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 either the OIC presiding officer or an administrative law judge from the Office of Administrative Hearings (OAH), and an initial order will be issued.
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 network pharmacy must file the petition for review with the commissioner within 30 days of receiving the PBM's decision or within 30 days of the deadline for the PBM's deadline for responding to the first tier appeal.
You can file an appeal with the OIC, if:
- It is filed by a small pharmacy that has no more than fifteen (15) 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 a multiple source drug(s);
- The small pharmacy has exhausted the reimbursement process through its PBM;
- The pharmacy has been issued a denial or an unsatisfactory reimbursement for the cost of the drug within the last 30 days; and
- It is filed by a person who has the authority, under WAC 284-180-505, to file the appeal
The Small Pharmacy Appeals Program is governed by the following Statutes and Regulations
RCW 48 is the State Insurance Code adopted by the State Legislature
WAC 284 contains additional regulations governing the business of insurance promulgated by the insurance commissioner
WAC 284-180-505 contains additional regulations governing the appeals process by network pharmacies
RCW 34.05 is the State’s Administrative Procedure Act
WAC 10-08 contains the model rules of procedures followed for administrative hearings