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Washington PBM MAC rights
Statute RCW 48.200.280 + WAC 284-180-507
Whether the statute gives a pharmacy a right to see the list of drugs priced off maximum allowable cost.
Some states require it to be electronic and searchable. Most say nothing, which in practice means a PDF.
A demonstrably staler list is itself a violation in most states.
Read the trigger carefully. A clock running from adjudication is much shorter in practice than one running from payment.
The strongest provision in this area. A named drug code, and better a named wholesaler, is a claim you can check against your own catalogue.
In a few states a successful appeal corrects the price for every similarly situated pharmacy, sometimes retroactively.
The weakest column in our data. Several are marked unverified rather than guessed at.
Before you rely on a deadline, know which plan is behind the claim
State MAC rights are strongest on commercial claims — individual plans, fully insured employer plans, and in many states the state employee plan. For self-funded employer plans they stand, because the Supreme Court's 2020 Rutledge decision specifically upheld MAC update and appeal mandates.
Medicare Part D is the real problem. Federal law expressly supersedes state regulation of Part D plans, two federal circuits apply that rule at very different levels of generality, and in Arkansas a federal court entered final judgment that the state MAC law is preempted as to Part D. Part D is roughly a quarter of a typical independent's volume, so this is not a footnote.
Medicaid depends entirely on your own state's statute — some exempt it by name, some cover it by name, most are silent. TRICARE and federal-employee claims should be treated as outside these rights.
What to do with this
- Check your own contract first. In most states it has to name the pricing sources the PBM uses. That is a document you already have.
- Ask for the list. There is a free template here. No state publishes one, so we wrote it.
- Send it to the right place. Sixty-odd licensed PBMs collapse to about eight actual appeal endpoints. Here is where each one goes.
- Tell us what happened. Nobody publishes whether these duties are actually honoured. Two minutes, and it becomes public data.
Sources
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