Official Government Website

PBM Complaint Form

Pharmacy Benefit Manager Complaint Form

Please fill out the form below if a potential violation of Idaho Code § 41-349 has been identified.
Please complete a separate form for each PBM if there are multiple complaints.

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.

If your complaint includes supporting documentation, please email it directly to pbm@doi.idaho.gov with the documentation attached. Any missing information from the initial email may be requested through the PBM complaint form if necessary.

Pharmacy Benefits (#20)


Section I. Complainant Information

The following information is needed to act on your request. Questions marked * are required.



Complainant Information


Section II. General Information

The following information is needed to act on your request. Questions marked * are required.


Pharmacy Information



Covered Individual Information


PBM Information


Section III. Complaint Details

The following information is needed to act on your request. Questions marked * are required.




For additional claim information, please use the Blank Manual PBM Complaint Form, or the ID DOI Pharmacy Claim Payment Complaint Template and email directly to pbm@doi.idaho.gov.


Complaint Type

The Department assists pharmacies with concerns related to violations of the law. The following are examples of types of violations of which the Department can assist. Please select all applicable reasons for your complaint.


Appeals Information

Provide as many details as possible regarding any appeal processes you have engaged with the PBM.


Desired Resolution

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:

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