College Recommendation Request

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Medicaid Services
F-00030 (01/2017)
FORWARDHEALTH
STATE 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 net cost 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 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 and expanded MAC rates
on file for a National Drug Code (NDC).
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
RESET FORM
Drug Authorization and Policy Override Center
313 Blettner Blvd
Madison, WI 53784
SECTION 1 – 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. Phone Number – Provider
7. Fax Number – Provider
8. Name – Contact Person
SECTION II – PRODUCT AND PRICE INFORMATION
9. NDC (11-Digit Number)
10. Drug Name
11. Current State MAC Price
12. Net Cost*
13. Describe the reason for state MAC review (e.g., no generic available at state MAC price).
*I certify that the price listed on the documentation reflects the actual net costs after rebates or discounts from the wholesaler/supplier.
14. SIGNATURE – Pharmacist
15. Date Signed
Internal Use Only

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