MAC Transparency Resources
What does Georgia’s new MAC transparency law mean for pharmacists? We’ll be updating this page with the latest information.
On January 1, 2016, Georgia’s new MAC law went into effect, the result of GPhA’s advocacy during the 2015 legislative session. The new law not only strengthens regulatory oversight of PBMs by the state commissioner of insurance, but also creates an appeal process through which, as a last recourse, pharmacies can challenge denied reimbursements if they believe the new law is being circumvented.
When to file an appeal
We’re getting a lot of questions from independent pharmacy owners about the MAC reimbursement appeal process. Specifically, pharmacists are wondering about filing appeals with Georgia’s Commissioner of Insurance.
VP of Public Policy Greg Reybold offers some guidelines on how and when to make the determination that such an appeal is the correct course to take:
Look at market cost. Does the reimbursement rate seem low? Determine what the drug at issue would cost today (aside from acquisition cost) from primary and secondary wholesalers, and document this cost. If there is a significant disparity between the reimbursement and the cost to purchase from a wholesaler today, then it may be that the MAC price has not been updated within the past five business days.
This disparity could be the basis of an appeal. If there is not a significant difference, it is likely not worth appealing. Bear in mind that just because a pharmacy loses money does not mean a violation of the law has occurred. Nothing in the new law assures that a pharmacy may recoup its acquisition costs for a MAC-listed drug.
Follow the PBM’s internal process. You’ll want to see if the PBM has a MAC appeal process. Review your PBM agreement or provider manual if you’re not sure.
Assuming an internal appeals process is in place, follow it. Note that under law, a pharmacy has 14 days following a reimbursement to appeal a claim internally. If the pharmacy does not follow the internal appeal process or bypasses it altogether, complaints to the Commissioner of Insurance will be rejected.
If you are unsuccessful through PBM channels, only then should you go the Commissioner of Insurance. If, after an internal appeal, you still feel you have a valid complaint, then look into whether there is a basis to appeal to the Commissioner of Insurance.
AIP members only: If you need further guidance, contact Jeff Lurey at email@example.com. He’ll be happy to discuss next steps with members who’ve had no luck working within the PBM appeals system.
How to file an appeal
Pharmacies submit MAC pricing complaints to the Commissioner of Insurance’s office the same way consumers submit complaints. There are three options: online, via fax, and via paper mail.
Regardless of the method you choose, you should redact any protected health information — i.e., personal information about the patient, including the prescription number — before you submit the complaint.
Important: Georgia Pharmacy Association members should download and complete our GPhA MAC appeal form. It provides an clear, standardized way of delivering the required information to the commissioner’s office.
The form is a fillable PDF. After you complete it (using Adobe Acrobat Reader or another PDF reader), you can save and/or print the completed form.
Using the Online Complaint Portal (preferred)
You may file a complaint with the Commissioner of Insurance using the Consumer Complaint Portal located at https://www.oci.ga.gov/ConsumerService/complaintprocess.aspx.
While submitting your complaint, you’ll have an opportunity to upload relevant documentation — that’s when to include your fully completed GPhA MAC appeal form.
You may fax your complaint to (404) 657-8542. You will need to download, complete, and print the commissioner’s provider complaint form (this is not the GPhA MAC Appeal form). Click here to view or download that form (PDF).
Along with the commissioner’s form you will also fax your completed GPhA MAC appeal form.
By paper mail
Georgia Department of Insurance
2 Martin Luther King Jr. Drive
Suite 716 West Tower
Atlanta GA 30334
What happens after a complaint is filed?
As this law took effect January 2016, it isn’t entirely clear what the complaint process/timeline will look like.
However, following the submission of a complaint, you will receive a communication from the commissioner’s office with the assigned investigator’s contact information and case number. You will need to reference this case number in any future communications or if you need to send additional information in connection with that case.
From there, the commissioner’s office will notify the PBM of the complaint, seek a detailed response, and, if it feels the law has not been adhered to, likely request corrective action.
General information about the MAC transparency law
Read the FAQ
The “Legal Injection” section of the February/March 2016 issue of Georgia Pharmacy answered frequently asked questions about the implemention of the MAC transparency law.
Click here to download or read the article (two-page PDF).
It answers questions such as…
- Does the new MAC pricing law guarantee I will not receive a negative reimbursement?
- Can single-source drugs be subject to MAC pricing?
- Do PBMs have 14 days to resolve appeals? (Hint: No.)
- Can I bypass the internal PBM appeal process and go directly to the commissioner of insurance? (Hint: No.)
Read the article
The cover story of the June/July 2015 issue of Georgia Pharmacy magazine featured details about the new MAC transparency (and other) laws: what it means and how it affects pharmacist.
You can view, download, and read that story by clicking here (eight-page PDF).
You can also click here to view or download a PDF with talking points on MAC transparency that we gave to legislators as we worked to pass the bill.
GPhA CEO Scott Brunner and attorney Greg Reybold discuss the ramifications of the MAC transparency law:
Even better, watch these videos of Georgia pharmacists talking about MAC pricing transparency: