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Requesting your MAC list
Three states publish an official appeal form. No state publishes a template for requesting the list itself, which is the step that comes first and the one almost nobody takes. So here is one. It is free, there is nothing to sign up for, and you should edit it.
Before you send it, two things. Check your state's page for whether the right exists there and how it is worded — in some states the duty is unconditional and in others it only triggers on request. And address it to the pharmacy benefit manager, not the health plan. The duty binds the PBM, and the PBM is often not the name on the card.
[Date]
[PBM name]
[Network/Provider Relations address]
Re: Request for maximum allowable cost list
Pharmacy: [name] · NPI [number] · NCPDP [number]
Contract/Network ID: [number]
To whom it may concern,
I am writing to request the maximum allowable cost list applicable to my
pharmacy under our network agreement, as provided for under [state] law
at [citation from your state page].
Specifically, I am requesting:
1. The list of drugs for which you set reimbursement by maximum
allowable cost, identified by national drug code.
2. The maximum allowable cost you currently apply to each, with the
effective date of each price.
3. The national drug pricing compendia and other data sources you use
to determine those prices, as identified in our contract.
4. The date the list was last reviewed and adjusted.
If your state requires a particular format, add:
Please provide the list in an electronic, computer-accessible and
searchable format.
Please confirm receipt of this request and let me know the date by which
I can expect the list. If you believe any part of this request falls
outside your obligations, please say which part and on what basis.
Thank you,
[Name], [title]
[Pharmacy], [address]
[Phone] · [Email]
What to expect
Several large PBMs already run self-serve portals for this and may simply point you at one, which is a fine outcome. Some will take weeks. Some will not answer, and in a number of states that non-response is itself a violation with a penalty attached — your state page shows whether that is true where you are.
Whatever happens, note the date you sent it. If you later need to complain to your insurance department, the date is the first thing they will ask for.
A note on what you get back
MAC lists are usually treated as confidential under your provider manual. That is a live constraint: it generally means you can use the list for your own business but not republish it or hand it to a third party. Read your own manual before sharing it with anyone, including a vendor — including us. We do not want your list and will not ask for it.
Then tell us what they did
How long they took and what came back. Not the list itself. It is the only public record anyone is keeping.
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