Washington Finalizes HCBM & PBM Rule (R 2025-11) to Clarify Registration, Reimbursement, and Appeal Rights

WA| Washington’s R 2025-11 rule, effective January 24, 2026, further implements E2SSB 5213 by expanding and clarifying regulation of health care benefit managers (HCBMs) and pharmacy benefit managers (PBMs), including definitions, registration, and oversight requirements. It updates multiple HCBM rules on applicability, definitions, registration and renewal fees, contract filing, self-funded plan opt-in, pharmacy reimbursement standards, and pharmacy appeal processes to HCBMs and the commissioner, and it adds a new section on enrollee rights and PBM obligations related to access, reimbursement, and cost-sharing for prescription drugs. The rule is intended to ensure entities understand their rights and obligations under provisions of E2SSB 5213 taking effect January 1, 2026 and to strengthen the Office of the Insurance Commissioner’s ability to supervise HCBMs and PBMs in Washington.

Click here to see WA Rule Change (R2025-11)