ODI - PBM Complaints Form

If you are a consumer wishing to file a complaint regarding an insurance company, please use our Consumer Complaints Form

The Consumer Services Division of the Ohio Department of Insurance provides information and investigates complaints involving pharmacy benefit managers (PBMs), pursuant to the requirements of Ohio Revised Code 3959. If you are a pharmacist filing a complaint against a (PBM), use this form. Please submit a separate complaint form for each PBM involved.

Please provide your basic contact information in case we need to follow up on your complaint.

Middle Name

Address Line Two

Pharmacy Services Administration Organization (PSAO)

Please provide the details regarding the PBM, Insurance company, and insurance plan information, if available.

Insurance Company

Insurance Plan Name or Number

Please select all of the applicable reasons for your complaint below.

Please provide as many details as possible regarding any appeal processes you have engaged in with the PBM.

Have you filed an appeal with the PBM?

Date of Appeal. Date of Appeal (!) Date PBM responded to appeal (if received)

Outcome of Appeal Outcome of Appeal (!)

Please provide the details of your appeal, along with the PBM's response. Supporting documentation can be included in a following section.

Additional Details Additional Details (!)

Please provide any additional details.

Outcome of Appeal

Please provide the details of your appeal, along with the PBM's response. Supporting documentation can be included in a following section.

Additional Details

Please provide any additional details.

Please provide as many details as possible regarding your complaint.

Licensure Complaints Licensure Complaints (!)

Please provide specific reason or information supporting claim that PBM is not licensed. Attach supporting documentation in the next section if applicable.

Pricing Complaints

Multiple complaints?

If you have multiple examples pertaining to one PBM, please use the next section to attach a document containing any additional examples.

Prescription (Rx) Number

Product Name

NDC

Date of Service

Date of initial claim for reimbursement Reimbursement Claim Date

Additional pricing complaint description

Please provide any additional information regarding your pricing complaint.

Other Complaints Other Complaints (!)

Please provide specific details, including the source of the information supporting your complaint.

Please describe your expected resolution for your complaint.

If you have any supporting documentation, please attach it below.

Public Records

This complaint form, all documents you send us, and any document received by our office as a result of handling your complaint may be a public record, subject to Ohio's Public Records Act. This law requires all public records to be available for inspection by anyone, upon request.

Supporting Document One

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Supporting Document Two

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Supporting Document Three

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To the best of my knowledge the above statement is correct. I understand that a copy of this form and any attachments may be sent to the insurance company or agent involved. I authorize the insurance company to release all of the medical records relating to this complaint to the Ohio Department of Insurance and I authorize the Ohio Department of Insurance to release medical records relating to this complaint to the insurance company or agent as necessary in order to resolve this complaint. I represent that I have the proper authority to execute this release.

I agree

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PBM Complaints Form

Contact Information

PBM and Insurance Information

Complaint Reasons

Appeals Information

Complaint Description

Licensure Complaints Licensure Complaints (!)

Pricing Complaints

Multiple complaints?

Other Complaints Other Complaints (!)

Supporting Documentation

Public Records

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