DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-00030 (03/09)
STATE OF WISCONSIN
DRUG PRICING REVIEW REQUEST
Instructions: The use of this form is mandatory to request the review of pricing for a National Drug Code (NDC) in the ForwardHealth drug index. Pharmacists are required to submit documentation to substantiate their actual net cost and sign the certifying statement below. The completed form may be returned to the Division of Health Care Access and Accountability via fax at (608) 266-1096 or by mail at the following address: Drug Price File Division of Health Care Access and Accountability PO Box 309 Madison WI 53701-0309 SECTION I -- PROVIDER INFORMATION Name -- Provider Address -- Provider (Street, City, State, ZIP Code) SECTION II -- PRODUCT AND PRICE INFORMATION NDC (11 Digit No.) Drug Name Package Size Currently Allowed Net Cost Effective Date National Provider Identifier Taxonomy Code ZIP+4 Practice Location Code
Telephone Number -- Provider
Describe reason for drug price update request (e.g., no generic available at MAC price, manufacturer prices increase and is not reflected on ForwardHealth price file).
I certify that the price listed on the documentation reflects my actual net costs after rebates or discounts from my wholesaler or other entity. SIGNATURE -- Pharmacist Date Signed
REMINDER: Attach a copy of documentation to verify any requests for price change.