Does Your PSAO Already Handle Your MAC Appeals? How to Tell What You’re Actually Getting

A Pharmacy Services Administrative Organization (PSAO) negotiates and administers PBM contracts on behalf of independent pharmacies that would otherwise have little leverage on their own. Roughly 83% of independent pharmacies contract with one. A PSAO typically handles network contracting, central pay and reconciliation, a help desk, and — relevant here — some level of reimbursement appeals.

One structural fact worth knowing: many of the largest PSAOs are owned by drug wholesalers. That isn’t inherently a problem, but it does mean your appeals advocate and your supplier can sit under the same corporate roof — a reason to understand exactly what your PSAO does and doesn’t pursue on your behalf.

When a PSAO says it handles MAC appeals, that most often means it submits appeals through the PBM’s own appeals channel, frequently in batches, referencing the PBM’s MAC list and methodology. That’s genuinely useful work. But notice the reference point: the appeal is generally framed against the PBM’s own pricing, not against an independent acquisition-cost benchmark like NADAC.

The distinction matters because the two can disagree (see NADAC vs. MAC). An appeal that asks “does this match the PBM’s list?” is a different question from “is this below what the drug costs to buy?” A claim can pass the first test and fail the second — and the second is where your margin actually leaks.

Here’s the gap in plain terms:

• A PSAO appeal usually disputes claims against the PBM’s MAC list.
• An independent check benchmarks every generic against NADAC, the public federal acquisition cost.
• Claims that are below NADAC but not obviously off the PBM’s own list can fall between those two approaches — flagged by neither.

None of this means your PSAO is failing you. PSAO practices vary widely, and some do benchmark aggressively. The point is that you usually can’t tell from the outside, and the difference is measured in real dollars per fill.

It’s also worth being honest about how hard appeals are even when filed well. Washington State’s transparency data showed pharmacies filing roughly 145 appeals per day from 2018–2020, with about 99.3% denied by PBMs. That’s not an argument against appealing — it’s an argument for benchmarking against NADAC, filing the claims most likely to win, and documenting each one with per-unit acquisition cost. Volume without documentation is how you end up in that 99.3%.

You don’t need to switch anything to get clarity. Ask your PSAO these, and the answers will tell you whether there’s a gap worth closing:

1. Do you benchmark my generic reimbursements against NADAC, or only against the PBM’s own MAC list?
2. Which PBMs and which claims do you actually appeal — all below-cost claims, or a subset?
3. Do you appeal per claim with documentation, or only flag list-level discrepancies?
4. Do you send me the outcomes — what was appealed, what was recovered, what was denied?
5. What is your win rate, and how is it measured?
6. Do you charge for appeals, or keep a share of recoveries?

If the answer to #1 is “the PBM’s MAC list,” that’s the gap. If you can’t get a clear answer to #4, you have no way of knowing what’s being left on the table.

The fastest way to find out whether NADAC-based gaps exist in your book is to look at your own data:

1. Start with your top generics by volume.
2. Compare per-unit reimbursement to NADAC for the same NDC and date.
3. Tally the gaps and note which payers recur.

You can see the below-NADAC pattern for your state in our public explorer with no login, and if you want it run across your own fills automatically — benchmarked against NADAC, with the appeal letters drafted — that’s what MarkupRx does, independently of your PSAO. It’s meant to sit alongside what your PSAO already does, not replace it. (For the mechanics, see how a MAC appeal actually works.)