For Consumers

How a small pharmacy can appeal a reimbursement decision

Small pharmacy reimbursement appeals news

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.

Important dates:

  • 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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