2200 Michener St.  *  Suite 10  *  Philadelphia PA 19115  *  215.464.9892

Pricing Problem Report


The following must be filled out for each pricing problem and will be included with our pricing to the appropriate contact person at each Plan or PBM via email. If you have contact names with email addresses for this plan or others, please contact our offices with the information.

*Please complete all fields below:
Plan or PBM

(Aetna, Keystone Mercy, Medco etc.)
 
Pharmacy Name:
NABP Number/NPI:
Date:
Rx Number:
NDC Number:
Quantity:
Drug Name & Strength:
Patient ID:
Date of Fill:
DAW:
Group Number:
Bin Number:
Pharmacy Cost:
Total Amount Paid:
Patient Co-Pay:
Dispensing Fee:
Wholesaler:
Total Reimbursement:
Comments:
Pharmacy Email:
Pharmacy Contact:
Pharmacy Phone Number:
Pharmacy Fax:
 
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