Follow the steps to complete the review request form online.

1. Press the ‘Get Form’ button to access and open the State Maximum Allowed Cost Drug Pricing Review Request form.
2. Begin filling out Section I — Pharmacy Information. Provide the name of the pharmacy in the first field and continue by entering the National Provider Identifier and the Taxonomy Code as required. Make sure to include the ZIP+4 Code for the practice location and the complete provider address, including street, city, state, and ZIP code.
3. Complete the contact information fields for the provider by entering the telephone number and the fax number. Additionally, list the name of the contact person for further communication.
4. Move to Section II — Product and Price Information. Fill in the NDC (11-digit number) and the name of the drug. Then, input the current State Maximum Allowed Cost price and the net cost to reflect actual expenses.
5. In the next field, describe the reason for the state MAC review, including details such as the absence of a generic alternative at the state MAC price. Ensure that you are as specific as possible.
6. Certify the documentation by signing in the designated space for the pharmacist's signature and enter the date you have signed the form.
7. Once all fields have been completed, you can save the changes made to the form. Afterward, the form can be downloaded, printed, or shared according to your needs.

Start completing your State Maximum Allowed Cost Drug Pricing Review Request form online today!