PHARMACY MAC PRICE INQUIRY FORM
Please complete all of the information below in order for Citizens Rx to complete the MAC review. Please allow us 5-7 business days to review your inquiry.
  • PHARMACY INFORMATION

    Please enter all information requested below.
  • Please enter the NCPDP or NPI Number.
  • Please provide us with the pharmacy's key contact's name.
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  • GENERIC DRUG INFORMATION

    Please enter the following information associated with the drug related to your inquiry. Please submit an additional entry if you have multiple MAC inquiries.
  • Please enter the drug name.
  • Please enter NDC-11
  • Please enter the quantity dispensed.
  • Please enter Days Supply.
  • $ .
    Please enter your unit acquisition cost.
  • PLAN INFORMATION

    Please enter the following submitted information.
  • Please enter BIN
  • Please enter PCN
  • Please enter the ID Number or Group Number
  • Limited to XLS, XLSX, CSV, DOC, DOCX, PDF, and TXT.