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PBM Complaint Form

  1. 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.
  2. 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.
  3. 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)
  4. Name of PBM:*
  5. Does an attorney represent you in this matter?*
  6. 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. 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.
  7. ***Please include copies of invoices, MAC appeals and replies from PBM with your complaint.
    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.
  8. Leave This Blank:

  9. This field is not part of the form submission.