Online Petition for Review Form
Please complete the online petition to request a review of the pharmacy benefit manager’s (PBM) decision. You will not attach or submit any documents at this time. After submitting the petition, you will be contacted by the OIC Hearings Unit or the Office of Administrative Hearings (OAH) with instructions on how to upload the required documentation. You will also have the option to print or save the confirmation page once your petition is submitted.
Please note: The appeal process officially begins only after all necessary documents have been received.