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.

Tennessee Pharmacies

PDCrx 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 PDCRx, 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