2025 PBM Complaints (Pharmacy Submitted)

Your First Name*

Your Middle Name

Your Last Name*

Pharmacy Name*

NCPCP / NABP Number

Pharmacy Address

Pharmacy Address (line 2 if needed)

City*

Zip*

County*

Select

Pharmacy Phone Number*

Please list the best number to contact you regarding your complaint.

Phone

Pharmacy Email Address*

How do you prefer to be contacted?*

Select or enter value

If you are a member of a PSAO, please list them here.*

Select

Insured's First Name

Insured's Middle Name

Insured's Last Name

Insured's Address

Insured's City

Insured's Zip

Insured's Date of Birth

Insured's Phone Number

Phone

Insured's Email Address

Name of Health Insurance Company

Pharmacy Benefit Manager*

Select

Insured's Member ID Number*

Prescription RxBIN*

Prescription Rx Group Number*

Prescription Rx PCN

Network Reimbursement ID (if known)

This info should be returned from the PBM with associated reimbursement information.

Prescription Rx Number*

Medication Name*

National Drug Code (NDC)*

Date Filled*

Days Supplied*

Quantity Filled*

Is there more than one prescription for this complaint?*

If yes, please use the provided Excel spreadsheet to send the prescription information for the complaint.

Please note: each complaint should be limited to one PBM only. If you have multiple complaints against different PBMs, you will need to submit each PBM's complaints as individual complaints with its own separate spreadsheet/template.

Select

What type of complaint has occurred?*

Not sure what in which category your complaints fits? Click here for descriptions and examples.

Select

Describe the violation.

Please tell us in your own words what violation you would like to report.

Time_Spent

Please attach any supporting documents here.

Please include any documents or files that support your complaint; these can be invoices, screenshots, correspondence from the PBM or any information relevant to your complaint.

Drag and drop files here or

Click below to submit your complaint.

We are committed to investigating each complaint we receive. Please allow 5-7 business days for our staff to review your complaint and contact you regarding any additional information they may require.

Thank you for taking the time to submit your complaint.

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