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Your
Appeal
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What is your name?
First Name
Last Name
What email will be used?
What email will be used to track the pharmacy appeals and receive decisions?
Please confirm your email address.
Does this appeal meet the regulatory requirements?
Is the appeal from a small pharmacy in WA State?
Yes
No
Is the appeal specific to only the reimbursement cost of the drug?
Yes
No
Is the PBM reimbursement rate being appealed for a multi-source generic drug?
Yes
No
Do you have the authority to submit an appeal on behalf of the pharmacy?
Yes
No
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Online Services (Production Web EUI) Release Date: Sunday, December 13, 2020
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