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Home>Documents>Healthcare>Medical Forms>Medicare/Medicaid>Florida Medicaid MAC Pricing Request Form

Florida Medicaid MAC Pricing Request Form

This form is used to request the Florida Medicaid Pharmacy Policy Section to research the MAC list price for a specified drug. It includes important details required for submission. Proper completion ensures timely processing of your request.

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How do I fill this out?

To fill out this form, start by entering your pharmacy and provider information. Next, provide the drug information including name, strength, and dosage form. Finally, ensure all required fields are completed before submission.

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How to fill out the Florida Medicaid MAC Pricing Request Form?

  1. 1

    Enter pharmacy name and contact details.

  2. 2

    Input the required drug information accurately.

  3. 3

    Fill in the date of service and patient ID.

  4. 4

    Review all fields to ensure they are complete.

  5. 5

    Submit the form with the required invoice attached.

Who needs the Florida Medicaid MAC Pricing Request Form?

  1. 1

    Pharmacies that need to verify drug pricing.

  2. 2

    Healthcare providers submitting pricing requests for patients.

  3. 3

    Insurance companies requiring MAC list information.

  4. 4

    Patients seeking clarity on their medication pricing.

  5. 5

    Medicaid administrators managing drug acquisitions.

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What are the instructions for submitting this form?

Please submit this form by faxing it to 800-332-1024 along with a copy of the invoice listing the current acquisition cost. Ensure that all required fields are completed to avoid processing delays. If needed, you may also mail the form to the Medicaid Pharmacy Policy office for manual handling.

What are the important dates for this form in 2024 and 2025?

For 2024, ensure you submit requests within the seven-day window following the date of service. For 2025, adhere to the same submission timeframe as specified in 2024 guidelines.

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What is the purpose of this form?

The purpose of this form is to facilitate the request for research regarding the MAC price of drugs under Florida Medicaid. It allows pharmacies and healthcare providers to verify pricing to ensure compliance with state regulations. This process helps maintain the integrity of drug pricing for patients and providers alike.

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Tell me about this form and its components and fields line-by-line.

This form contains several fields that must be completed for processing. Each component is essential for accurate submission and verification.
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  • 1. Pharmacy Name: The name of the pharmacy submitting the request.
  • 2. Pharmacy Contact Name: The name of the contact person at the pharmacy.
  • 3. Phone Number: Contact phone number for the pharmacy.
  • 4. Fax Number: Fax number for document submission.
  • 5. Drug Name: Name of the drug being inquired about.
  • 6. Drug Strength: Strength of the drug.
  • 7. Drug Dosage Form: Form in which the drug is administered.
  • 8. Rx Number: Prescription number associated with the drug.
  • 9. Date of Service: The date when the service was provided.
  • 10. Patient ID: Identification number for the patient.
  • 11. Quantity Dispensed: Amount of medication dispensed.
  • 12. NDC Number: National Drug Code for the drug.
  • 13. Pharmacy Acquisition Cost: Cost of acquisition by the pharmacy.
  • 14. Wholesaler Name: Name of the wholesaler supplying the drug.

What happens if I fail to submit this form?

Failure to submit this form can result in delays in price verification and potential impact on patient care. Incomplete submissions may cause processing issues and delay access to necessary medications.

  • Delayed Pricing Verification: Without timely submissions, verification of MAC pricing can be significantly delayed.
  • Impact on Patient Care: Delays in drug pricing information can impede patient access to necessary treatments.
  • Increased Administrative Burden: Incomplete forms may require additional follow-up and documentation, complicating the process.

How do I know when to use this form?

Use this form when you need to verify the Florida Medicaid MAC price for a specific drug. It is necessary for compliance with Medicaid regulations and assists in accurate pricing for patient medications.
fields
  • 1. Check Medicaid Pricing: To verify Medicaid MAC prices for prescribed medications.
  • 2. Ensure Compliance: To ensure all pricing inquiries are documented appropriately.
  • 3. Facilitate Patient Access: To help patients receive medications at the correct pricing.

Frequently Asked Questions

What is the purpose of this form?

This form requests the verification of the Medicaid MAC pricing for specific drugs.

How do I submit the form?

You can submit the form via fax or mail it to the Medicaid Pharmacy Policy.

Are there any fees to submit this form?

There are no fees associated with submitting this form.

How long does it take to process the request?

Processing time typically ranges from 3 to 5 business days.

What happens if I submit the form late?

Late submissions may result in processing delays.

Can I edit the PDF before submitting?

Yes, you can edit the PDF using PrintFriendly before submission.

What information do I need to fill in?

You need to provide pharmacy details, drug information, and patient ID.

Is there a deadline for submission?

Forms must be submitted within seven business days of the date of service.

Where can I find the MAC list?

The MAC list can be accessed through the Florida Medicaid website.

Can I share this form with others?

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