PBM complaints

File a PBM Complaint

Is Your State Enforcing PBM Regulations?

NO?

You must file complaints with
your state department of insurance!

THIS IS HOW YOU DO IT.

Virtually every single state has passed some form of pharmacy benefit manager regulations over the last several years. Although there have been great strides forward with comprehensive state PBM regulations and court victories, this is all irrelevant if the state departments of insurance are not enforcing these laws.

You must be proactive and hold your insurance regulator's feet to the fire. You do that by filing complaints when the insurers/PBMs are NOT following the law in your respective state. It happens all the time (shocking, we know, PBMs not following the law). The more legitimate, factual-based complaints a department of insurance receives, the more likely it is to investigate and ENFORCE the law.

How to use this resource to file a complaint:

1) Go to the link for your state below. It includes information on the state's PBM laws and a link to the state's department of insurance complaint form.

2) Check NCPA's state law tracker (includes state-by-state PBM laws).

  • What are the laws in your state(s)?

  • Are insurers/PBMs in compliance?

  • If the answer is “no” then move on to step three.

3) Find the link to your state department of insurance's complaint form. NCPA has provided a link to all state complaint forms.

  • Not all states will have a specific PBM complaint form so it's OK to use the general consumer health insurance complaint form.

4) Fill out the complaint form (most state have online and hard copy options).

  • Include a clear and concise description of the insurer/PBM's non-compliance (i.e., state law prohibits clawbacks and PBMs continue to claw back funds after the point of sale).

  • Cite the specific state statute (which is included on the state law tracker).

  • Include records/claim/other evidence of the PBMs' violations.

  • Include all other information required by your respective state's complaint form.

Remember: When it comes to filing complaints, quantity and quality are equally important. The number of complaints matters as does the quality of the complaint, meaning it's important to have evidence/supporting documents included with your complaint.

Should you have any questions about filing, please feel to reach out to Anne Cassity or Joel Kurzman. Also, your state pharmacy association is always a great resource for these issues.

Note — state departments of insurance have regulatory authority over commercial insurers/claims. Any complaints against PBMs operating in the state Medicaid managed care program will generally have to be filed with the state Medicaid/health agency.

  • Alabama

    Complaint form: ALDOI - PBM Compliance Division

    Prohibition against retroactive claim adjustments: Ala. Code 27-45A-10

    Prohibition against adjudication fees: Ala. Code 27-45A-13

    Fair pharmacy audit procedures: Ala. Code 34-23-180 through -187

    Protection from under reimbursements (decline to dispense): Ala. Code 27-45A-10

    Prohibition of patient steering: Ala. Code 27-45A-8

    Reimbursement Floor:

    Commercial: Ala. Code 27-45A-13 (Independents)

  • Alaska

    Complaint form: Provider Complaints

    Prohibition against retroactive claim adjustments: Alaska Stat. 21.36.520

    Prohibition against adjudication fees: Alaska Stat. 21.36.520

    Fair pharmacy audit procedures: Alaska Stat. 21.27.910 through .940

    Prohibition of patient steering: Limits - Alaska Stat. 21.36.520

  • Arizona

    Complaint form: Health Care Providers | DIFI

    Prohibition against adjudication fees: ARS 20-3332

    Fair pharmacy audit procedures: ARS 20-3321 through -3324

  • Arkansa

    Complaint form: PBM Complaints - Arkansas Pharmacists Association

    Prohibition against retroactive claim adjustments: Ark. Code 23-92-506

    Prohibition against adjudication fees: Ark. Code 23-92-506

    Fair pharmacy audit procedures: Ark. Code 17-92-1201

    Protection from under reimbursements (decline to dispense): Ark. Code 17-92-507

    Prohibition of patient steering: A.C.A. § 17-92-416 (ownership law)

    Reimbursement Floor:

    Commercial: Ark. Code 23-92-506(b) (requires NADAC) and AID Rule 128 

    (requires "fair and reasonable" professional dispensing fee)

  • California

    Complaint form: Consumer & Provider Health Inquiries & Complaints

    Prohibition against retroactive claim adjustments: Cal. HSC 1385.0029

    Fair pharmacy audit procedures: Cal. BPC 4431 through 4438

    Prohibition of patient steering: Cal. HSC 1385.0027

  • Colorado

    Complaint form: Pharmacy Benefit Manager (PBM) Complaints | DORA - Division of Insurance

