Why appeal??

Why Completing MAC Appeals and Utilizing Other Provisions of TCA Title 56 / Rule 0780-01-95 is Crucial for Tennessee Pharmacies

1. Ensure Fair Reimbursement (Especially for Generic Drugs)

• MAC = Maximum Allowable Cost — the upper limit PBMs will pay for a drug, especially generics.

• Sometimes, the MAC set by the PBM is lower than the actual cost a pharmacy pays to acquire the drug.

• Filing a MAC appeal allows the pharmacy to challenge under-reimbursement and potentially receive more appropriate payment.

  
  

Without appealing, the pharmacy may lose money on every prescription dispensed for that drug.

2. Protect Your Rights Under State Law

• Tennessee has passed pro-pharmacy legislation under TCA § 56-7-3101–3108 and Rule 0780-01-95 that gives clear rights and protections to pharmacies:

  • Right to appeal MAC pricing

  • Right to external review by the Commissioner of Commerce & Insurance

  • Right to receive information on how MAC prices are set and adjusted

    
    

These rights are only actionable if the pharmacy engages the process — not using them means losing protection the law intended to give.

3. Recover Financial Losses

• Successful MAC appeals can result in:

  • Higher reimbursement for specific claims

  • Reprocessing of prior underpaid claims

  • Even future claims being adjusted to fairer MAC levels

    
    

Without appeals, PBMs have no incentive to update inaccurate MAC pricing — and your pharmacy continues to take a hit.

4. Regulatory Leverage

• The TN rules (0780-01-95) include the right to escalate to the state if appeals are ignored, denied unfairly, or handled inconsistently.

• This can result in state enforcement action against the PBM — but only if the appeal trail exists.

  
  

Documenting MAC appeals builds the paper trail you need to take action beyond the PBM.

5. Strengthen Future Reform

• Pharmacy participation in the appeals and external review process helps gather data on:

  • PBM practices

  • Reimbursement trends

  • Pharmacy financial stress

    
    

This drives policy changes and industry advocacy — your appeals have a significant impact beyond your store.