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Sales Code  
Health System  
City and State  
Contact Name, Title, Phone  
RecoveRx TM Profile Facility 1
Facility 2
Facility 3
Facility 4
Facility 5
Inpatient Section - If none, skip to the Oncology/Infusion Center section.
1. Do you have an Inpatient Drug Recovery program?
If Yes, what is the average total cost of the drugs recovered each month?
If Yes, how many applications are submitted each month?
2.Inpatient drug expense last year
3. Inpatient Payor Mix (%) - Medicare
- Medicaid
- Insurance/3rd Party (3rd party payor not M'care or M'caid)
- Self-Pay (uninsured not classified as Charity Care)
- Charity Care (uninsured and/or funded by the hospital)
- Other (if applicable - patients not in a payer class above)
Outpatient Oncology/Infusion Center Sections - If none, skip to Outpatient Rx Section.
4. Do you have an Outpatient Oncology/Infusion Center Drug Recovery program?
If Yes, what is the average total cost of the drugs recovered each month?
If Yes, how many applications are submitted each month?
5. Oncology/Infusion drug expense last year
Are the purchases in #5 included in the inpatient purchases listed in #2 above?
6.What Percentage of your Oncology/Infusion care would be considered charity care?
Outpatient Rx Section (Filling take-home Rxs) - if none, skip to instructions.
7.Do you already have a drug recovery program at your Outpatient Pharmacy?
If Yes, what is the average total cost of the drugs recovered each month?
If Yes, how many applications are submitted each month?
8. What is the average number of prescriptions per day filled by this pharmacy?
9.Outpatient Pharmacy's drug expense last year?
10.Are the purchases in #9 included in the inpatient purchases listed in #2 above?
11.Outpt Rx Payor Mix (%) - Medicaid
- Medicare
- Insurance/3rd Party (3rd party payor not M'care or M'caid)
- Self-Pay (uninsured not classified as Charity Care)
- Charity Care (uninsured and/or funded by the hospital)
- Other (if applicable - patients not in a payer class above)
Instructions
Questions or clarification? Contact Jill Masson at 810-730-1402
 
Please providle an 80/20 -or- Top 300 Pharmacy purchase report
(in Excel, .txt or .csv format) for the past 6 full months for each Pharmacy account
Forward completed form and purchase report(s) to jmasson@pharmhs.com




IndiCare is a Pharmacy HealthCare Solutions Service