    Prohibition against retroactive claim adjustments: C.R.S. 10-16-122.3

    Fair pharmacy audit procedures: C.R.S. 10-16-122.5

    Reimbursement Floor:

    Commercial: C.R.S. 10-16-122.3 (Independents)

    State Employee Health Plans: C.R.S. 10-16-122.3 (Independents)

  • Connecticut

    Complaint form: File a Complaint or Ask a Question-Connecticut Insurance Department

    Prohibition against retroactive claim adjustments: Ct. Stat. 38a-477cc

    Fair pharmacy audit procedures: Ct. Stat. 38a-479iii

  • Delaware

    Complaint form: File a Complaint/Appeal - Delaware Department of Insurance - State of Delaware

    Prohibition against retroactive claim adjustments: Del. Code Tit. 18 Sec. 3372A

    Prohibition against adjudication fees: Del. Code Tit. 18 Sec. 3372A

    Fair pharmacy audit procedures: Del. Code Tit. 18 Ch. 33A Subch. I

    Protection from under reimbursements (decline to dispense): Del. Code Tit. 18 Sec. 3325A

  • Florida

    Complaints on issues regarding PBMs can be made to the Department of Financial Services (DFS), Division of Consumer Services by emailing PBMPharmacyComplaints@MyFloridaCFO.com. For more information, please visit the DFS Consumer Services website here.  

    Complaints on PBM issues regarding Florida Medicaid providers should be submitted to the Agency for Health Care Administration (AHCA). More information is available on AHCA's website here.

    Prohibition against retroactive claim adjustments: Fla. Stat. 626.8825

    Prohibition against adjudication fees: Fla. Stats. 626.8825

    Fair pharmacy audit procedures: Fla. Stat. 465.1885

    Protection from under reimbursements (decline to dispense): 2026 HB 697 Pace Program

    Prohibition of patient steering: Fla Stat. 626.8825 - incentives, marketing

     

  • Georgia

    Complaint form: File a Complaint | Office of the Commissioner of Insurance and Safety Fire

    Prohibition against retroactive claim adjustments: OCGA 33-64-11

    Prohibition against adjudication fees: OCGA 33-64-11

    Fair pharmacy audit procedures: OCGA 26-4-118

    Prohibition of patient steering: OCGA 33-64-11 (and 26-4-119 mandates, incentives, marketing)

    Reimbursement Floor:

    Managed Medicaid: DCH Provider Manual p. 37

    State Employee Health Plans: OCGA 45-18-22

  • Hawaii

    Complaint form: Filing a Complaint - DCCA Hawaii

  • Idaho

    Complaint form: File a Consumer Complaint | Department of Insurance

    Prohibition against retroactive claim adjustments: Id. Stat. 41-349

    Prohibition against adjudication fees: Id. Stat. 41-349

    Fair pharmacy audit procedures: Id. Stat. 41-6601 thru 6605

    Protection from under reimbursements (decline to dispense): Id. Stat. 41-349

  • Illinois

    Complaint form: Home - IDOI

    Prohibition of patient steering: 215 ILCS 5/513b1

  • Indiana

    Complaint form: IDOI: Complaints

    Prohibition against retroactive claim adjustments: IC 27-1-24.5-19 & IC 27-1-24.2

    Fair pharmacy audit procedures: IC 25-26-22

    Prohibition of patient steering: IC 27-1-24.2 (limits but not a prohibition)

    Reimbursement Floor:

    Commercial: IC 27-1-24.2-15 (Independents)

  • Iowa

    Complaint form: File a Pharmacy Benefits Manager Complaint | Iowa Insurance Division

    Prohibition against retroactive claim adjustments: IC 510B.8D

    Prohibition against adjudication fees: IC 510B.7

    Fair pharmacy audit procedures: IAC 191—59.4(510B)

    Reimbursement Floor:

    Managed Medicaid: Informational Letters 1627-MC, 1562-MC

    Commercial: IC 510B.8B

  • Kansas

    Complaint form: File an Insurance Complaint | Kansas Department of Insurance

    Kansas Pharmacists Association

    Fair pharmacy audit procedures: KSA 65-16,121

    Reimbursement Floor:

