MAC Appeal Submission Form

To submit your MAC appeal, complete the following fields carefully and accurately. You will also need to include a scanned copy of your wholesaler invoice for cost verification. MAC appeals older than 14 days cannot be accepted.

Pharmacy Information

Pharmacy Name
Contact Name
Contact Email
Contact Phone
Contact Fax

Patient Information

Patient First Name
Patient Last Name
Date of Birth

Prescription Information

BIN Number
Group Number
Rx Number
Date of Service
Member ID
Claim Authorization #

Cost and Price

Usual and Customary Price
Pharmacy Acqusition Cost
Patients Co-Pay Amount
Amount Paid by Third Party
Reimbursed to Pharmacy

Attach Wholesaler Invoice

Please scan and attach your wholesaler invoice.
NOTE: Black out any drug pricing that is not related to this MAC Appeal. See Example.

Please upload a PDF file, some other file types may not send correctly.