PBM Reimbursement

Shortcut to PBM Complaint Form for Arkansas Insurance Department

Act 900 of 2015 is a law passed by the Arkansas legislature that requires PBMs to pay pharmacies reimbursements for generic drugs at or above the cost the pharmacy paid to acquire the drug. However, some PBMs are still paying below acquisition cost. Below is a list of steps to take if you find yourself dealing with a PBM that is paying below acquisition cost for generic drugs.

Step 1 – Read the details of state law Act 900

  • The PBM must Provide access to its Maximum Allowable Cost List to each pharmacy subject to the Maximum Allowable Cost List;
  • The PBM must update its Maximum Allowable Cost List on a timely basis, but in no event longer than seven (7) calendar days from an increase of ten percent (10%) or more in the pharmacy acquisition cost from sixty percent (60%) or more of the pharmaceutical wholesaler doing business in the state or a change in the methodology on which the Maximum Allowable Cost List is based or in the value of a variable involved in the methodology;
  • Provide a reasonable administrative appeal procedure to 4 allow pharmacies to challenge maximum allowable costs and reimbursements made 5 under a maximum allowable cost for a specific drug or drugs;
  • The pharmacy benefits manager shall respond to the challenge under subdivision (c)(4)(A)(i) of this section within seven (7) business days after receipt of the challenge.

If a challenge is under subdivision (c)(4)(A)(i) of the law, the pharmacy benefits manager shall within seven (7) business days after receipt of the challenge either: 

If the appeal is upheld: (to pay you above your cost)

(a) Make the change in the maximum allowable cost;
(b) Permit the challenging pharmacy or pharmacist to reverse and rebill the claim in question; and
(c) Provide the National Drug Code number that the increase or change is based on to the pharmacy or pharmacist; and
(d) Make the change under subdivision (c)(4)(C)(i)(a) of this section effective for each similarly situated pharmacy as defined by the payor subject to the Maximum Allowable Cost List;


If the appeal is denied, provide the 2 challenging pharmacy or pharmacist the National Drug Code number from and the 3 name of the national or regional pharmaceutical wholesalers operating in 4 Arkansas that have the drug currently in stock at a price below the Maximum 5 Allowable Cost List.;

Step 2 – file an appeal with the PBM for below cost MAC reimbursement.  The appeal would be with the PBM not the insurance company.

For instance, to appeal Arkansas Blue Cross Blue Shield or Ambetter claims (CVS Caremark), visit https://rxservices.cvscaremark.com

For Qualchoice (OptumRx), visit https://professionals.optumrx.com/resources/manuals-guides/appeals-submission-guide.html

Step 3 - Try to find out if the employer (and the plan) is fully insured (state law does apply) or self-insured (ERISA federal law means state law does not apply)

Examples of fully insured plans in Arkansas (not comprehensive):

Arkansas Works / “Obamacare” / Exchange Marketplace:
QualChoice / OptumRx
Bin: 005947

QualChoice / OptumRx
Bin:  005947
Group: QCA

Arkansas BCBS / CVS Caremark 
Bin: 004336
Group: Rx3956

Arkansas BCBS / CVS Caremark
Bin: 004336
Group: Rx3961

Ambetter (Centene) / CVS Caremark
Bin: 004336
Group: Rx5448

Commercial Fully Insured:
Arkansas BCBS / CVS Caremark
Bin:  004336
Group: Rx3963


Step 4 – Assuming the PBM does not comply within 7 days by either increasing the MAC fairly, or providing you with the NDC and name of wholesaler where you can purchase the drug less than the proposed reimbursement:

Educate them about the law, ACT 900 of 2015, and remind them that a violation of this section is a deceptive and unconscionable trade practice under § 4-88-101 et seq. This law was upheld in federal court by Judge Brian Miller in 2017.

At this point you have 3 options (Note that option 1 and 3 are not viable if it is a self insured plan protected by ERISA federal exemption from state law)

Step 5 - For future claims, a pharmacy or pharmacist may decline to provide the pharmacist services to a patient or pharmacy benefits manager if, as a result of a Maximum Allowable Cost List, a pharmacy or pharmacist is to be paid less than the pharmacy acquisition cost of the pharmacy providing pharmacist services.