Program Overview Get Started Pharmacy InformationPharmacy Name* Email* DIR Fee Insurance: UnderwritingPlease supply your past 3 months dispensing data in CSV or Excel Format. Drop files here or Select files Max. file size: 50 MB. This will be utilized for underwriting & risk analysis. Data needed: Drug Name, NDC, Dose, Quantity & Date Range. APPA cares deeply about the privacy & security of your data. View our Data Privacy Policy.File Transfer Alternative: Share a Link If you receive an error utilizing the file upload system above, please provide a dropbox or other file sharing link here. Cost Savings AnalysisTo ensure our schedule of approved & insured products does not impact your cost of goods, please provide the following information:Are you currently using SureCost?* Yes No PricingSpecialty: Invoice WAC* Speciality Rebate* Brand: Invoice WAC* Brand Rebate* Generic: Invoice Total* Generic Rebate* BlendSpecialty Volume* Brand Volume* Generic Volume* Do you participate in a 340B Program?* Yes No Patient EngagementHow do you currently deliver product?*Mark All That Apply In-store Mail Order Closed Door Delivery If Delivery, please provide radius from store location: Prescriber Engagement & Clinical ServicesCurrent Professional & Commercial Insurance Company: (Pharmacist Mutual, etc)* Number of Prescribers* Patient Population Size* CommentsThis field is for validation purposes and should be left unchanged. Δ
