Pharmacy Formula Price List (PFPL) Application Pharmacy Price List 4/14/2015

                       Store name Telephone Store or Corporate Email Address County

                       Store Address City State Zip Code

           Manager name Work Telephone

           Name of person completing this Price List Work Telephone

Instructions:1) Enter the county in which your store resides. If already authorized enter your four digit Vendor Stamp number

County:       Vendor Stamp #:      

Now save this document to your computer. Name it by the county, your four digit Vendor Stamp #, and the letter “PFPL” (Example: Allen0124 PFPL)Applicants, (stores not currently authorized) name by county, store name and address. (Example: Low Price Drugs 123 Main St. Indianapolis PFPL)You may encounter a message while in the process of saving the form that states there may be a minor loss of fidelity, if this occurs, click continue and save the form.

2) This Formula Price List must be completed on a computer. Phone 800 522.0874 if you are unable to do this.3) Open the saved Formula Price List from your computer. Tab to advance through the document. Incomplete Formula Price Lists cannot be processed and will be returned to the store. 4) If you have questions, explanations or comments, please enter them on the last page. 5) Save the completed Formula Price List with the correct name to your computer for your record.6) Last step; e-mail the completed Formula Price List and Vendor Application to: WICVendorMail@ISDH.IN.GOV with 2 attachments.

PRESCRIPTION FORMULA

Reminder: Pharmacies must list prices for all formulas on this page. List per can prices except where 4 pack, 6 pack, 24 per case or 48 per case is indicated. Pharmacies must provide any prescribed formula to WIC participants within two working days of notification.

Powder Size as Specified Ready to Feed Liquid Concentrate Case

Size Price Size Price Size Price Size Price

Boost (any flavor) 8 oz. 6 pack      Boost Kid Essentials 1.0 cal. (any flavor) 8.25 oz. 4 pack      

EleCare for Infants w/DHA& ARA 14.1 oz.      Enfamil Nutramigen w/Enflora 12.6 oz.      

Enfamil Nutramigen quart       13 oz.      Enfamil EnfaCare 12.8 oz.       quart       *2 oz. /48/case      

Ensure 8 oz. 6 pack      Gerber Good Start Gentle 12.7 oz.       8.45 oz. 4 pack       12.1 oz.      

Gerber Good Start Soy 12.9 oz.       8.45 oz. 4 pack      Gerber Good Start Soothe 12.4 oz.      

Neocate Infant w/DHA&ARA 14.1 oz.      Neocate Junior 14.1 oz.      

Pediasure (any flavor) 8 oz. 6 pack      Pediasure w/Fiber (any flavor) 8 oz. 6 pack      Pediasure 1.5 cal (any flavor) 8 oz. can/24/case      

Pediasure Peptide 1.0 cal (any flavor) 8 oz. can/24/case      Similac Expert Care Alimentum 16 oz.       quart      

Similac Expert Care NeoSure 13.1 oz.       quart      

*This is not a complete list of all prescription formulas. It includes the most commonly prescribed WIC formulas. See complete list at http://www.in.gov/isdh/files/Indiana_WICFormulary.pdf .

The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited basis will apply to all programs and/or employment activities.) 

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov.

Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).

USDA is an equal opportunity provider and employer.

Explanations and comments: