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

PBM 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.

Contact Information

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

Name, Phone & Email



Address


PSAO Organization

PBM and Insurance Information

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


Complaint Reasons

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

Appeals Information

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


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

Please provide any additional details.

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

Please provide any additional details.

Complaint Description

Please provide as many details as possible regarding your complaint.

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.

Please provide any additional information regarding your pricing complaint.

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

Please describe your expected resolution for your complaint.

Supporting Documentation

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.

Submit Complaint

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.

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