PBM Complaint Form

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Please only use this form for Pharmacy/PSAO complaints regarding Pharmacy Benefits Managers.

Complainant's Information
First Name*
Last Name*
Phone*
Email*
Name of the Insured*
First Last
Date of Birth (of the Insured)*
MM slash DD slash YYYY
Insurance ID#*
Pharmacy Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Who is the complaint against?
Name of Pharmacy Benefit Manager (PBM)*
PBM Claim Number:
Name of Health Insurance Company*
Insurance Plan Type
Rx Number
NDC #
Drug Name
Fill Date
MM slash DD slash YYYY
Quantity Dispensed
Please Provide the Consumer's Claim Information
Bin #
PCN#
Group
Please Select the Applicable Complaint Type
Select all that apply
- PBM did not provide the Pharmacy a “reasonable MAC appeals procedure process”
Maximal Allowable Cost (MAC) (Fill in amount below)
Acquisition Cost*
Reimbursement*
Upon asking the PBM, did they provide the sources utilized to determine the maximum allowable cost (MAC) pricing of the pharmacy, update MAC pricing at least every (7) calendar days, and establish a process for providers to readily access the MAC list specific to that provider?*
- yes
- no
- not researched
Is the medication that is reimbursed by the PBM at MAC meet the following requirements?*
- yes
- no
- not researched
Is the medication listed as "A" or "B" rated in the most recent version of the FDA's Approved Drug Products with Therapeutic Equivalence Evaluations, also known as the Orange Book?*
- yes
- no
- not researched
When appealed to the PBM in their documented process, what was the result?*
- Approved
- Denied without a documented reason
- Denied with a documented reason
Did the medication that is MAC priced have an "NR" or "NA" rating or a similar rating by a nationally recognized reference, and the drug is generally available for purchase by pharmacies in the state from national or regional wholesalers and is not obsolete?*
- yes
- no
- not researched
Did the PBM place a MAC on a medication where there are not at least two therapeutically equivalent, multiple-source drugs, or at least one generic drug available from only one manufacturer, generally available for purchase by network pharmacies from national or regional wholesalers.*
- yes
- no
- not researched
The MAC appeal to the PBM, did they respond with a resolution or denial within 10 days of the appeal request?*
- yes
- no
If the reimbursement appeal is denied, did the PBM provide the reason for the denial, including the National Drug Code number from national or regional wholesalers where the drug is generally available for purchase by pharmacies in the state at or below the PBM's reimbursement.*
- yes
- no
Is your pharmacy currently contracted with any of the wholesalers the PBM listed?*
- yes
- no
Is your pharmacy able to purchase the medication at the MAC price listed by the PBM?*
- yes
- no
Pharmacy & Therapeutics Committee Participation
- Pharmacy & Therapeutics Committee Participation
Do you have information related to the Pharmacy & Therapeutics committee that has impacted committee decisions or tier placement of a medication?*
- yes
- no
Please provide a copy of the marketing material with the partial hospital, pharmacy, or other healthcare provider network listing in the supporting documentation box on the PBM complaint forms 1st page.
- Contract Restriction Related to Consumer Cost Share Discussion
Is this contract restrictive language a new contract offering?*
- yes
- no
Is this contract restrictive language in an existing contract?*
- yes
- no
Has the PBM brought forward a contract action against your pharmacy as a result of this language?*
- yes
- no
Has the PBM actions against your pharmacy resulted in termination, sanctions or fines that resulted in loss of business to your pharmacy?*
- yes
- no
If a prescription claim is denied what is denial code number received from the PBM on your claim?
- PBM contract that disincentives Pharmacy staff in discussing pricing and copay comparisons with consumers.
Is this contract restrictive language a new contract offering?*
- yes
- no
Is this contract restrictive language in an existing contract?*
- yes
- no
Has the PBM brought forward a contract action against your pharmacy as a result of this language?*
- yes
- no
Has the PBM actions against your pharmacy resulted in termination, sanctions or fines that resulted in loss of business to your pharmacy?*
- yes
- no
If a prescription claim is denied what is denial code number received from the PBM on your claim?*
- Network Consumer Share (Co-pay) Differential
Did the consumer have a lower out of pocket at the preferred, specialty or mail order pharmacy than at a retail network provider?*
- yes
- no
- not sure
If known what the consumers is out of pocket difference between the two pharmacies*
- Less than $10
- Between $10 and $30
- Over $30
Did the consumer switch the prescription to the preferred pharmacy?*
- yes
- no
- not sure
Did the consumer request from the PBM an opt out option or an override for the preferred, specialty or mail order mandated options to retail?*
- yes
- no
- not sure
