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PUTT Blog | Guest Post: The Story of Tennessee’s MAC Law — and Why It Matters Now

  • Writer: PUTT
    PUTT
  • Aug 29
  • 3 min read

Author: Kayla Copeland


At the heart of Tennessee’s PBM reforms is the Maximum Allowable Cost (MAC) law. A MAC is the reimbursement cap a Pharmacy Benefit Manager (PBM) sets for a generic or multi-source medication. Tennessee law requires PBMs to ensure that any drug on a MAC list is generally available from national or regional wholesalers at or below the reimbursement price. Pharmacies must also be reimbursed no less than their actual acquisition cost (AAC) of the medication — the true price they pay to purchase it — plus a professional dispensing fee. If a PBM sets a reimbursement that falls below AAC or fails to include the proper dispensing fee, the pharmacy is entitled to file an appeal.


Tennessee began this work in 2014 with early MAC regulations, but it was Public Chapter 569 (2021) and Public Chapter 1070 (2022) that transformed PBM oversight into enforceable law. Championed by Governor Bill Lee, Lt. Gov. Randy McNally, Speaker Cameron Sexton, and strongly supported by the Tennessee Pharmacists Association (TPA), these laws mandated PBM transparency, timely removal of drugs no longer available, proper reimbursement, and the creation of a clear appeal process under the oversight of the Tennessee Department of Commerce and Insurance (TDCI). In 2023, updated rules were formally adopted, strengthening enforcement and aiming to level the playing field between PBMs and pharmacies.


Importantly, Tennessee has also contracted with Myers and Stauffer to handle external appeals. This means that when a PBM denies, delays, or ignores an appeal, it is not the end of the road. Pharmacies can escalate unresolved disputes to Myers and Stauffer, giving them another soldier in the fight for fair reimbursement. External appeals provide pharmacies with an independent review, ensuring PBMs cannot simply close the door on claims without accountability.


In addition, pharmacies can file PBM complaints directly with TDCI if they believe a PBM is in direct violation of state law. After working closely with TDCI myself over the past few years, I can say with confidence that every complaint submitted is reviewed thoroughly and with pharmacies’ best interests in mind. Proof of this came earlier this year, when the department acted on multiple complaints (including those from my own pharmacy and others across the state) and issued a $250,000 civil penalty order against Express Scripts (ESI). While $250,000 may only be a drop in the bucket for a corporation like ESI, imagine the impact if every single independent and non-chain pharmacy in Tennessee filed accurate, well-documented complaints. The cumulative effect would be undeniable.


Challenges Pharmacies Still Face Under Tennessee’s PBM Law


  • Repetitive Appeals for the Same NDC – Pharmacies often must refile appeals month after month, even on the same refill, because PBMs don’t automatically correct reimbursements forward.

  • Strict Seven-Business-Day Deadline – Appeals must be submitted within 7 business days of the claim’s adjudication, leaving little margin for error or staffing shortages.

  • Multiple PBM Platforms – Each PBM has its own portal, logins, and formats, adding unnecessary inefficiency.

  • Complex Data Tracking – Valid appeals require invoices, claim data, dispensing records, and acquisition cost documentation — pulling multiple data sources together accurately.

  • Workflow Strain – Appeals are often an “add-on” task to an already strained team, instead of a streamlined workflow.

  • Vague or Shifting PBM Responses – PBMs issue unclear denials, forcing pharmacies into repeated cycles of resubmission.


Why It Matters


These pitfalls are not accidents. They are friction points PBMs exploit to wear pharmacies down. By design, they make the process so time-consuming and confusing that pharmacies often give up. That’s why consistent appeals and complaints are critical: every action taken strengthens enforcement, builds a record of PBM violations, and keeps the law alive in practice.


The path forward is clear: pharmacies must leverage every tool — MAC appeals, external reviews with Myers and Stauffer, and formal TDCI complaints — to hold PBMs accountable. Each step taken reinforces the law’s value and ensures PBMs are forced to comply. Far from being optional, this process is essential to protecting pharmacies, their patients, and the future of fair reimbursement in Tennessee.


Our Mission — LJA Consulting


At LJA Consulting, our mission is to close the gap between laws on paper and what happens in practice. We’ve built tools like the M.O.M. Manual (MAC Operational Manual) and hands-on training resources to help pharmacies identify eligible claims, submit airtight appeals, and enforce their rights under Tennessee’s PBM laws. Too often, laws sit idle because no one shows pharmacies how to use them. That’s where we step in — giving pharmacies the knowledge, workflow support, and confidence to hold PBMs accountable.


📩 Contact: Kayla Copeland — Founder, LJA Consulting🌐 Website: LJAConsultingMAC.com📧 Email: kcopelandrx@gmail.com


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