The Issues
Clear, sourced explanations of the issues the coalition works on — written to inform, with every claim attributed. Where views differ, we set out the other side and our response.
A MAC appeal is the formal process by which a pharmacy challenges a pharmacy benefit manager's reimbursement for a generic drug priced below what the pharmacy paid to acquire it. Most states with PBM laws now require PBMs to offer an appeals procedure with a defined filing window, but the deadline, the evidence required, and what the PBM must do if the appeal succeeds vary by state and by PBM.
NADAC — the National Average Drug Acquisition Cost — is a benchmark, published by the Centers for Medicare & Medicaid Services (CMS), of what retail community pharmacies actually pay to buy a drug, based on a voluntary monthly survey of pharmacies. A growing number of states use NADAC plus a professional dispensing fee as the reimbursement floor a PBM must meet, because it is tied to real acquisition cost rather than to a price the PBM itself sets.