MAC Appeals Passes into Law
Monday, December 21, 2015
Posted by: PSSNY Office
December 16, 2015
The Pharmacists Society of the State of New York (PSSNY) and the New York State Chain Pharmacy Association worked together to successfully pass a MAC Appeal bill that was recently signed into law by Governor Cuomo. The new public health law takes effect on March 10, 2016, and requires a reasonable process to appeal, investigate and resolve disputes regarding multi-source generic drug pricing (MACs) within contracts between pharmacies or pharmacy contracting agents and pharmacy benefit managers.
The law is simple and straightforward. It starts with a working definition of a pharmacy benefit manager (PBM): “An entity that contracts with pharmacies or pharmacy contracting agents (PSAOs) on behalf of a health plan, state agency, insurer, managed care organization, or other third party payor to provide pharmacy health benefit services or administration.”
The contracts between PBMs and pharmacies and/or PSAOs “shall include a reasonable process to appeal, investigate and resolve disputes regarding multi-source generic drug pricing (MACs).”
- The pharmacy or PSAO has thirty days following initial claim submission in which to file an appeal;
- The PBM “shall respond within seven business days indicating its determination.”
The contract must include:
- The telephone number and e-mail address of the individual at the PBM responsible for processing MAC appeals.
If the appeal is determined to be valid:
- The PBM “shall require the appealing pharmacy to reverse and rebill the claim in question in order to obtain the corrected reimbursement”; and
- The PBM or payor “shall adjust the maximum allowable cost of the drug effective for all similarly situated pharmacies in its network in NY on the date the appeal was determined to be valid”.
If the appeal is denied:
- The PBM “shall identify the NDC of a therapeutically equivalent drug as determined by the FDA that is available for purchase from wholesalers registered in NYS at a price which is equal to or less than the maximum allowable cost for the drug as determined by the PBM”.
The PSSNY Board of Directors has created a Task Force that will engage with the prominent PSAOs in New York to develop tools, guidelines and processes for the submission and monitoring of appeals and the success of this legislation.
The Pharmacists Society of the State of New York (PSSNY) was established in 1879, a not-for-profit incorporated society representing the pharmacist profession, the largest pharmacy association in New York State. PSSNY’s mission is to unite the pharmacists of the State for mutual assistance, encouragement, and improvement in order to maintain the standard of pharmacy practice at a high professional and ethical level. www.pssny.org
The New York State Chain Pharmacy Association’s mission is to advance the interests and objectives of the chain community pharmacy industry, by fostering its growth and promoting its role as a provider of healthcare services and consumer products.