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Act 169 of 2016

 

What does Act 169 of 2016 do?

  • Requires Pharmacy Benefit Managers (PBMs) to register with the Pennsylvania Insurance Department 
  • Provides for greater transparency in the establishment and management of multiple source generic lists to pharmacies
  • Provides for uniform and fair standards in the auditing of pharmacy claims
  • Rebalances PACE reimbursement to National Average Drug Acquisition Cost (NADAC) + a $13 professional dispensing fee or Wholesale Acquisition Cost (WAC) +3.2% (when NADAC is not available)

Click here to view a detailed summary of the key provisions of Act 169 of 2016.

 

Click here to view of the full text of Act 169 of 2016.

 

 

Implementation

  • MAC Appeals: Act 169 of 2016 provides increased transparency around the development and maintenance of Maximum Allowable Cost (MAC) lists. Further, the law provides uniform provisions for pharmacies to appeal prices on MAC lists. Below are the steps to follow for appealing:

1. Submit an official appeal to the PBM (below are links to appeal forms for the major PBMs in Pennsylvania).

 

- AetnaClick here for an appeal form that should be completed and submitted by email to AetnaMedicareMACAdmin@aetna.com

 

- Argus Health Systems: Click here for an appeal form that should be completed and submitted by email to MACInquires@argushealth.com

 

- Cigna: Click here for an appeal form that should be completed and submitted by email to MACInquiry@Cigna.com

 

- CVS Caremark: Click here for an appeal form that should be completed and submitted by email to MACPRICE@CVSCAREMARK.COM

 

- Medicare Part D: Submit Medicare Part D complaints by email to PartDComplaints_RO3@cms.hhs.gov

 

- Optum Rx: Click here for an appeal form that should be completed and submitted by fax to 1-866-285-8652

 

2. If the appeal is denied, click here to file a complaint with the Pennsylvania Department of Insurance.

 

 

 

 

For questions, contact Jeff Stuby.

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