1 NADAC Survey Tool

National Average Drug Acquisition Cost (NADAC)

Survey Request for Information

<<Insert date>>

Y

Copies of all wholesaler, distributor, or manufacturer invoices, reflecting all brand, generic and OTC drug purchases transacted with all your wholesale supplier(s) and/or drug manufacturer(s) between

(Insert first date of month) through (Insert last date of month)

our pharmacy has been randomly selected for a sampling of invoices. We are requesting your pharmacy provide the following information within 14 days:

These records are to be limited to drug ingredient costs only. All costs that are not drug ingredient costs, such as those for shipping, storage, warehousing, or other administrative costs or other internal mark-ups, will not be considered when calculating the NADAC. For purposes of this survey, drug ingredient costs should represent the invoice price paid by your pharmacy to an unrelated third party supplier of outpatient drugs, such as your wholesaler or pharmacy manufacturer. Drug ingredient costs charged to your pharmacy by related parties that also include administrative costs or other mark-ups will not be included in the NADAC calculations. Please do not submit any patient-identifiable information.

Information should be submitted in printed or electronic format and should include the following information:

1. National Drug Code (NDC)

2. Purchase price of drug (drug ingredient cost only – see instructions above)

3. Quantity purchased

4. Purchase date for each product

5. “Item number”-to-NDC crosswalk, if item numbers or other proprietary nomenclature is used on your invoices.

As a time-saving alternative to you or your pharmacy staff submitting invoice records, you may contact your drug supplier(s) to request and authorize them to forward an electronic or hard copy of your purchasing history (as described above) for the requested period directly to Myers and Stauffer LC.

Please do not include any invoices that include Public Health Services 340B drug pricing.

Information should be mailed, faxed, or sent electronically to the following address within 14 days:

Myers and Stauffer LC

Attention: CMS Pharmacy Study

9265 Counselors Row, Suite 200

Indianapolis, IN 46240-6419

OR

317-571-8481 FAX

OR

cmspharmacy@mslccms.com (Please indicate “CMS Pharmacy Survey” in the subject line.)

*** PLEASE USE THE ENCLOSED COVER SHEET WHEN SUBMITTING YOUR PHARMACY’S INFORMATION TO IDENTIFY THIS INFORMATION AS PROPRIETARY. FAILURE TO DO SO MAY MEAN IT WILL NOT BE CONSIDERED PROPRIETARY.

Please be aware that information submitted will not be returned, therefore, please submit copies or electronic files of these records. Your participation in this endeavor is strongly encouraged and greatly appreciated. Please contact the Help Desk operated by Myers and Stauffer LC at (800) 591-1183 should you have any questions.