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For network pharmacies

Claims Disputes

For MaxCareRx network pharmacies: how to dispute a claim or appeal MAC pricing, and who to contact.

Claims and pricing dispute information for pharmacies

General claim disputes

In the event a Network Pharmacy Provider seeks to dispute a Claim due to alleged error, miscalculation, discrepancy or non-compliance to terms specified in the Agreement or otherwise questions the accuracy of any Claim, the Network Pharmacy Provider must notify PBM within 120 days of the date of fill in writing.

Written outreach must include Pharmacy NCPDP number, Eligible Person ID number, Prescription number, date of fill and details such as why an adjustment is needed (e.g. wrong NDC submitted, wrong quantity submitted, etc.) Should the Network Pharmacy Provider fail to contact PBM within the required response time, Network Pharmacy Provider deems the accuracy of processing and payment of Claims, as set forth in that cycle. Overpayments made to the Network Pharmacy Provider are not applicable. Network Pharmacy Providers may only submit Claims to PBM for Drug Products properly labeled and dispensed in accordance with the Prescription order for the Drug Product.

Maximum Allowable Cost (MAC) pricing, review and appeals

To assure the MAC list accurately reflects market pricing and the availability of Generic Drugs, PBM utilizes multiple sources to determine MAC pricing. The sources include de-identified market pricing benchmark data such as AWP and WAC, wholesaler information on market availability, PAC (Predictive Acquisition Cost) database information, and general pharmacy information from inquiries. A synthesis of these and other sources helps create a market-based MAC price for Generic Drugs on the MAC list.

These sources are also monitored and updated at least every seven (7) calendar days to help manage market pricing fluctuations on the MAC list. PBM’s MAC lists are also regularly reviewed at least every seven (7) calendar days and updated accordingly. PBM reserves the right to update its MAC pricing methodology and to use alternative, reputable sources at its discretion. Upon written request, as well as to the extent required by law, PBM will make available the current and applicable MAC price information to Network Pharmacy Provider. Such MAC price lists constitute confidential information.

To comply with applicable state laws, PBM has implemented an appeal process to allow a participating network pharmacy to dispute applicable and particular MAC pricing of a Covered Prescription Service Drug Product (i.e. MAC Appeal). This process also includes a timely review and investigation to resolve MAC disputes. For a MAC Appeal, pharmacy must obtain, fully complete and submit the MAC Appeal form (“MAC Form”) to PBM within thirty (30) calendar days from the date of service submitted on the Claim, as well as adhere to state-specific requirements. For pharmacies contracted with a PSAO, MAC appeals may be submitted to the PSAO for processing.

PBM shall investigate and resolve the appeal within thirty (30) business days after the fully completed form is received. All MAC appeal review determinations on any individual claim from a pharmacy are final and will not be reviewed again. This section shall be considered a part of the Agreement by and between PBM and Network Pharmacy Provider (including all amendments, addenda or Compensation Exhibits) to the extent the Network Pharmacy Provider provides Covered Prescription Services to Members in applicable states. The terms of this section shall be considered general information regarding MAC. Network Pharmacy Provider agrees and understands to the extent any state-specific law, rule or regulation differs or contradicts the terms set forth herein, PBM shall follow the state-specific law, rule or regulation. Network Pharmacy Provider is subject to any MAC list(s) associated with the network(s) in which Network Pharmacy Provider participates.

MAC appeal requests will be reviewed to determine the appropriateness of pricing utilized by PBM for reimbursement. PBM will utilize all available information to deduce the appropriateness of reimbursement. Participating pharmacies may be required to submit their actual acquisition cost (including any rebates) for each item being reviewed. When required, failure to submit the actual acquisition cost (including rebates) will not result in PBM rejecting Claims for review but could diminish the accuracy of review and therefore the likelihood of a successful and complete review.

Contacts for pharmacies