One of the following people will review your appeal and issue an initial order:
- Our presiding officer
- An administrative law judge from the Office of Administrative Hearings (OAH)
You can submit an appeal after a PBM denies your reimbursement request or if you disagree with the PBM's decision.
You need to send us your appeal within 30 days of receiving the PBM's decision or within 30 days of the PBM's deadline for responding to the first-tier appeal.
To file an appeal, you also need to meet all the requirements below:
- You're a small pharmacy with no more than 15 retail locations.
- You filled the prescription in Washington state.
- You filled the prescription for a customer with a fully insured, non-ERISA plan.
- The prescription was for a multiple source drug(s).
- You completed the reimbursement process through your PBM.
- Within the past 30 days, you received a denial or a reimbursement you disagree with.
- The person submitting the appeal has the authority to file it under WAC 284-180-505.
The Small Pharmacy Appeals Program follows these laws and rules:
- RCW 48 is the State Insurance Code.
- WAC 284 contains rules for the insurance industry.
- WAC 284-180-505 contains rules for appeals from network pharmacies.
- RCW 34.05 is the State’s Administrative Procedure Act.
- WAC 10-08 contains procedures for administrative hearings.