Form F-00030 "State and Specialty Maximum Allowed Cost Drug Pricing Review Request" - Wisconsin

What Is Form F-00030?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2017;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F-00030 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-00030 "State and Specialty Maximum Allowed Cost Drug Pricing Review Request" - Wisconsin

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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:
info@mslcrps.com
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 Policy Override Center
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
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:
info@mslcrps.com
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 Policy Override Center
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
STATE AND SPECIALTY MAXIMUM ALLOWED COST DRUG PRICING REVIEW REQUEST
2 of 2
F-00030 (04/2017)
SECTION II – PRODUCT AND PRICE INFORMATION (Continued)
13. Describe the reason for state or specialty MAC drug rate review (e.g., no generic available at state MAC drug price).
* I certify that the price listed on the documentation reflects the AAC after rebates or discounts from the wholesaler / supplier.
14. SIGNATURE – Requesting Provider
15. Date Signed
Internal Use Only
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