File A PBM Complaint


Before you file a PBM request for assistance with the Alabama Department of Insurance, you should first contact the Pharmacy Benefit Management Company (PBM) or the insurance company to resolve the issue(s) through their Appeals Process.

If you do not receive a satisfactory response, then download the PBM Complaint form (Request for Assistance) and spreadsheet.

PBM Complaint Form
PBM Complaint Spreadsheet

If you are, an Individual Complainant filing a complaint:

  • Fill out the complaint form in its entirety and provide:
    • Appeal denial documentation from the PBM and
    • Sign PBM Complaint form.

If you are, Pharmacy/Pharmacist filing a complaint:

  • Fill out the complaint form in its entirety unless you have multiple insureds with the same type complaint. In this case, skip question number 3.
    • Provide question 3.a-f information on a spreadsheet when there are multiple files of the same type/reason being filed.
    • Each Complaint type, e.g., Steering and Clawbacks, must be filed with separate PBM Complaint forms and a separate Spread Sheet.

WE CAN...

  • Submit your complaint to the PBM (Pharmacy Benefit Manager). They are required to respond to the Alabama Department of Insurance.
  • Review the response to determine if the PBM is acting according to Title 27, Section 45A as revised by Act 2021-341 (the Act).
  • If we determine that the PBM or Insurance Company did not meet the legal obligations of the Act, we will require corrective action.

WE CANNOT...

  • Provide assistance with your complaint if you have an attorney.
  • Provide legal advice or provide legal representation.
  • Provide medical advice.
  • Intervene on your behalf in a pending lawsuit.
  • Determine who was negligent or at fault.
  • Determine the value of a claim or the amount of money owed to you.
  • Determine the facts regarding any other disagreement between you and another party.
  • Help resolve PBM complaints or investigate matters for plans that are not subject to the laws of the State of Alabama.

    Note: If the plan is a self-funded plan that is governed by the federal Employee Retirement Income Security Act (ERISA), your employer or a TPA chosen by your Employer administers the program. You will need to contact your employer for assistance.