How a small pharmacy can appeal a reimbursement decision
Beginning July 1, 2017, small pharmacies can submit an appeal to the Office of the Insurance Commissioner (OIC) regarding a pharmacy benefit manager’s decision (first-tier appeal) related to reimbursement for a drug. The drug must be subject to predetermined reimbursement costs for multisource generic drugs.
What is a small pharmacy?
A small pharmacy has less than 15 retail outlets within the state of Washington under its corporate umbrella (WAC 284-180-420 (1)(e) (leg.wa.gov).
Will the OIC hear any appeal between a small pharmacy and pharmacy benefit manager?
The OIC hears only appeals that meet the requirements of WAC 284-180-420 (leg.wa.gov):
- The pharmacy benefit manager's decision must have denied the network pharmacy's first-tier appeal, or the network pharmacy must be unsatisfied with the outcome of its appeal to the pharmacy benefit manager.
- The appeal is regarding reimbursement for a drug subject to predetermined reimbursement costs for multisource generic drugs.
- The network pharmacy must file the petition for review with the commissioner within 30 days of receiving the pharmacy benefit manager's decision.
- The network pharmacy making the appeal must have fewer than 15 retail outlets under its corporate umbrella within the state of Washington.
- Small pharmacy training: May through June 2017
- Pharmacy benefit manager training: May through June 2017
- The OIC begins accepting appeals: July 1, 2017
How do I learn more about filing a small pharmacy reimbursement appeal?
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