1. Purpose:

To establish and implement a fair, transparent, and compliant process for managing appeals and grievances filed by pharmacies or beneficiaries, with a specific focus on MAC-related pricing disputes, as required under IC 27-1-24.5

2. Scope:

This policy applies to all internal PBM departments that handle provider (pharmacy) or member (beneficiary) complaints, appeals, and grievances related to claims adjudication, MAC pricing, benefit determinations, or any other service delivered by the PBM.

3. Definitions:

• Appeal: A formal request for review of a denied or disputed reimbursement or benefit.
• Grievance: Any expression or dissatisfaction regarding PBM services or operations not involving a claim denial or pricing.
• MAC(Maximum Allowable Cost): The maximum amount that a PBM will reimburse a pharmacy for a multi-source prescription drug. The means by which prompt review of maximum allowable cost list updates in a format that is readily available and accessible on the SevaRx website. If the website is not accessible to a pharmacist/pharmacy, SevaRx will work with them to ensure they get access to the information for MAC they require. As a base reference NADAC pricing will be the prevailing maximum allowable cost pricing.
• Contracted Pharmacy: A pharmacy that has entered into an agreement with the PBM to provide covered drugs
• Beneficiary (Member): An individual who is eligible to receive prescription drug benefits through the PBM plan sponsor.

4. General Principles:

• Appeals and Grievances must be handled in a timely, transparent and equitable manner
• Processes must be easily accessible to pharmacies and members.
• PBM shall maintain clear records of all appeals, grievances and outcomes
• Retaliation against any pharmacy or beneficiary for filing an appeal or grievance is strictly prohibited

5. MAC Appeal Process (Pharmacy-Initiated)

1. Eligibility for Appeal
   • A contracted pharmacy may appeal a MAC reimbursement if:
     • The reimbursement is less than the acquisition cost, or
     • The drug is not available from at least three wholesalers at or below the MAC price
2. Filing the Appeal
   • Must be filed within 60 days from the initial submission.
   • Must be submitted via the PBMs secure portal, email or fax
   • Required Information:
     • NDC Number of the drug
     • Date of Fill
     • Pharmacy’s acquisition cost with supporting invoices
     • Wholesaler information and dates
     • Pharmacy contact information
3. Internal Review and Determination:
   • PBM must complete a review and provide a written response within 7 business days.
   • If the appeal is upheld:
     • Reimbursement must be adjusted retroactively to the date of service
     • If applicable, the MAC list will be updated within 1 business day.
     • If applicable, the update to the MAC list will be adjusted for all pharmacies in the same network that filled a prescription for patients covered under the same health plan on the initial date of service the appealed drug was dispensed.
     • SevaRx will notify each pharmacy in the managed network that the MAC for the drug has been adjusted as a result of an upheld appeal.
     • SevaRx will adjust and allow for the appealing and contracted pharmacies in the network to reverse and resubmit adjust the drug product reimbursement for claims to reflect the adjusted MAC of the appealed drug product.
   • If denied, the PBM must:
     • Provide a specific reason for denial
     • Include sources used to determine the MAC price, including the national drug code number of the prescription drug that is available from a national or regional wholesaler operating in Indiana.
4. Right to Escalate
   • Pharmacies may escalate denied appeals to PBMs MAC review Committee for secondary review.
   • A final determination will be issued within 5 business days of escalation
5. Recordkeeping:
   • MAC appeal logs, outcomes and supporting documentation must be retained for at least 3 years.

6. Members Appeals and Grievances

1. Filing a Grievance or Appeal
   • Members may submit a grievance or appeal regarding:
     • Denied Claims
     • Coverage Limits
     • Customer Service Issues
     • Network Pharmacy Availability
     • Other dissatisfaction with PBM Services
2. Submission Methods
   • Accepted via:
     • Phone (with verbal attestation)
     • Written correspondence
     • Fax or email
3. Timeframes
   • Grievances: Must be acknowledged within 5 calendar days and resolved within 30 calendar days
   • Appeals: Must be resolved within 30 calendar days (expedited appeals must be resolved within 72 hours)
   • Member has 180 calendar days from the date of denial to file an appeal
4. Review Process
   1. PBM must assign appeals to a qualified clinical reviewer not involved in the original denial
   2. Member and Provider will be notified in writing of the outcome, including:
      • The reason for the decision
      • Any applicable benefits
      • The process for further appeal or external review, if applicable

7. Grievance Procedures (Pharmacy or Member-Initiated)

• Any pharmacy or member may file a grievance unrelated to claim reimbursement or MAC pricing
• PBM must log all grievances and respond within 15 business days
• If resolution requires more time, a written notice of extension must be provided

8. Appeals and Grievance Oversight

• PBM shall maintain and Appeals and Grievances Compliance Committee that:
  • Reviews trends quarterly
  • Identifies systemic issues
  • Implements correct action plans, if needed

9. Notifications and Reporting

• All appeal outcomes must be communicated in writing and stored in the pharmacy or members case file
• PBM shall submit annual reports to the DOI summarizing:
  • Number of appeals/grievances
  • Resolution timeframes
  • MAC pricing disputes and outcomes

10. Training

All relevant PBM staff must receive initial and annual training on MAC requirements and grievance protocols.

11. Confidentiality

All data, including appeal records and patient information must be protected under HIPAA and state confidentiality laws.