Pharmacy services

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 form

MAC 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
09-01-2024	Download
08-01-2024	Download
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.

Common Formatting Errors

• 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