State Tracker Updated June 15, 2026

Washington: what the PBM reimbursement law requires

Washington gives small pharmacies (15 or fewer locations) on fully-insured plans a route to appeal reimbursement below their actual acquisition cost, with review by the Insurance Commissioner — but it sets no statutory reimbursement floor.

Status	Partially enacted
Law	E2SSB 5213 (2024) — RCW 48.200.280; small-pharmacy appeals (WAC 284-180-507)
Effective date	RCW 48.200.280 effective January 1, 2026; the appeals program is operating now
Reimbursement basis	No statutory reimbursement floor. Small/independent pharmacies (15 or fewer retail locations) on fully-insured commercial plans may appeal reimbursement that falls below the pharmacy's actual drug acquisition cost; the PBM must reconsider, and the Insurance Commissioner can review. Self-funded ERISA plans are excluded.
Professional dispensing fee	Not specified in statute
Appeal route	Appeal to the PBM, then commissioner review within 30 calendar days of the decision; appeals completed within 30 calendar days

Washington does not impose a NADAC or acquisition-cost reimbursement floor. Instead, it gives small and independent pharmacies — those with 15 or fewer retail locations — on fully-insured commercial plans a route to appeal reimbursement that falls below the pharmacy’s actual acquisition cost, with documentation, and to seek review by the Office of the Insurance Commissioner.

The appeals program is run by the Insurance Commissioner now, and the expanded statute (RCW 48.200.280) takes effect January 1, 2026. The mechanism is a below-cost appeal, not a statutory floor, and it excludes self-funded ERISA plans.

Sources

RCW 48.200.280 — Washington State Legislature (codified) Primary source
Washington OIC — Small Pharmacy Reimbursement Appeals Primary source

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