PBM Complaint Form • PBM • Idaho Department of Insurance

Pharmacy Benefit Manager Complaint Form

Please fill out the form below if a potential violation of Idaho Code § 41-349 has been identified.

Pharmacies, pharmacists, and health insurance companies can file a complaint regarding potential violations of the Idaho Code § 41-349.

If you are unsure whether your problem or question is related to the Idaho Code § 41-349, please contact the PBM Market Examiner at pbm@doi.idaho.gov.

Pharmacy Benefits (#20)

Full Name

Phone

Fax

Preferred method of contact:

Address

Street

Apt./Suite

City

State

Zip Code

Name of PBM your complaint is against and their contact information.

Name of PBM Company

PBM License Number

PBM BIN

PBM RX Group Number

PBM PCN

Phone

Fax

Street

Apt./Suite

City

State

Zip Code

Complaint Category

Date of service start or individual day

And/Through Date Selection

Date of service end or individual day

Have you reached out to the PBM about this issue? Are they trying to assist you?

Please describe your concern or complaint.

Before submitting this form, please print this page for your records. A copy will also be sent to your email address entered.

Have more questions?

Contact the PBM Market Examiner: