1. A. Submission requirements. A MAC appeal submission include:

   1. (1) fill date;
   2. (2) BIN number (six digits);
   3. (3) NCPDP (seven digits);
   4. (4) Rx number;
   5. (5) NDC 11 (11 digits);
   6. (6) drug name;
   7. (7) drug strength;
   8. (8) invoice price and net purchase price of drug (whole dollar with two decimal places);
   9. (9) total reimbursement (whole dollar with two decimal places);
   10. (10) reason for review;
   11. (11) any information required by contract; and
   12. (12) notes (optional).
2. B. No additional information required. A PBM shall not require or request additional information to process a MAC appeal but shall accept and consider any additional information provided in a MAC appeal submission.

[13.10.30.13 NMAC – Rp, 13.10.30.13 NMAC, 3/1/2022]