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Revised January, 2010 CONFIDENTIAL AND PROPRIETARY - page 19 / 31





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Walgreens Health Initiatives’ MAC Pricing Appeal Process

If your pharmacy holds an independent contract with Walgreens Health Initiatives, you may appeal directly to Walgreens Health Initiatives. If you are part of a chain, franchise, PSAO/TPA, please direct your appeals to your corporate office, PSAO/TPA.

Criteria for MAC Appeal

  • 1.

    Claim was paid based on maximum allowable cost (MAC) pricing

  • 2.

    Total paid (Walgreens Health Initiatives’ payment plus patient copay plus

dispensing fee) must be less than the acquisition cost

Documentation required for MAC Appeal

Claim Information: Rx number, NCPDP number and pharmacy name, Rx date, drug name, drug NDC Contact name and contact information for individual appealing Copy of invoice for specific NDC you are appealing

If MAC appeals are being sent by chains or PSAOs/TPAs, it is expected that they will be screened by the chain or PSAO/TPA PRIOR to being forwarded to Walgreens Health Initiatives. Claims reimbursed at contracted rates based on AWP discounts, usual and customary or ingredient costs submitted by the pharmacies do NOT qualify for review or appeal unless it is suspected that our claims adjudication system processed incorrectly.

MAC appeals can be requested at Provider.Relations@walgreens.com group email. In the subject, please put REQUESTING MAC APPEAL FORM.

Long-Term Care

Some pharmacies have executed a long-term care pharmacy (LTC) agreement with Walgreens Health Initiatives. Please see the guidance below specific to LTC pharmacies. For further guidance please also see the NCPDP Guidelines, located at www.ncpdp.org.

LTC Signature Logs

Walgreens Health Initiatives recognizes that LTC pharmacies have different practice requirements than community retail pharmacies. While individual patient signatures are not practical for LTC pharmacies, Walgreens Health Initiatives expects there to be a signed record for ALL medications delivered to a facility by a pharmacy. These logs can be signed by facility staff members with the authority to receive these medications. These logs should be made available to Walgreens Health Initiatives as requested during onsite audits or from desktop audits. Failure to produce a signed log may result in a charge back to the pharmacy.

Walgreens Health Initiatives – Pharmacy Manual


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