How to Manage MAC Appeals in Pharmacy Marketplace

Overview

The PBM Appeals feature helps your pharmacy identify prescription claims where you were reimbursed below your acquisition cost (what we call "underwater" claims) and manage the full appeal workflow from submission through resolution. Pharmacy Marketplace automatically surfaces these opportunities for you, so you're not spending hours manually auditing claims.

This guide walks you through the complete appeals process from start to finish.

Step 1: Review Your Appeal Opportunities

When you log in, navigate to PBM Appeals in the main menu. Here you'll see your Opportunities; a list of claims identified as potentially eligible for appeal, ranked and filtered to help you prioritize.

Each opportunity displays the claim's drug name, fill date, PBM, amount paid, and the estimated amount you may be able to recover. Use the quick filters at the top to focus on what matters most:

• New eligible appeals: claims ready to be submitted
• Due today: claims with an appeal deadline today
• In progress: appeals currently in flight

You can also search by Rx number or BIN, filter by PBM, and sort by amount lost to prioritize your highest-value opportunities.

Step 2: Submit an Initial Appeal

Click on any New opportunity to open its detail view. Before submitting to the PBM portal, review the pre-populated appeal information, including acquisition cost, quantity dispensed, and pricing comparison, and confirm it looks accurate.

Important: Each state has a filing deadline from the date of fill, so don't delay. Appeals filed after the deadline are automatically ineligible.

To submit:

1. Use the claim details shown in Pharmacy Marketplace to complete the appeal in your PBM's portal (CVS Caremark, Express Scripts, OptumRx, etc.)
2. Return to Pharmacy Marketplace and click Mark Appeal as Submitted
3. The opportunity status will update to Submitted

Step 3: Track and Respond to PBM Decisions

After submission, the PBM has a set number of business days to respond. While you wait, Pharmacy Marketplace keeps the opportunity in your In Progress view so nothing slips through the cracks.

Once you receive a response from the PBM, return to the opportunity and record the outcome by clicking Record PBM Response. You'll choose from:

• Approved: the PBM accepted the appeal
• Rejected: the PBM denied the appeal
• Pending More Information: the PBM needs additional documentation from you
• No Response: the deadline passed with no reply

Step 4: Provide Additional Information (If Requested)

If the PBM requests more information, the opportunity status changes to Pending More Information. Click Submit More Info and follow the PBM's instructions; this typically involves uploading a wholesaler invoice for the drug on or before the fill date.

You have a limited window to respond (often 5 business days), so address these promptly. Upload supporting documents directly to the opportunity to keep everything in one place.

Step 5: Handle a Rejection — Submit an External Appeal

If your initial appeal is rejected (or the PBM doesn't respond), you may have the right to escalate to an external appeal with your state's regulatory authority. The opportunity status will show Rejected, and you'll see a Submit External Appeal button.

You typically have between 3-30 days (the exact timeline depends on your state) from the date of the PBM's final decision to file an external appeal. Pharmacy Marketplace will track this deadline for you.

Step 6: Record Final Outcomes

When an appeal is Approved, wait for the adjustment to process, then click Reverse, Rebill & Record to log the final adjudicated amount. Recording both the original paid amount and the final amount is important for reconciliation and for tracking your recovered revenue over time.

Once everything is documented, mark the opportunity as Completed.