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Pharmacy Price Inquiry Form

Pharmacy Price Inquiry Form 2026

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4.3 out of 5

42 votes

The document is a Pharmacy Price Inquiry Form that outlines the process for pharmacies to request pricing reviews. It requires pharmacies to submit a completed form along with a purchase invoice from their wholesaler to the Pharmacy Network Department via email or fax. The form collects essential information such as claim details, pharmacy contact information, and drug specifics necessary for processing the inquiry.

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Click ‘Get Form’ to open the Pharmacy Price Inquiry Form in the editor.
Begin by filling out the Claim Information section. Enter the *Rx Number* and *Date of Fill*, ensuring all required fields are completed.
Next, move to the Pharmacy Information section. Provide details such as *Contact Person*, *NCPDP #*, *Chain/PSAO ID #*, *Pharmacy Name*, *Phone*, and other required fields marked with an asterisk.
In the Drug Information section, input the *Drug name and strength*, *NDC#*, and *Dosage form*. Also, specify the **Metric quantity that was dispensed** and provide the lowest price attainable for that amount.
Finally, review all entries for accuracy before submitting. Once complete, email or fax your form along with a purchase invoice to the Pharmacy Network Department.

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Versions	Form popularity	Fillable & printable
2014	4.3 Satisfied (42 Votes)

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