A small pharmacy can submit their reimbursement appeal to the Office of the Insurance Commissioner (OIC). The appeal will be reviewed and either stay with OIC or be transferred to the Office of Administrative Hearings (OAH).
What you will file
The small pharmacy will need to file the following in order to complete review of the petition for appeal:
- All documents that were provided to and by the Pharmacy Benefit Manager (PBM) as part of your original appeal invoice
- Invoice
- MAC List
- PBM Determination
- Other appeal support documents
These documents are required by WAC 284-180-520.
Contact the Hearings Unit if you have questions about the documentation required for submission.
File your petition
Fill out a petition for an appeal of a small pharmacy reimbursement decision.
You will not upload any documents at this time. After your online petition for appeal has been submitted, you will be contacted by either OIC or OAH with further instructions on how to upload the documents required for your appeal.
After you file your petition
The OIC or OAH will contact you with any further instructions, including a confirmation of receipt. The agency will also notify the PBM. The PBM will have an opportunity to respond and file documents for consideration.
The OIC presiding officer or an administrative law judge (ALJ) from the OAH will review your petition and the documentation provided by the small pharmacy and the PBM. They 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, unless the presiding officer or ALJ allows additional time. The presiding officer or ALJ may also decide to hear oral testimony from the parties by telephone, videoconference, or in person. Once the time for submission of documents has passed, the presiding officer or ALJ will review the submissions of both the small pharmacy and the PBM, then issue a decision.
The decision becomes final after 21 days.
This entire process takes 30 calendar days to complete. The clock starts once all appeal documents have been submitted.
If you are not satisfied with the initial decision from OIC or OAH, you may submit a petition for review within 21 days of service of the initial order. If you are still unsatisfied with the decision, you may be able to file an appeal in Superior Court.