Submit MAC Appeal | MeridianRx

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Submit MAC Appeal

MAC Appeal Status

Submit Medical Pharmacy Claim Dispute

Documents & Forms

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Maximum Allowable Cost (MAC) Appeal

For multiple pricing appeals, download the Pricing Appeal Template

Pharmacy Information

NCPDP *

Date of Claim (MM/DD/YYYY) *

Rx # *

Claim #

Pharmacy Name

Drug Information

NDC *

Labeler

Label Name

Pharmacy Cost ($) *

Contact Information

Contact Name *

Email Address *

Phone Number *

Fax Number

Additional Comments

*Indicates required field