How a small pharmacy can appeal a reimbursement decision
A small pharmacy located in Washington state can submit an appeal to the Office of the Insurance Commissioner (OIC) to review a Pharmacy Benefit Manager's (PBM) decision regarding the reimbursement of a drug's cost. This appeal will be reviewed by an administrative law judge at the Office of Administrative Hearings (OAH) (oah.wa.gov).
An appeal may be filed after the small pharmacy has made a reimbursement request with the PBM and received either a denied claim or is unsatisfied with the PBM's determination.
You can file a small pharmacy appeal on the OIC’s website if the following is true:
- It is filed by a small pharmacy that has up to fourteen (14) retail outlets
- The prescription was filled in Washington state
- The prescription was filled for a customer covered by a fully insured, non-ERISA plan
- The prescription was for generic, multi-source drugs
- The small pharmacy has exhausted the reimbursement process through its PBM
- The pharmacy has been issued a denial or an unsatisfactory reimbursement
- If for the cost of the drug
- It is filed by a person who has the authority, under WAC 284-180-410 (leg.wa.gov), to file the appeal
To start the small pharmacy reimbursement appeal process:
Use the link below to fill out the online petition for an appeal. You will not upload any documents at this time. After your online petition for appeal has been submitted, you will be contacted by the Office of Administrative Hearings with further instructions on how to upload the documents required for your appeal.
What you will file at the Office of Administrative Hearings
The Office of Administrative Hearings will need the small pharmacy to file the following in order to complete review of the petition for appeal:
- All documents that were provided to and by the PBM as part of your original appeal invoice
- MAC List
- PBM Determination
- Other appeal support documents
What happens now?
After you fill out and submit the online petition for appeal, the Office of Administrative Hearings will contact you with further instructions, including how to upload/file the documents necessary to complete the review. The Office of Administrative Hearings will also notify the PBM. The PBM will have an opportunity to respond and file documents for consideration.
The administrative law judge assigned to your appeal will review the documentation provided by the small pharmacy and the PBM. The administrative law judge may request additional information and/or documentation in order to fully review your appeal. If additional documentation is requested, you will have 7 days to provide the requested information to the administrative law judge. Once the time for submission of documents has passed, the judge will review the submissions of both the small pharmacy and the PBM and then issue a decision.
If you are not satisfied with the initial decision, you may request a review of the judge's decision with the OIC.
How do I request a review of my initial decision?
Find more information on how to request a review.
- Look up prior Small Pharmacy Reimbursement Appeal decisions. If you need an order number for the search, please contact the OIC's Administrative Hearings office.
Templates for use by Small Pharmacy Benefit Managers: