Pharmacy + provider tools

Access Prime’s:

• Prime’s maximum allowable cost (MAC) list | MAC Pricing
• Specialty fee schedule(s)
• Compound fee schedule
• 835 health care electronic remittance advice
• Electronic funds transfer (EFT)
• Prime’s Credentialing Threshold

Log in | Sign up

---

A pharmacy may submit a MAC pricing appeal via:

• Email at MACAppeals@primetherapeutics.com
• Fax at 877-823-6373. If a fax is sent, an email address is required so a response may be provided.
• Phone Monday through Friday 6:00 AM – 2:00 PM PST at 888-277-5510 Option 1
• Mail to: Attn: MAC Appeal-2900 Ames Crossing Road-Eagan, MN 55121

*If the claim is hitting an Express Scripts contract between the pharmacy and Express Scripts the appeal must be submitted via: prc.express-scripts.com

The following information needs to be provided in order to initiate the appeal process:

• A copy of the original invoice that contains the purchase price of the drug being appealed.
• Pharmacy NPI or NCPDP, member ID, Rx #, and date of fill.
• Generic drug name, and NDC #
• Brief explanation as to the nature of the appeal.

The sources currently used to determine MAC pricing are Cardinal, Amerisource, and Anda wholesale price lists, and National Average Drug Acquisition Cost (NADAC) published by CMS. Medi-Span average wholesale pricing (AWP) is currently used to calculate MAC rates. Prime reserves the right to change any pricing source at any time.

Once a MAC pricing appeal is submitted, the MAC Pricing Specialist will investigate the claim and proceed based on the following situations:

• ALL submitted and verified MAC related appeals will receive an email confirmation that the appeal has been entered into the database and will be reviewed for a MAC pricing change within 7 business days, unless another time period for review is specified by applicable law.
• Appeals submitted for drug NDC’s that are not on the Prime Therapeutics MAC list or a claim that has been entered as usual and customary and/or submitted will be returned as a non-MAC related issue and appeal will be closed.
• The appeal will remain on file for continual review for up to 90 days.

Prime will notify the appealing pharmacy within 3 business days that the appeal has been received and is being reviewed.

New Mexico Pharmacies

If the pharmacy contract with the PSAO requires notices of payment recoupment of reduction go through the PSAO, the MCO must require the PSAO to forward such notices including the opportunity to appeal the pharmacy within 3 business days of receipt from the MCO and the PSAO to forward any response to the MCO within 3 days of receipt from the pharmacy.

Tennessee Pharmacies

Prime’s initial appeal process is available for all prescription drugs or devices in Tennessee for which a pharmacy alleges it did not receive its actual cost.

In lieu of the information identified above, a pharmacy may submit the “Standard Pharmacy Reimbursement Appeal Form” that is available the TN Department of Commerce and Insurance: https://www.tn.gov/content/dam/tn/commerce/documents/insurance/forms/StandardAppealForm012023.pdf

• If a pharmacy submits an incomplete appeal, the Pricing Specialist will hold the appeal open until requested information from the pharmacy has been provided. During this time, the Pricing Specialist must reach out to the pharmacy within five (5) business days and request the needed information to continue with the appeal review process.

o   If the pharmacy provides the requested information, the timeline for making a final determination outlined in Tennessee rule shall start.

o   If the pharmacy fails to provide the requested information within five business days of receipt of the notice from the DPA, the DPA may deny the initial appeal to Tennessee law.

• If Prime fails to comply with the timing and notice requirements under Tennessee rule, the pharmacy’s initial appeal shall be resolved in favor of the pharmacy. If a pharmacy fails to comply with the timing requirements under Tennessee rule, the DPA may deny the initial appeal pursuant to Tennessee Statute.
• If the appeal is granted:

o   The Pricing Specialist must provide:

• A written statement and summary outlining the basis of the granted decision.
• Notification the PBM has adjusted the challenged rate of reimbursement.
• Detailed instructions for how to reverse and rebill the claim upon which the initial appeal is based.

o   The adjustment for the appealing pharmacy will be effective from the date the pharmacy’s appeal was filed, and the pharmacy will be instructed on how to reverse and rebill the claim in question in order to receive the corrected reimbursement, and

o   The MAC price of the drug or medical product or device will be adjusted for similarly situated pharmacies in the network (pharmacies using the same MAC list) within seven (7) business days for claims submitted in the next payment cycle.

• All similarly situated pharmacies within the state of Tennessee will be notified of the change via email.
• If the appeal is denied:

o   The DPA must provide a statement and summary outlining the basis of the denial decision.

o   If applicable, evidence that Prime has adjust the challenged rate of reimbursement.

o   If applicable, detailed instructions for how to reverse and rebill the claim upon which the initial appeal is based.

o   Instructions on how to make an external appeal of Prime’s decision to the Commissioner by:

• Explaining how to submit an appeal (see below).
• Provide the following link and phone number to the appealing pharmacy:
• TN Department of Insurance Website: https://www.tn.gov/commerce/insurance/pbm.html
• TN Department of Commerce & Insurance Phone #: (615)741-2241

Pursuant to T.C.A § 56-7-3206(9)(2) a pharmacy has the right to appeal the initial appeal decision to the Commissioner of the Tennessee Department of Commerce and Insurance.

• The pharmacy may file an appeal with the Commissioner within 30 days of the pharmacy’s receipt of the PBM’s final determination.
• Prime must file a response to the appeal to the Commissioner within ten (10) business daysof receipt of notice from the Commissioner that Prime’s decision has been appealed.
• The Commissioner will provide a final determination no later than ninety (90) daysafter receipt of Prime’s response or the complete appeal from the pharmacy, whichever is later.
• If Prime’s final determination is overturned by the Commissioner, Prime must pay the pharmacy within seven (7) days of notification of the Commissioner’s decision.

o   The reimbursement adjust must be applied to all other similarly situated pharmacies.

• Prime shall pay, within thirty (30) days of receipt, all costs associated with the appeal process performed by the Department.

For questions concerning Reimbursement appeals please contact:

Scott Verley

Director of Financial Modeling

Scott.Verley@primetherapeutics.com

612-777-2532