South Dakota Maximum Allowable Cost (MAC) program
Appeals must be submitted within 30 days of the claim fill date or within such time period as may be required by applicable state law. Appeals exceeding the allowable submission period will NOT be reviewed. Please refer back to the pharmacy manual via the OptumRx Pharmacy Portal for information specific to your state.
Any other form of appeal submission will not be accepted for review. Excel file for Appeals can be found here:
Mac appeal formMAC Appeal Detail must be filled out completely unless noted as "Optional". Submissions with missing information will be invalid and excluded from review.
Please submit all MAC Appeal requests using the approved OptumRx MAC Appeal spreadsheet via the Pharmacy Portal link using your Optum One Healthcare ID:
Healthcare Professionals Portal (optumrx.com)
*If you do not have an Optum One Healthcare ID you may register for it via the ‘Register’ link just below the Pharmacy Portal sign accessed via the above OptumRx Pharmacy Portal link.
State Maximum Allowable Cost list
Effective date | List |
07-01-2024 | Download |
06-01-2024 | Download |
05-01-2024 | Download |
04-01-2024 | Download |
03-01-2024 | Download |
02-01-2024 | Download |
01-01-2024 | Download |
Go to State Maximum Allowable Cost list archive
OptumRx MAC Appeal Submission Guide and FAQ
Appeals must be submitted within 30 days of the claim fill date or within such time period as may be required by applicable state law. Appeals exceeding the allowable submission period will NOT be reviewed. Please refer back to the pharmacy manual for information specific to your state.
Any other form of appeal submission will not be accepted for review. Appeals must be submitted using the approved OptumRx spreadsheet available above via the MAC Pricing Appeal Form button.
MAC Appeal Detail must be filled out completely unless noted as "Optional". Submissions with missing information will be invalid and excluded from review.
All reviews of any individual claim from a pharmacy are final and will NOT be reviewed again.
MAC Appeal Detail must be filled out completely unless noted as "Optional". Submissions with missing information will be Invalid and excluded from review.
Alternate and/or reference National Drug Code information provided on denied appeal responses, where applicable and required by law, represent products identified by OptumRx as being available from a national wholesaler operating in your state at or below the maximum allowable cost as determined by OptumRx.
OptumRx MAC review process does not provide clinical advice nor direction for product substitutions. Please refer to your state substitution laws.
Required Information
The following fields must be filled out in order to be processed:
-Filled Date
-BIN
-PCN
-NCPDP
-RX #
-NDC
-Compound
-Reason for Appeal
Additional available fields on the MAC Appeal Submission Form not listed above are optional.
Formatting
Any formatting errors will cause the entire file to be sent back for corrections and resubmission. Please follow the specifications in the headings so your appeals can be processed as quickly as possible.
- Following Fields must reflect information from the Drop Down Menu as follows: Reason for Review
- MAC Unit is below cost
- Drug is experiencing supply issues, please review MAC.
- Dispensed least expensive generic
- Other - Please use the notes section to explain
Compound Y/N
- Y (select Y to indicate a compound)
- N (select N to indicate a non-compound)
- If more than one ingredient is to be reviewed fill out individual lines for each NDC.
- Not including leading zeros in BIN, NCPDP, RX#, PCN, or NDC (example NCPDP 412345 instead of 0412345).
- Incorrect or missing date of fill (example 3/10/2103 instead of 3/10/2013).
- Changing the format to custom to give the appearance of leading zeros. Numbers must be in text format to be processed.
- Missing any of the required fields.
- Adding letters to BIN numbers (example 012353A instead of 012353).
- Entering NDC with dashes (example 00012-3456-78 instead of 00012345678).
- If you have any questions regarding this process or any concerns, please let us know so we can address them. Please refer to the Pharmacy Manual for contact information.
- Any resolved appeals returned with the status of:
- Any resolved appeals with the status of Claim Paid according to the effective rate contracted, implies that the claim paid according to the Effective Rate contracting, providing increased pricing transparency and predictability of rate trends. Guarantees offer PSAO with guardrails to protect the financial interest of its affiliated pharmacies while ensuring access to OptumRx networks.
Resolution Responses and definitions:
Appeal Reason Description | Definitions | Status |
Approved Pricing Reconciliation | OptumRx has reviewed and approved appeal. Payment will be issued for amount due as a result of adjusted reimbursement. (R&R not required) | Approved |
Acq not Provided | ACQ cost needs to be submitted | Denied |
Appeal window exceeded | Appeal exceeds allowable submission period | Denied |
AWP | Claim paid at the contracted AWP rate | Denied |
Claim not found | Claim could not be found within Optum given the supplied criteria. | Denied |
Claim Not Found - Unknown RxNumber | Claim could not be found within Optum given the supplied criteria. | Denied |
Claim Paid according to effective rate contracted | Claim Paid at the Contracted Rate | Denied |
Claim Paid at Provider submitted U & C | Claim Paid at Submitted Usual and Customary cost | Denied |
Client MAC | Contact client to review claim | Denied |
Duplicate/Duplicate Appeal | Duplicate Appeal Submission | Denied |
FUL | Claim Paid at Federal Upper Limit | Denied |
No change | Appeal denied. MAC price accurate | Denied |
No Change MAC Price Valid | Appeal denied. MAC price accurate | Denied |
Non Paid Claim | Rejected / X (Reversed) /Claim Reversed. Appeal as submitted is for a reversed or rejected claim. Can only appeal paid claims. | Denied |
Non-MAC claim | Claim could not be found within Optum given the supplied criteria. | Denied |
Non-OptumRx claim | Claim could not be found within Optum given the supplied criteria. | Denied |
Non-paid claim | Rejected / X (Reversed) /Claim Reversed. Appeal as submitted is for a reversed or rejected claim. Can only appeal paid claims. | Denied |
Not Found | Claim could not be found within Optum given the supplied criteria. | Denied |
Paid at AAC | Claim paid at the contracted AAC rate | Denied |
Paid at AWP/WAC | Claim paid at the contracted AWP rate/paid at WAC pricing | Denied |
Paid at Contracted Rate | Claim Paid at the Contracted Rate | Denied |
Paid at FUL | Claim Paid at Federal Upper Limit | Denied |
Paid at NADAC | Claim paid at NADAC pricing | Denied |
Paid at pharmacy submitted | Claim Paid at Submitted Usual and Customary cost | Denied |
Paid at SD | Claim Paid at Submitted Usual and Customary cost | Denied |
Paid at SM | Claim Paid at the Contracted Rate | Denied |
Paid at U&C | Claim Paid at Submitted Usual and Customary cost | Denied |
Paid at WAC | Claim paid at WAC pricing | Denied |
Paid at zero | Non MAC Claim | Denied |
Pending Review | Appeal is under review | Denied |
Previous Change | MAC price increased | Denied |
Provider Reimbursed >= Provided Submitted | No Change | Denied |
Too Old | Appeal exceeds allowable submission period | Denied |
Unknown BIN | Claim could not be found within Optum given the supplied criteria. | Denied |
Unknown Date of Service | Claim could not be found within Optum given the supplied criteria. | Denied |
Unknown NCDPDId | Claim could not be found within Optum given the supplied criteria. | Denied |
Unknown NDC | Claim could not be found within Optum given the supplied criteria. | Denied |
Unknown RxNumber | Claim could not be found within Optum given the supplied criteria. | Denied |
WAC | Claim paid at WAC pricing | Denied |