If a prescription claim is denied what is denial code number received from the PBM on your claim?
- Referred to Network Provider Owned or Affiliated with the PBM/Health Plan
Did your pharmacy have a prescription claim denied by the PBM/Health Plan?*
- yes
- no
If Yes, do you have evidence that your claim is reimbursed at less the PBM/Health Plans Owned pharmacy?*
- yes
- no
Did your pharmacy lose consumers to this PBM/Owned pharmacy over the last year?*
- yes
- no
Approximately how many prescriptions did you lose to the PBM/Owned pharmacy over the last year?*
- 50 to 100
- 101 to 500
- 501 to 1000
- 1000 plus
If a prescription claim is denied what is denial code number received from the PBM on your claim?
- Pharmacies Contracted PSAO Requested and Not Offered or Denied Network Entry
Has your PSAO been offered a preferred pharmacy contract in the past from this PBM?*
- yes
- no
- not sure
After review of the PBM/Health Plan contract offer did your PSAO and or your pharmacy refuse to participate in contract offering for business reasons.*
- yes
- no
Did your PSAO or pharmacy have the opportunity to discuss (negotiate) what it would require for the contract to be acceptable and partner with the PBM/HealthPlan.*
- yes
- no
Has the PBM refused/denied your PSAO request for preferred, retail or mail pharmacy network contract for your review & consideration for participation.*
- yes
- no
Did your pharmacy have a denied prescription claim?*
- yes
- no
Did your pharmacy lose consumers to the preferred retail, mail order or specialty pharmacy mandated by the PBM/Health Plan?*
- yes
- no
Approximately how many prescriptions did you lose to the preferred retail, mail order or specialty pharmacy mandated by the PBM/Health Plan in the last year?*
- 50 to 100
- 101 to 500
- 501 to 1000
- 1000 plus
What is denial code number you received from the PBM on your claim?
- Pharmacy Requested and Not Offered or Denied Network Entry
Has your PSAO been offered a preferred pharmacy contract in the past from this PBM?*
- yes
- no
- not sure
After review of the PBM/Health Plan contract offer did your PSAO and or your pharmacy refuse to participate in contract offering for business reasons.*
- yes
- no
Did your PSAO or pharmacy have the opportunity to discuss (negotiate) what it would require for the contract to be acceptable and partner with the PBM/HealthPlan.*
- yes
- no
Has the PBM refused/denied your PSAO request for preferred, retail or mail pharmacy network contract for your review & consideration for participation.*
- yes
- no
Did your pharmacy have a denied prescription claim?*
- yes
- no
Did your pharmacy lose consumers to the preferred retail, mail order or specialty pharmacy mandated by the PBM/Health Plan?*
- yes
- no
Approximately how many prescriptions did you lose to the preferred retail, mail order or specialty pharmacy mandated by the PBM/Health Plan in the last year?*
- 50 to 100
- 101 to 500
- 501 to 1000
- 1000 plus
What is denial code number you received from the PBM on your claim?
- Consumer Mandated PBM Specialty Pharmacy
Did your pharmacy have a prescription claim denied by the PBM/Health Plan?*
- yes
- no
If Yes, do you have evidence that your claim is reimbursed at less the PBM/Health Plans*
- yes
- no
Owned pharmacy?*
- yes
- no
Did your pharmacy lose consumers to this PBM/Owned pharmacy over the last year?*
- yes
- no
Approximately how many prescriptions did you lose to the PBM/Owned specialty pharmacy over the last year?*
- 50 to 100
- 101 to 500
- 501 to 1000
- 1000 plus
If a prescription claim is denied what is denial code number received from the PBM on your claim?
- Consumer Mail or Preferred Network opt Out Denied at PBM or Health Plan
Did your pharmacy have a consumer’s prescription drug claim denied by a PBM/Health Plan mandating the consumer to receive medication thru a preferred retail, mail order or specialty pharmacy?*
- yes
- no
Did the consumer reach out to the PBM/Health Plan requesting they have an override due to specific circumstances related to their health, travel restrictions, or family situation?*
- yes
- no
How did the PBM/Health Plan respond to the consumers request for an override?*
- The request was approved
- The request was denied
Did the consumer receive a written response?*
- yes
- no
Did the consumer receive or offered information related to their appeals rights related to this denial?*
- yes
- no
- not sure
Did the consumer leave your pharmacy without medication on the visit?*
- yes
- no
Did the consumer receive a mailing or email that provided a partial list of network pharmacies in which they may receive medications going forward?*
- yes
- no
If a prescription claim is denied what is denial code number received from the PBM on your claim?
- PBM Retroactively Denied or Reduced Rx Claim Payment
Has your pharmacy received an action by the PBM/Health Plan that resulted in them changing the reimbursement on a previously adjudicated prescription claim?*
- yes
- no
Did they provide a detailed explanation to this change in reimbursement for previously adjudicated prescription claim?*
- yes
- no
With the change in reimbursement for previously adjudicated claims did the PBM/Health Plan provide an appeal process to your pharmacy or PSAO?*
