Horizon NJ Health Maximum Allowable Cost (MAC) Appeal

Horizon NJ Health

1700 American Blvd.

Pennington, NJ 08534

horizonNJhealth.com

Products and policies provided by Horizon NJ Health and services provided by Horizon Blue Cross Blue Shield of New Jersey, each an independent licensee of the Blue Cross and Blue Shield Association. Communications may be

issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all of its companies. EC00781

Horizon NJ Health Maximum Allowable Cost (MAC) Appeal

Pharmacy providers MUST use this form to appeal changes in Maximum Allowable Cost (MAC) pricing. MAC pricing appeals MUST be submitted within 14 days of the

claim’s date of service. Any inquiry submitted after 14 days will not be reviewed.

NOTE: ALL FIELDS MARKED WITH AN ASTERISK (*) MUST BE COMPLETED FOR PROPER SUBMISSION OF THIS FORM

Pharmacy Provider Information

*Pharmacy Name

*Pharmacy NPI *Primary Wholesaler

*Contact Person Secondary Wholesaler

*Pharmacy Phone

*E-mail address

Drug Information: Please enter information for one (1) drug per submitted form

*Drug Name

*National Drug Code (NDC) (e.g. 12345-0123-98)

*NOTE: THE NDC SUBMITTED IN THE RX CLAIM MUST MATCH THE NDC SUBMITTED ON THE WHOLESALER INVOICE*

Provider Cost Information (Circle One)

*Cost Per Package * Has there been a recent increase in acquisition cost? Y/N

*Package Size * Are there availability issues? Y/N

*Date of Purchase * Is there a date provided by the manufacturer that the issue will be resolved?* Y/N If yes, date:

Claim Information

*RX # * *

*Dispense Date *

Quantity Dispensed

Dispensing Fee

Total Reimbursement

Please fax this form to 1-973-522-2965 Attn: Pharmacy Network Management or e-mail: [email protected]. Once complete information

is received, we will evaluate your inquiry and respond within 14 days. For questions or to check on the status of an inquiry, please contact us by phone at 1-800-682-

9094 x53110 or x53111.

*

NOTE: A copy of the wholesaler invoice is REQUIRED. Claims will not be reviewed until the wholesaler invoice is received.*