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Maximum Allowable Charge (MAC) Review for Pharmacies


A pharmacy contracted to provide certain medical supplies and injectables may ask HMSA to review specific maximum allowable charges (MACs) by completing a Pharmacy Maximum Allowable Charge Review form. Please be aware that this process is for participating pharmacies that are contracted to provide certain medical supplies and injectables.


This process is not meant to initiate a review of MACs related to generic drugs on the quarterly Generic Drug list. For generic drug MAC reviews, refer to Maximum Allowable Charge Reviews.


The form must be submitted with a copy of the manufacturer's invoice for the service in question. If the written request or the manufacturer's invoice is missing, or if HMSA needs more information, the pharmacy will be notified and asked to provide the missing document and/or information.


Once all requested information is received, HMSA will analyze the request and communicate its decision after a determination is made. If HMSA determines that a change in the MAC is appropriate, adjustments to the MAC will be made prospectively and there will be no retroactive adjustments. HMSA's decision to review a specific MAC does not necessarily mean that the MAC will be adjusted.


Maximum Allowable Charge (MAC) Reviews for Pharmacies are not applicable to Medicare Advantage Plans.


To initiate a review, please fax the form and invoice to Provider Correspondence.


First Published:03/25/2008
Latest Revision:12/12/2017
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