Several States throughout the United States have passed laws regarding Maximum Allowable Cost (MAC) pricing and the corresponding appeals process. Some States have enacted legislation that is more favorable to independent pharmacies, than other States. One excellent example of a “pro-pharmacy” MAC-appeal State is Washington. In Washington, PBMs are required to uphold a pharmacy’s MAC appeal if: (1) the pharmacy has fewer than 15 retail locations within the State of Washington, and (2) the pharmacy or pharmacist demonstrates that it cannot purchase a therapeutically equivalent interchangeable product from a supplier doing business in Washington at the PBM’s list price. This law not only simplifies the appeal process for most independent pharmacies in Washington, but also provides a bright-line rule upon which an independent pharmacy may rely to successfully prosecute its MAC appeal against an unscrupulous PBM. Moreover, if the appeal is upheld, the PBM must make the price adjustment within one day.
In addition, under Washington’s law, if an appeal is denied, the PBM must provide the reason for the denial and the National Drug Code (NDC) of a drug that has been purchased by other network pharmacies located in Washington at a price that is equal to or less than the predetermined reimbursement price for the drug.
While PBMs are often required by law to have procedures in place for MAC appeals, frequently the manner in which the PBMs conduct the appeals process is unfair. Washington’s MAC laws level the proverbial “playing field” and give independent pharmacies a bona fide opportunity to challenge the PBM’s MAC pricing practices.
Frier Levitt represents pharmacies across the United States in challenging PBM audits, network access and reimbursement practices and policies, including MAC appeals. Contact Frier Levitt today to speak with an attorney about how your pharmacy may leverage Washington’s MAC appeal laws.