Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-180 - Health care benefit managers › Subchapter E - APPEALS › Section 284-180-520 - Appeals by network pharmacies to the commissioner

Current through Register Vol. 24-14, July 15, 2024
The following procedure applies to brief adjudicative
				  proceedings before the commissioner for actions involving a network pharmacy's
				  appeal of a pharmacy benefit manager's decision in a first tier appeal
				  regarding reimbursement for a drug subject to predetermined reimbursement costs
				  for multisource generic drugs, unless the matter is converted to a formal
				  proceeding as provided in WAC
				  284-180-540(3).
(1)
Grounds for appeal.
A
				network pharmacy or its representative may appeal a pharmacy benefit manager's
				decision to the commissioner if it meets all the following requirements:
(a) The pharmacy benefit manager's decision
				must have denied the network pharmacy's appeal, or the network pharmacy must be
				unsatisfied with the outcome of its appeal to the pharmacy benefit
				manager;
(b) The network pharmacy
				must request review of the pharmacy benefit manager's decision by submitting a
				petition at
www.insurance.wa.gov
according to the filing instructions.
The petition for review must include:
(i) The network pharmacy's basis for
				appealing the pharmacy benefit manager's decision in the first tier
				appeal;
(ii) The network pharmacy's
				business address and mailing address; and
(iii) Documents supporting the
				appeal;
(c) Documents
				supporting the appeal include:
(i) The
				documents from the first tier review, including the documents that the pharmacy
				submitted to the pharmacy benefit manager as well as the documents that the
				pharmacy benefit manager provided to the pharmacy in response to the first tier
				review, if any (if the pharmacy benefit manager has not issued a decision on
				the first tier appeal in a timely manner, a signed attestation to that fact
				must be submitted by the appealing pharmacy);
(ii) Documentation evidencing the net amount
				paid for the drug by the small pharmacy;
(iii) If the first-tier appeal was denied by
				the pharmacy benefit manager because a therapeutically equivalent drug was
				available in the state of Washington at a price less than or equal to the
				predetermined reimbursement cost for the multisource generic drug and
				documentation provided by the pharmacy benefit manager evidencing the national
				drug code of the therapeutically equivalent drug; and
(iv) Any additional information that the
				commissioner may require;
(d) The network pharmacy must file the
				petition for review with the commissioner within 30 days of receipt of the
				pharmacy benefit manager's decision or within 30 days after the deadline for
				the pharmacy benefit manager's deadline for responding to the first tier
				appeal;
(e) The network pharmacy
				making the appeal must have less than 15 retail outlets within the state of
				Washington under its corporate umbrella. The petition for review that the
				network pharmacy submits to the commissioner must include a signed attestation
				that this requirement is satisfied; and
(f) Electronic signatures and electronic
				records may be used to facilitate electronic transactions consistent with the
				Uniform Electronic Transactions Act chapter 1.80 RCW.