EmailMe Form - PHARMACY MAC PRICE INQUIRY FORM

Request Type *

PHARMACY INFORMATION

Please enter all information requested below.

NCPDP or NPI *

Pharmacy ID *

Please enter the NCPDP or NPI Number.

Pharmacy or Chain Name *

Pharmacy or Chain Contact Name *

First Last

Please provide us with the pharmacy's key contact's name.

Pharmacy or Chain Contact Email *

Pharmacy or Chain Phone Number *

### - ### - ####

Pharmacy or Chain Fax *

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GENERIC DRUG INFORMATION

Please enter the following information associated with the drug related to your inquiry. Please submit an additional entry if you have multiple MAC inquiries.

Drug Name *

Please enter the drug name.

National Drug Code *

Please enter NDC-11

Quantity Dispensed

Please enter the quantity dispensed.

Rx# *

Date of Service *

MM / DD / YYYY

Days Supply

Please enter Days Supply.

Acquisition Cost *

$ Dollars . Cents

Please enter your unit acquisition cost.

File Upload

Please upload invoice or other record demonstrating pharmacy actual cost of the drug at issue.
Limited to XLS, XLSX, CSV, DOC, DOCX, PDF, and TXT.

PLAN INFORMATION

Please enter the following submitted information.

Bank Identification Number (BIN)

Please enter BIN

Processor Control Number (PCN)

Please enter PCN

ID Number or Group Number

Please enter the ID Number or Group Number

Reference ID