DatA Request Form - West

The following information is necessary to conduct a thorough pharmacy benefit analysis.
Additionally, line item prescription specific data is the most effective way to evaluate the
effects of new pricing or trend management programs. Please see the detailed list below of
data elements necessary to provide a definitive analysis. Please contact Michael Ochoa with
any questions at 949-278-7464 or m.ochoa@ascendpbm.com.

Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Drag files here or choose files

Please contact Michael Ochoa with any questions at:
949-278-7464 or m.ochoa@ascendpbm.com

ARE YOU READY TO DISCUSS YOUR BENEFIT PLAN WITH AN EXPERT?