    Managed Medicaid: KMAP Provider Manual 8400 8-11

  • Kentucky

    Complaint form: DEPARTMENT OF INSURANCE

    Prohibition against retroactive claim adjustments: KRS 304.17A-595(2)(b)(1)

    Prohibition against adjudication fees: KRS 304.17A-595(2)(b)(1)

    Fair pharmacy audit procedures: KRS 304.17A-741

    Prohibition of patient steering: KRS 304.17A-597(1)(a)5-6

    Reimbursement Floor:

    Managed Medicaid: KRS 205.5514; KRS 205.647

    Commercial: KRS 304.17A-595 (Independents)

    State Employee Health Plans: KRS 304.17A-595 (Independents)

  • Louisiana

    Complaint form: Louisiana Department of Insurance - PBM Complaint Form

    Prohibition against retroactive claim adjustments: LRS 40:2870

    Prohibition against adjudication fees: LRS 22:1860.2

    Fair pharmacy audit procedures: LRS 22:1856.1

    Protection from under reimbursements (decline to dispense): LRS 22:1860.3E

    Prohibition of patient steering: LRS 40:2870 - inducements, penalties

    Reimbursement Floor:

    Managed Medicaid: LRS 46:460.36(D)

    Commercial: LRS 22:1868

  • Maine

    Complaint form: File a Complaint/Dispute | PFR Insurance

    Prohibition against retroactive claim adjustments: MRS 24-A, 4350

    Prohibition against adjudication fees: MRS 24-A, 4317

    Fair pharmacy audit procedures: MRS 24-A, 4317

  • Maryland

    Complaint form: File A Complaint

    Prohibition against retroactive claim adjustments: Md. Code, Ins. 15-1631

    Prohibition against adjudication fees: Md. Code, Ins. 15-1628.3

    Fair pharmacy audit procedures: Md. Code, Ins. 15-1629

    Prohibition of patient steering: Md. Code, Ins 15-1611.1 - mandates (does not apply to specialty)

  • Massachusetts

    Complaint form: Filing An Insurance Complaint | Mass.gov

    Fair pharmacy audit procedures: Mass. Gen. Law 175, Sec. 226

    Reimbursement Floor:

    Managed Medicaid: 101 CMR 331.00

  • Michigan

    Complaint form: Filing a Complaint with DIFS 

    Prohibition against retroactive claim adjustments: MI Comp L 550.825 

    Prohibition against adjudication fees: MI Comp L 550.825 

    Fair pharmacy audit procedures: MI Comp L 550.838 

    Prohibition of patient steering: MI Comp 550.829.new - mandates, inducements 

    Reimbursement Floor: 

               Managed Medicaid: Section 105i of the 2023 Public Act (PA) 279 

               (not more than 7 retail outlets) 

  • Minnesota

    Complaint form: Insurance / Minnesota Department of Commerce - Insurance

    Prohibition against retroactive claim adjustments: Minn. Stat. 62W.13

    Fair pharmacy audit procedures: Minn. Stat. 62W.09

    Prohibition of patient steering: Minn. Stat. 62W.07 - mandates, incentives, penalties

    Reimbursement Floor:

    Managed Medicaid: Sec. 10. Minnesota Statutes 2025 Supplement, section 256B.69, subdivision 6d

  • Mississippi

    Complaint form: Pharmacy Benefit Managers (PBM) | Mississippi Board of Pharmacy

    Prohibition against retroactive claim adjustments: Miss. Code 73-21-155

    Fair pharmacy audit procedures: Miss. Code 73-21-183

    Reimbursement Floor:

    Managed Medicaid: DOM SPA 17-0002

  • Missouri

    Complaint form: Insurance Complaints | Missouri Department of Insurance

    Prohibition against adjudication fees: Mo. Rev. Stat. 376.387

    Fair pharmacy audit procedures: Mo. Rev. Stat. 338.600

  • Montana

    Complaint form: HB 740 PBM Complaint Form

    Prohibition against adjudication fees: MCA 33-22-175

    Prohibition against retroactive claim adjustments: MCA 33-22-175

    Fair pharmacy audit procedures: MCA 22-2

    Protection from under reimbursements (decline to dispense): MCA 33-22-174

    Prohibition of patient steering: MCA 33-22-177

    Reimbursement Floor:

