Why Filing MAC Appeals Should be a “Win-Win” for Pharmacies

Pharmacy Benefit Managers (PBMs) Maximum Allowable Cost or “MAC” pricing continues to be one of the most challenging issues facing independent pharmacies throughout the United States—MAC is one of the primary ways in which PBMs reimburse independent pharmacies in the United States. MAC lists which identify MAC prices for numerous drugs are created entirely by PBMs and kept highly confidential by PBMs. As a result, PBM MAC lists and MAC prices are often cloaked in secrecy and avoid public scrutiny. In response to this issue, many states have enacted “MAC Appeal” laws providing pharmacies with rights to challenge improper PBM MAC pricing. There are currently 36 states that have passed some form of law regarding MAC pricing.

Pharmacies should take advantage of MAC laws that contain a MAC appeal process, especially because many of these laws theoretically provide for a potential “win-win” outcome. For example, in Georgia, all PBM-pharmacy contracts must contain a process to appeal MAC pricing. Georgia’s law further provides that for “successful” MAC appeals the PBM must

(1) adjust the MAC price that was appealed effective on the day after the appeal is decided;

(2) apply the adjusted MAC price to all similarly situated pharmacies;

(3) allow pharmacies that successfully appealed to reverse/rebill the claim appealed.

However, Georgia’s MAC law, also requires that if an appeal is denied, the PBM must provide the reason for the denial and identify the NDC of a drug product that may be purchased by contracted pharmacies at a price at or below the MAC. Thus, in theory, a MAC appeal in Georgia should be a win for the pharmacy, regardless of whether it is “successful” or “denied.” Essentially, pharmacies should either receive a favorable price adjustment or receive new information about how to purchase drugs at a better price. Pharmacies should file MAC appeals when necessary and pharmacies who are not receiving responses that comply with their state’s MAC law should pursue appropriate legal recourse to ensure compliance with the law.   

How Frier Levitt Can Help

Frier Levitt represents pharmacies across the United States in challenging PBM audits, network access, reimbursement practices and has extensive knowledge on all aspects of PBM MAC pricing and MAC reimbursement. Contact Frier Levitt today to speak with an attorney about how your pharmacy can leverage the various laws and protections afforded to pharmacies regarding Maximum Allowable Cost.

Tagged with: , , , , , , , , , , ,
Share: