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Dates of Fill more than 30 days prior to the submission date of this form will not be reviewed.
Please submit a claim only once, duplicate claims will NOT be reviewed (validations will be made within the same submissions well as previous submissions). All reviews of any individual claim from a pharmacy are final and will NOT be reviewed again.
Include Purchase Price of Drug from primary wholesaler. Invoice may be required.
MAC Appeal Detail must be filled out completely unless noted as "Optional". Submissions with missing information will be Invalid and excluded from review:
|Date Filled||NABP||RX#||NDC#||Drug Name|
|Drug Strength||Purchase Price||Reimbursement||Reason For Review||Special Notes|