MAC Appeals

A pharmacy may submit a MAC pricing appeal via:

  • Email at price@pdcrx.com

  • Fax at 888.901.9286. If a fax is sent, an email address is required so a response may be provided.

Please use the attached form for your submission.

Maximum Allowable Cost (MAC)

The PDCRx Maximum Allowable Cost (MAC) program sets the maximum per unit price for drugs, based on current market sources. All products are regularly reviewed and adjusted as necessary according to market conditions. PDCRx updates MAC lists at least every seven (7) days or as required by law. If a drug becomes scarce, the MAC may be suspended or the drug may be permanently removed from MAC lists at PDCRx’s discretion. The drug may be reinstated when PDCRx market sources confirm sufficient supply and distribution. The current sources used to determine MAC pricing include regional and national wholesalers, the National Average Drug Acquisition Cost (NADAC) published by CMS, Predictive Acquisition Cost (PAC) pricing, and Medi-Span. PDCRx reserves the right to change pricing sources at any time. The MAC list is available upon request and can be obtained by emailing price@pdcrx.com

Required documents:

  • The pharmacy must provide the PBM with all invoices or other records demonstrating its actual cost for the drug, medical product, or device, including the manufacturer's / distributor rebate received.

  • The appeal must be submitted at least within seven business days of its submission of the initial claim for reimbursement for the drug medical product, or device.

  • PDCRx will make a final determination of the appeal at least within seven business days of its submission of the initial claim for reimbursement for the drug, or medical product or device.

Idaho Pharmacies

The pharmacy or pharmacist must be given at least thirty (30) business days after a maximum allowable cost update or after an adjudication for an electronic claim or reimbursement for a non-lectronic claim to file the administrative appeal.

South Carolina Pharmacies

We have adopted processes to ensure compliance with the requirements outlined in Section 38-71-2240 of the Code of Laws of South Carolina 1976, as amended. Our policies and procedures manual includes detailed documentation demonstrating our adherence to these requirements. This includes written policies and procedures describing the appeals dispute resolution process for in-network or contracted pharmacists or pharmacies.

Tennessee Pharmacies

PDCr Rx offers an initial appeals process for all prescription drugs or devices in Tennessee for which a pharmacy claims it did not receive its actual cost. To start an initial appeal, a pharmacy must submit the “Standard Pharmacy Reimbursement Appeal Form” available through the TN Department of Commerce and Insurance: 

https://www.tn.gov/content/dam/tn/commerce/documents/insurance/forms/StandardAppealForm012023.pdf

The pharmacy should send the completed form to PDC Rx, at the address and email mentioned above, along with a copy of all invoices or other records showing the pharmacy’s actual cost for the drug or medical product or device in question, taking into account all discounts, price concessions, or other reductions received as of the date the pharmacy filed its initial appeal. Use this link to review the details of the appeal process, including submission deadlines, as per TN 2021 legislation HB2661. Please send all appeals using the contact information provided above.

TN External Right to Appeal

Pursuant to T.C.A § 56-7-3206(9)(2) a pharmacy has the right to appeal the initial appeal decision to the Commissioner of the Tennessee Department of Commerce and Insurance.

  • The pharmacy may file an appeal with the Commissioner within 30 days of the pharmacy's receipt of the PBM's final determination.

TN Department of Commerce & Insurance Phone #: (615)741-2241

Kentucky

PDC Rx shall make its Maximum Allowable Cost (MAC) pricing appeal process readily accessible electronically through publication on its website and shall make such process available through this Agreement and/or a Pharmacy Provider Manual distributed to contracted Pharmacies, Pharmacy Services Administrative Organizations (PSAOs), and Group Purchasing Organizations (GPOs), in accordance with KRS 304.17A-162 and 806 KAR 17:575.

Kentucky Maximum Allowable Cost (MAC) List Availability

PDC Rx maintains a comprehensive Maximum Allowable Cost (MAC) pricing list for contracted pharmacies in accordance with KRS 304.17A-162 and 806 KAR 17:575.

The MAC pricing list is electronically searchable and sortable by:

  • Drug name

  • National Drug Code (NDC)

  • Generic Code Number (GCN)

The MAC pricing list includes:

  • Drug name

  • National Drug Code (NDC)

  • Generic Code Number (GCN)

  • Drug strength

  • Per unit reimbursement price

  • Applicable Maximum Allowable Cost (MAC)

  • Effective date of the MAC price

  • Date the MAC list was last updated

  • Applicable health plan information, when applicable

PDC Rx updates MAC pricing at least every seven (7) calendar days or more frequently as required by applicable law.

Historical MAC pricing data is retained for a minimum of one hundred twenty (120) days and may be made available to contracted pharmacies upon request.

Contracted pharmacies may request MAC pricing information electronically by contacting:
price@pdcrx.com

NADAC Reports