South Dakota Maximum Allowable Cost (MAC) program




MAC Pricing Appeal Form can be emailed to: MAC@optum.com

State Maximum Allowable Cost list


Effective date List
05-01-2020 Download
04-01-2020 Download
03-01-2020 Download
02-01-2020 Download
01-01-2020 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.

Appeals must be submitted using the approved OptumRx spreadsheet available above via the MAC Pricing Appeal Form button. Any other form of appeal submission will not be accepted for review.

Please submit all Appeals to MAC@optum.com. Submit a claim only once, duplicate claims will NOT be reviewed.  If e-mail is not an option, please fax completed Appeals form to 1-866-576-1656.

Please submit a claim only once, duplicate claims will NOT be reviewed.

MAC Appeal Detail must be filled out completely unless noted as "Optional". Submissions with missing information will be Invalid and excluded from review.

Purchase Price of Drug from primary wholesaler may be required. Invoice may be requested if additional information is required.

All reviews of any individual claim from a pharmacy are final and will NOT be reviewed again.

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.

Common Formatting Errors

Resolution Responses and definitions:

Action: Definitions:

Increase

MAC price increased

OK

Appeal denied. MAC price accurate

Non-CTRx

Claim could not be found within Optum given the supplied criteria.

Non-OPTRx

Claim could not be found within Optum given the supplied criteria.

Duplicate Appeal

Duplicate Appeal Submission

Not found

Claim could not be found within Optum given the supplied criteria.

FUL

Claim Paid at Federal Upper Limit

No Change

Appeal denied. MAC price accurate

Previous Change

MAC price increased

Non Paid Claim

Rejected / X (Reversed) /Claim Reversed. Appeal as submitted is for a reversed or rejected claim. Can only appeal paid claims.

Submitted/SD

Claim Paid at Submitted Usual and Customary cost

Too Old

Appeal exceeds allowable submission period

U&C

Claim Paid at Submitted Usual and Customary cost

Pending Review

Pending Review

WAC

Claim paid at WAC pricing

PatPay

Non MAC Claim

ZERO

Non MAC Claim

CLIENT MAC

Contact client to review claim

Claim Paid according to effective rate contracted

Claim Paid at the Contracted Rate

PLAN MAC

Claim Paid at the Contracted Rate

NADAC

Claim paid at NADAC pricing