For Consumers

Review of small pharmacy reimbursement appeals initial orders

Beginning July 1, 2017, small pharmacies can appeal a pharmacy benefit manager (PBM)’s decision (first-tier appeal) related to reimbursement for a drug to the Office of the Insurance Commissioner (OIC). The OIC will review the decision and issue an initial order. RCW 19.340.100(6) (leg.wa.gov)

If the small pharmacy or PBM is dissatisfied with the initial order, either party can request review of that order by filing a petition for review with the OIC Hearings Unit. WAC 284-180-430 (leg.wa.gov)

How to request review

Complete the Petition for Review of Initial Order (PDF, 1.3MB)

Completing your petition

  • Give the reason(s) you are requesting a review
  • You must file a copy of the initial order and any evidence or documents you want the reviewing officer to consider
  • Serve the petition for review on all parties (required). Service can be made according to the methods provided in WAC 284-180-440(2) (leg.wa.gov) including email, mail or fax. 
  • File within 21 days after the initial order is served
  • After completing the petition, email it to the Hearings Unit. (It cannot be filed via the OIC online portal). You can also deliver, mail or fax your petition to:

Hearings Unit
Office of the Insurance Commissioner

Fax:
360-664-2782

Mailing address:
P.O. Box 40255
Olympia, WA 98504-0255

Street address:
5500 Capitol Blvd. SE
Tumwater, WA 98501

Responding to the petition for review

If you are not the party requesting review, you can file a response and any relevant evidence or documents to be considered by the reviewing officer. Email the response and relevant documents to the Hearings Unit within seven days of receipt of the petition for review, and serve them on all other parties listed on the petition for review.  

How the review is conducted

A reviewing officer, appointed by the commissioner, will review and decide your case. The reviewing officer considers the following evidence (although these need not be the exclusive basis for the decision): 

  1. The initial order,
  2. The record from the appeal, including the recording of any hearing held in the case, and
  3.  Any records or documents submitted to the reviewing officer.

The reviewing officer may request additional evidence from a party. The party has seven days after service of the request to provide the evidence to the reviewing officer and to the other parties.

In most cases, the reviewing officer decides the case by reviewing the records and documents received. However, the reviewing officer may decide that oral testimony is needed and will schedule a time for both parties to present that testimony by telephone.

When is a decision made?

The reviewing officer will make a decision and issue a final order within 20 days after receipt of the petition for review. If the reviewing officer does not issue a final order, the petition for review is deemed denied and the initial order becomes the final order. RCW 34.05.491(5) (leg.wa.gov).

Where can I view petitions for review and final orders?

Petitions for review and final orders are available through the OIC’s consumer toolkit. You can search by:

  •  Name or order number (click the “Orders” tab) and
  •  Company (click the “Agency and Company Lookup” tab)