This complaint form is for pharmacies or interested parties to file complaints with the South Carolina Department of Insurance
relating to pharmacy benefit manager (PBM) services. Please complete all fields and mail, email or fax the completed form to the
address above with associated documentation.
Note: SC law requires pharmacies to make reasonable efforts to exhaust a PBM’s internal appeal requirements prior to
filing a complaint with the SCDOI. You must provide a copy of the appeal outcome with your complaint submission or
explain why you have not exhausted the internal appeals process as a part of your complaint submission.
Please Note: The SCDOI does not have regulatory authority over the following health plan types:
Self-Insured Groups Out-of-State Plans Federal Healthcare Programs (e.g., Medicaid, Medicare,
TRICARE, Veterans Health Administration, Indian Health Services, Children’s Health Insurance Program)
I declare that the information I have provided is true and accurate to the best of my knowledge. This information will be
forwarded to the PBM (and/or other party that is the subject of your complaint) for the investigation of this matter. I
understand that, under South Carolina’s Freedom of Information Act, this complaint becomes a public record once my file
is closed (medical and personal records will remain confidential). By submitting this form, I am authorizing the SC
Department of Insurance to pursue an investigation into my complaint and the party(ies) complained against to release
all relevant information, documents, and records to the SC Department of Insurance.
All proprietary information submitted or obtained during our investigation of this complaint shall be considered confidential under Regulation 69-77.II.C. and Sections 38-71-2220(C) and 30-4-40 of the Code of Laws of South Carolina, 1976, as amended.
This field is not part of the form submission.
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