PBM Complaints (Submitted by Patient/Insured)

Please tell us a little about the patient for whom the prescription was filled.

Sometimes called the Insured, Member, or Subscriber.

Insured/Patient First Name

Insured/Patient Middle Name

Insured/Patient Last Name

Insured/Patient Address

Insured/Patient City

Insured/Patient Zip

Insured/Patient Phone

Insured/Patient Email

Insured (Patient) date of birth

mm/dd/yyyy

How do you preferred to be contacted?

Phone

Are you the Insured/Patient?

Yes

Please tell us about the Pharmacy where the prescription was filled.

Or where you intended to fill the prescription if you were unable.

Pharmacy Name

Pharmacy Address

Pharmacy Address (Line 2 if needed)

Pharmacy City

Pharmacy Zip Code

County

Pharmacy Phone Number

Phone

Pharmacy Email Address

Name of Insurance Company

Pharmacy Benefit Manager

Not always the same as the Insurance Company. This can usually be found on the Prescription ID Card.

Member_ID

You can find this information on your Insurance ID card or your Prescription Benefits Card. Sometimes called the Insured ID or Subscriber Number.

Prescription RxBIN Number

Also found on the Insurance Benefits/ID card. Rx BIN or BIN.

Prescription Rx Group Number

Processor Control Number

(if any)

Prescription Number

This is a unique number given to every prescription filled. It will be located on the medication label as well as the receipt.

Medication Name

National Drug Code (NDC)

A unique identifier given to all medications manufactured. This 10 or 11 digit number can typically be found on the medication packaging and accompanying paperwork.

Date Filled

The date on the label of the prescription.

mm/dd/yyyy

Days Supplied

Quantity Supplied

Where was the prescription filled?

Retail

Mail-Order

Is there more than one prescription for this complaint?

Yes

Tell us about your complaint.

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

Complaint Type

Please share any information you believe will aid in the investigation of your complaint.

Upload any documents or files supporting your complaint.

Examples include prescription receipts, any documents from the PBM or Insurance Company restricting your choice of pharmacy, or any other documents supporting your complaint.

File Upload

Drop your files here

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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