Washington State Office of the Insurance Commissioner

What is your name?

First Name

Last Name

What email will be used to track the pharmacy appeals and receive decisions?

Please confirm your email address.

Is the appeal from a small pharmacy in WA State?

Is the appeal specific to only the reimbursement cost of the drug?

Is the PBM reimbursement rate being appealed for a multi-source generic drug?

Do you have the authority to submit an appeal on behalf of the pharmacy?

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