SC DOI Online Forms Center

2. Pharmacy Benefits Manager (PBM) Complaints Form
   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.
4. 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.
6. Pharmacy Name:*
7. NCPDP#:*
9. Mailing Address:*
10. Contact Email:*
12. Contact Person:*
13. Phone #:*
17. Name of PSAO (if applicable):
18. Contact Email:
20. Contact Person:
21. Phone #:
25. Name of Health Plan (if known):
26. PCN:
28. Member/Subscriber ID:
29. BIN:

31. Please Note: The SCDOI does not have regulatory authority over the following health plan types:

    Out-of-State Plans Government Healthcare Programs (e.g., Medicaid, Medicare, TRICARE, Veterans Health Administration, Indian Health Services, Children’s Health Insurance Program and State Health Insurance)

35. Name of PBM:*

    1. CVS/Caremark
    2. Express Scripts
    3. OptumRx
    4. Other
36. Other:
40. Name of Medication (if applicable):
41. NDC:
43. RX#:
44. Fill Date:
45. Quantity Dispensed:
49. Reimbursement Amout:
51. Date of Appeal with PBM:
53. Date PBM Denied Appeal (must provide copy of denial):
55. Description and Details of the Complaint:*
57. State section of the law that you believe the PBM is violating. (refer to 2019 SC Act No. 48 and Reg. 69-77)*
59. References
    2019 SC Act No. 48
61. Reg. 69-77
63. Does an attorney represent you in this matter?*

    1. Yes
    2. No
65. If yes, we will need written authorization from your attorney for us to intervene in this matter. You may have your attorney co-sign this form or include a signed letter of authorization that is on the attorney’s letterhead with this form.

    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. 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.

67. Signature of Complainant:*
68. Date:*
70. ***Please include copies of invoices, MAC appeals and replies from PBM with your complaint.

    The information or data acquired during an examination or review is considered proprietary and confidential and is not subject to the South Carolina Freedom of Information Act, in accordance with Regulation 69-77.II.C. and Sections 38-71-2220(C), 38-71-2250 and 30-4-40 of the Code of Laws of South Carolina, 1976, as amended.

72. Upload Invoices Here
74. Upload MAC Appeals Here
76. Upload PBM Correspondence Here
78. Upload Any Other Supporting Documents Here
Leave This Blank:


80. 1. Receive an email copy of this form.
81. Email address

    This field is not part of the form submission.

82. Submit

* indicates a required field