- yes
- no
On the prescription claims impacted by the change in reimbursement how long ago were these prescription claims originally processed?*
- yes
- no
During the previous 12 months approximately how many prescription claims were impacted by a similar change in reimbursement for the earlier identified PBM?*
- yes
- no
The impacted previously adjudicated prescription claims, where your pharmacies changed reimburse related actions by your pharmacy or the entire pharmacy network?*
- yes
- no
For your pharmacy what is reduction of reimbursement related to similar changes on previously adjudicated claims over the last 12 months?*
- $1 to $1000
- $1001 to $5000
- $5001 to $10,000
- $10,000 plus
If a prescription claim is denied what is denial code number received from the PBM on your claim?*
- Pharmacy Preferred Network Access Standards Not Met (consumer required to travel over 5 miles in URBAN areas, over 7 miles in SUBURBAN areas, or over 18 miles in RURAL areas) of Oklahoma.
Is this complaint related to the PBM not meeting a Preferred Pharmacy Network Access Standards?*
- yes
- no
Is the location of your pharmacy considered to be?*
- Urban
- Suburban
- Rural
How far do you need to travel to reach your Pharmacy?*
- Less than 2 miles
- Between 2 and 5 miles
- Between 5 and 7 miles
- Between 7 and 15 miles
- Between 15 and 18 miles
- Over 18 miles
(*You may use a mapping software program to calculate mileage)
Did the consumer switch the prescription to the preferred pharmacy?*
- yes
- no
- not sure
Has your pharmacy or PSAO been offered a preferred pharmacy contract in the past?*
- yes
- no
- not sure
After review of the PBM/Health Plan contract offer did your PSAO and or your pharmacy refuse to participate in contract offering for business reasons.*
- yes
- no
Did your PSAO or pharmacy have the opportunity to discuss (negotiate) what it would require for the contract to be acceptable and partner with the PBM/HealthPlan.*
- yes
- no
Has the PBM refused/denied your PSAO or Pharmacy’s’ request for preferred, retail or mail pharmacy network contract for your review & consideration for participation.*
- yes
- no
Did your pharmacy have a denied prescription claim?*
- yes
- no
What is denial code number you received from the PBM on your claim?
Retail Pharmacy Paid Less Than PBM Owned Pharmacies
- Retail Pharmacy Paid Less Than PBM Owned Pharmacies
Is your PBM complaint related to documented information related to a competing PBM/Health Plan owned or associated pharmacy is being reimbursed more than your pharmacy?*
- yes
- no
In which of the following areas is your pharmacy recommending audits of reimbursements rates that are proposed to be lower than the PBM/Health Plans owned or associated pharmacies?*
- Brands AWP discounts?
- Generics MAC pricing table vs AWP discounts?
- Brand dispensing fees?
- Generic dispensing fees?
- Pharmacy Rebates Shared with the PBM/Health Plan owned pharmacy?
- Contract terms that limit dispensing day supply or number of fills at your pharmacy And not at the competitor PBM/Health Plan owned or associated pharmacies?
Which PBM/Health Plan owned, or associated pharmacy or dispenser competitor is reimbursed at higher amount than your pharmacy?*
- Retail Pharmacy Competitor
- Mail Order Pharmacy Competitor
- Specialty Medication Pharmacy Competitor
- Compounding Pharmacy Competitor
- On Site Clinic Pharmacy Competitor
- On Site Prescriber Dispensing
- Diabetic Supply Provider/Pharmacy
- Other Disease Specific Provider/Pharmacy Competitor sponsored by PBM/Health Plans
America Heart Association, American Cancer Society, American Diabetes Association, or Formulary Rebated Manufacturers associated dispensers?*
- Contact Lens Competitor Provider?
- Breathing Medication & Supply Provider Competitor?
- Ostomy Supply Competitor Provider?
- Preferred Network Pharmacy Competitor?
- Vitamin Supply Competitor Provider?
- Over the Counter Sales Competitor Provider?
- Other PBM/Health Plan owned, or associated Competitor Dispenser not listed
If a prescription claim is denied, what is denial code number received from the PBM on your claim?*
Other
- Other
Please explain:
Supporting Documents
Max. file size: 50 MB.
You can also send documents to:
PBMcomplaints@oid.ok.gov or mail your documents to the Oklahoma Insurance Department PBM Compliance & Enforcement Division 400 NE 50th Street Oklahoma City, OK 73105
Consent*
Authorization
With this knowledge, I give my consent to the release of all information related to this complaint including any information concerning my identity and release the OKLAHOMA INSURANCE DEPARTMENT and its duly authorized agents and employees from any liability in connection with the release of the information contained herein.
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INSURANCE COMMISSIONER

Take Action

Find a Rep

Report Fraud

Verify an Insurance Agent/Licensee

Please only use this form for Pharmacy/PSAO complaints regarding Pharmacy Benefits Managers.

Complainant's Information

Who is the complaint against?

Please Provide the Consumer's Claim Information

Please Select the Applicable Complaint Type

You can also send documents to: