Pharmacy MAC Appeal Submission
Contact Information
Your Name
Email Address
Phone Number
Pharmacy Information
You may only enter appeals for one pharmacy within each submission.
Pharmacy Name
NCPDP
NPI
MAC Appeal
Member ID
Insurance Card Group
PCN
BIN
Please select...
610502
004336
Proposed / Requested Price (Package Price)
Please limit to 5 digits before and 5 digits after the decimal maximum
x
Rx Number
Invoice Date
Date Filled
Invoice Price (Package Price)
Please limit to 5 digits before and 5 digits after the decimal maximum
x
Wholesaler
Dispensed Quantity
Please limit to 5 digits before and 3 digits after the decimal maximum
x
Days Supply
NDC
Drug Name
Compound?
Yes
No
Contact Information