Pharmacy Benefit Manager (PBM) Complaint Form (FIS 0030)

Before You Begin

We encourage consumers to first attempt to resolve disputes directly with the Pharmacy Benefit Manager (PBM). If a resolution cannot be reached, our department can help try to resolve your dispute.

If you choose to file your complaint online you will need to have a valid email address and the ability to include relevant documentation as attachments. If you do not have a valid email address or the means to provide documents electronically, we recommend filing your complaint by fax or mail.

For more information regarding fax or mail submissions, please visit DIFS How to File a Complaint to download the appropriate form.

Warning!

For security purposes, should you be inactive for 20 minutes, this form will reset. To avoid losing your work, a popup will be presented to you after 15 minutes of inactivity. Click the 'Continue' button to keep your work and continue.

 1. Contact Information
* - Required Field
Contact Name
Contact Address
Contact Methods

*You must provide at least one phone number at which you can be reached in addition to an email address.

If you have a preferred contact number, select the 'preferred number' option next to that number. If only one phone number has been entered, that is assumed to be your preferred contact number.

Home is Preferred Contact Number
Cell is Preferred Contact Number
Work is Preferred Contact Number
Pharmacy Name(s)

To remove a pharmacy from this list, click on the Remove button next to it.

 2. Pharmacy Benefit Manager Details

In this section, indicate the name of the Pharmacy Benefit Manager (PBM) involved in your complaint. If more than one PBM is involved, you may enter additional PBMs as needed.

* - Required Field

Pharmacy Benefit Manager Details

You have not identified any pharmacy benefit managers.
 Add a Pharmacy Benefit Manager

3. Review & Submit

 3. Review & Submit

Review Request

Below you will find the details of the complaint you have completed. If you need to make changes, you may use the "Previous" button or edit links next to each section to make changes.

Contact Information  Edit This Section

Name: 

Role: 

Address:

Contact Information:

Pharmacy Name(s):

Pharmacy Benefit Manager Details  Edit This Section

*Authorization
 Submit