MAC Pricing (Maximum Allowable Cost)

What Is MAC Pricing?

Maximum allowable cost (MAC) is an ingredient-cost reimbursement limit used by a payer, PBM, or state Medicaid program, commonly for generic and multisource drugs. MAC is a payment methodology, not the drug's purchase price or the patient's copay.

How It Works

A MAC amount below acquisition cost can create a loss for the pharmacy. It does not authorize false product selection codes or dispensing a different product without meeting legal and prescription requirements.

MAC vs. Other Benchmarks

There is no single national formula that every payer uses. A drug absent from one MAC list does not automatically receive AWP reimbursement. DAW 1 records a prescriber's substitution restriction; it does not automatically bypass a payer's MAC, formulary, or prior authorization requirements.

Technician Responsibilities

• Submit the dispensed NDC, quantity, day supply, and DAW code accurately.
• Refer underpayment or coverage concerns to the pharmacist and billing staff.
• Follow the plan's appeal and documentation procedures.
• Distinguish pharmacy reimbursement from the patient's cost sharing.

Exam Alert

MAC lists can be established by PBMs and by state Medicaid programs. Identify the payer and applicable contract before applying a formula or assuming brand coverage.

Source: CMS Medicaid reimbursement information by state, September 2026.