taxonomy Code 4. ZIP+4 Code Practice Location – 5. Address Provider (Street, City, State, ZIP Code) – 6. Telephone Number Provider 7. Fax Number Provider – – 8. Name Contact Person – SECTION II PRODUCT AND PRICE INFORMATION – 11. Current State or Specialty MAC 9. NDC (11-Digit No.) 10. Drug Name 12. Net Cost Per Unit Rate* – Drug Rate Per Unit Rate – Continued 2 of 2 STATE AND SPECIALTY MAXIMUM ALLOWED COST DRUG PRICING REVIEW REQUEST F-00030 (04/2017) SECTION II PRODUCT AND PRICE INFORMATION (Continued) –
DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Medicaid Services Wis. Admin. Code §§ DHS 107.10(2), 152.06(3)(h), 153.06(3)(g), 154.06(3)(g) F-00030 (04/2017) FORWARDHEALTH STATE AND SPECIALTY MAXIMUM ALLOWED COST DRUG PRICING REVIEW REQUEST Instructions: The use of this form is mandatory to request the review of state Maximum Allowed Cost (MAC) pricing in the ForwardHealth drug index. Pharmacists are required to submit documentation to substantiate their actual acquisition cost (AAC) and sign the certifying statement below. The pharmacy must submit an invoice having a product date of purchase within 60 days of submitting the request. Refer to the State and Specialty Maximum Allowed Cost Drug Pricing Review Request Completion Instructions, F-00030A, for more information. Requests for pricing review will not be accepted for Wholesale Acquisition Cost, National Average Drug Acquisition Cost (NADAC), or ceiling price rates on file for a National Drug Code (NDC). National Average Drug Acquisition Cost review requests are submitted via the following: Telephone (toll-free): 855-457-5264 Email: Fax: 844-860-0236 The completed form may be returned to the Drug Authorization and Policy Override Center via fax at 608-250-0246 or by mail at the following address: ForwardHealth Drug Authorization and 313 Blettner Blvd Madison WI 53784 SECTION I – PHARMACY INFORMATION 1. Name – Pharmacy 2. National Provider Identifier 3. Taxonomy Code 4. ZIP+4 Code – Practice Location 5. Address – Provider (Street, City, State, ZIP Code) 6. Telephone Number – Provider 7. Fax Number – Provider 8. Name – Contact Person SECTION II – PRODUCT AND PRICE INFORMATION 9. NDC (11-Digit No.) 10. Drug Name 11. Current State or Specialty MAC Drug Rate – Per Unit Rate 12. Net Cost – Per Unit Rate* Continued STATE AND SPECIALTY MAXIMUM ALLOWED COST DRUG PRICING REVIEW REQUEST 2 of 2 F-00030 (04/2017) SECTION II – PRODUCT AND PRICE INFORMATION (Continued)
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