State Compliance

Maximum Allowable Cost (MAC)

To assure the Maximum Allowable Cost (MAC) list accurately reflects market pricing and the availability of generic medications, Optum utilizes multiple sources to determine MAC pricing. The sources include de-identified market pricing benchmark data such as AWP and WAC, wholesaler information on market availability, and pharmacy information from inquiries.

The following states have passed legislation requiring workers’ compensation pharmacy benefit managers (PBMs) to provide a process for pharmacies to make an inquiry about MAC pricing for a specific medication and to provide for an appeals process: Arizona, Arkansas, Delaware, Georgia, Idaho, Kentucky, Louisiana, Maine, Minnesota, Mississippi, Montana, New Mexico, New York, Oklahoma, and Vermont.

If you represent a pharmacy that would like to receive information regarding our MAC pricing for a specific medication, please complete the MAC Inquiry form, along with a signed non-disclosure agreement, and email the documents to MACresolution@optum.com.

If you represent a pharmacy that would like to file an appeal or otherwise dispute our MAC pricing for a specific medication, please complete the MAC Dispute form along with a signed non-disclosure agreement, and email the documents to MACresolution@optum.com.

In accordance with requirements established by certain states, call 1-855-264-8815 with questions regarding MAC pricing.

Links to the MAC Inquiry Form and MAC Dispute Form are located at the bottom of this page, as is a Non-Disclosure Agreement. If you have general questions regarding our MAC pricing, please email us at MACresolution@optum.com.

HIPAA Notice of Privacy Practices: To read more about our privacy practices regarding health and medical information under the Health Insurance Portability and Accountability Act (“HIPAA”), visit our Notice of Privacy Practices.

Non-Disclosure Agreement

Optum MAC Reimbursement Rate Dispute 2023

Optum MAC Reimbursement Rate Inquiry 2023

Kentucky

Step Therapy Law

In response to Kentucky Senate Bill 140 from 2022 (Acts Ch. 19), Optum Workers’ Compensation and Auto No-fault (Optum) notes that it has some standard point-of-sale adjudication processes in place with network pharmacies that may rely on certain step therapy recommendations. In doing so, Optum complies with relevant portions of amended KRS 304.17A-163. Optum processes workers’ compensation pharmacy transactions in Kentucky and complies with the medical treatment guidelines and pharmaceutical formulary as adopted by the Kentucky Department of Workers’ Claims.

Some of our insurer, self-insured employer and third-party administrator clients may also have custom step therapy protocols in place which differ from the Optum standard point-of-sale adjudication processes. Optum does not handle step therapy exception requests or appeals for our clients, and health care professionals should contact the responsible insurer, self-insured employer or third-party administrator for more information on their specific exception request or appeal processes. Given this, reporting for those exception requests or appeals is also outside of the scope of Optum services as a workers’ compensation PBM.

New York

Pharmacy network designation

Pursuant to the New York State Workers’ Compensation Law and Regulations of the New York State Workers’ Compensation Board (NYS-WCB), a carrier or self-insured employer may designate one or more independent pharmacies, pharmacy chain, or pharmacy benefit manager for injured workers to obtain outpatient prescription medications.

For New York injured workers you can use our Tmesys retail pharmacy network and home delivery to provide pharmacy services. To ensure full compliance, as required, Tmesys files information with the NYS-WCB on a regular basis. Additionally, you can send notifications for utilizing a network pharmacy for work-related injuries to your employees. This notification includes information about participating network pharmacies and a locator tool for the Tmesys network.

Under Board regulations, each pharmacy within the network is required to have a sufficient inventory so that it may service claimants without undue delay. Each designated pharmacy must also either be a remote pharmacy or be open for business hours that are regular and customary in the community.

More information on these pharmacy network programs, including specific regulatory compliance requirements, are contained in Chapter V of Title 12 NYCRR Subchapter M Part 440 of the New York Regulations.

Should you have any additional questions concerning this information, please contact us at:

Tmesys Retail Pharmacy Operations
Contact: Aisha Shelton OptumWC.Compliance@optum.com

Texas

Voluntary/Informal pharmacy network

Tmesys

Pursuant to Texas Voluntary/Informal pharmacy network notification requirements – Texas Labor Code 408.0281(d) – this website contains information pertaining to clients (carriers, third-party administrators and self-insured employers) who have contractual arrangements to access the Tmesys pharmacy network for the provision of pharmacy services at rates inconsistent with the Texas workers’ compensation pharmacy fee guidelines.

Pharmacy transactions processed through our networks are submitted directly to Tmesys and are paid directly by Tmesys to the provider at the specific rates established in the contract between Tmesys and the provider. Tmesys does not sell, lease, transfer, or convey its specific contractual fee arrangement rates with network providers to any other entity.

As a pharmacy provider within the Tmesys Texas network, initial notification of this web address and associated information is provided to you, and revised communications and updates are sent as required by the law. Tmesys will update required compliance information posted on this website, and we urge you to refer to this information frequently.

Should you have any additional questions concerning this information, please contact:

Tmesys Retail Pharmacy Operations
Contact: Aisha Shelton OptumWC.Compliance@optum.com

Home Health and Durable Medical Equipment

Pursuant to Texas Labor Code § 408.0284, et seq., please find this web page as our notice to Texas providers about our workers’ compensation informal network for home health and durable medical equipment (DME) in the state of Texas, as required under the code section(s).

Should you have any additional questions concerning this information, please contact:

ANCILLARY SERVICES
1-800-777-3574
OptumWC.Ancillary@optum.com

Third-party Administrator

Pursuant to specific direction from the Texas Department of Insurance (TDI), Optum has been licensed as an “administrator” as that term is specifically defined under Texas Insurance Code Section 4151.001. This designation requires certain compliance steps to be taken by both Optum and our clients, including but not limited to the following:

Written agreements between Optum and our carrier, self-insured employer, and third-party administrator clients
Semi-annual reviews and bi-annual on-site audits of Helios by our carrier and self-insured employer clients for which Optum, in the aggregate, administers benefits in Texas for more than 100 injured employees
Notice to each insured/injured employee of Helios' identity and the relationship between Optum, client, and insured/injured employee
Compliance with proper notification and other reporting requirements to TDI by Optum

The following are links to additional relevant information pertaining to compliance requirements:

Optum Standard Texas Administrator Agreement

TDI TPA Licensing Information

Texas Insurance Code Chapter 4151