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) regarding a Pharmacy Benefit Manager's (PBM) decision regarding the reimbursement of a drug's cost.
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.
The OIC can accept an appeal if:
- 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; and
- It is filed by a person who has the authority, under WAC 284-180-410 (leg.wa.gov) , to file the appeal.
Before you begin
The small pharmacy should have all of your documents and information ready to upload including:
- 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
A written petition will be generated by the online system when you have submitted your appeal to the OIC. The petition is an official document that becomes a part of your request.
I'm ready to file an appeal.
What Happens now?
Once you have filed your appeal you will receive an email notification that your appeal has been received. If this is your first appeal with the OIC, you will also receive your Resolution Center user account information. The Resolution Center is where you can log in to monitor your appeal, upload additional information or responses, and request additional appeals.
Once the appeal has been accepted, the PBM will be notified and given an opportunity to respond.
The OIC will review the documentation provided by the small pharmacy and the PBM. The OIC may request additional information and/or documentation in order to fully review your appeal. If additional documentation is requested, you will have seven (7) days to provide the requested information to us.
A decision should be made within 30 days from receipt of the appeal
If you are not satisfied with the initial decision you may request a review with the OIC.
How do I request a review of my initial decision?
You can find more information on how to request a review here.