    Commercial: MCA 33-22-172 (Independents)

    State Employee Health Plans: MCA 33-22-172 (Independents)

  • Nebraska

    Complaint form: File a Complaint | Nebraska Department of Insurance

    Fair pharmacy audit procedures: NRS 44-4607

    Protection from under reimbursements (decline to dispense): NRS 44-4615

    Prohibition of patient steering: Incentives against - NRS 44-4614

    Reimbursement Floor:

    Managed Medicaid: NRS 68-901 Laws 2024, LB 204, § 1 (6 stores or less)

  • Nevada

    No PBM regulations at this time.

    Complaint form: Nevada Division of Insurance

  • New Hampshire

    Complaint form: Filing a Complaint | New Hampshire Insurance Department

    Prohibition against retroactive claim adjustments: N.H. Rev. Stat. 402-N:4

    Fair pharmacy audit procedures: N.H. Rev. Stat. 318:62

  • New Jersey

    Complaint form: NJDOBI | How to Request Assistance - Consumer Information

    Prohibition against retroactive claim adjustments: N.J. Stat. 17B:27F-7

  • New Mexico

    Complaint form: PBM File a Complaint - NM OSI

    Prohibition against retroactive claim adjustments: NMSA 59A-61-6

    Prohibition against adjudication fees: NMSA 59A-61-7

    Fair pharmacy audit procedures: NMSA 61-11-18.2

    Reimbursement Floor:

    Managed Medicaid: NM Stat § 27-2-12.34 (2025)

    State Employee Health Plans: NMSA Health Care Purchasing Act Chapter 13, Article 7 (Independents)

  • New York

    Complaint form: File a Complaint | Department of Financial Services

    Fair pharmacy audit procedures: NY Pub. Health Law 280-c

  • North Carolina

    Complaint form: Assistance or File a Complaint | NC DOI

    Prohibition against retroactive claim adjustments: NC Gen. Stat. 58-56A-4

    Prohibition against adjudication fees: NC Gen. Stat. 58-56A-4

    Fair pharmacy audit procedures: NC Gen. Stat. 90-85.50 through 90-85.52

    Protection from under reimbursements (decline to dispense): Gen. Stat. 58-56A-4

    Prohibition of patient steering: Incentives against - NC Gen. Stat. 58-51-37

    Reimbursement Floor:

    Managed Medicaid: S.L. 2021-180, § 9D.19A, 

    as amended and extended through June 30, 2031 by S.L. 2025-69, Part XI

  • North Dakota

    Complaint form: Complaints | North Dakota Insurance Department

    Prohibition against adjudication fees: ND Code 19-02.1-16.1 and 19-02.1-16.5

    Fair pharmacy audit procedures: ND Code 19-03.6-02

    Prohibition of patient steering: 19-02.1-16.6 - mandates, penalties

  • Ohio

    Complaint form: ODI - PBM Complaints Form

    Prohibition against retroactive claim adjustments: ORC 3959.20

    Prohibition against adjudication fees: ORC 3959.20

    Fair pharmacy audit procedures: ORC 3901.81 through 3901.815

    Reimbursement Floor:

    Managed Medicaid: ORC 5164.02; OAC 5160-9-10

  • Oklahoma

    Complaint form: PBM Compliance and Enforcement

    Prohibition against retroactive claim adjustments: Okla. Stat. 36-6962

    Prohibition against adjudication fees: Okla. Stat. 36-6962

    Fair pharmacy audit procedures: Okla. Stat. 59-356

    Protection from under reimbursements (decline to dispense): Okla. Stat. 59-360

    Prohibition of patient steering: Okla. Stat. 36-6963 - requirements, incentives

  • Oregon

    Complaint form: Division of Financial Regulation : File a complaint : File a complaint or check a license : State of Oregon

    Prohibition against retroactive claim adjustments: ORS 735.534

    Fair pharmacy audit procedures: ORS 735.540 through 735.552

  • Pennsylvania

    Complaint form: The Pennsylvania Insurance Department Pharmacist Portal

    Fair pharmacy audit procedures: 40 P.S. 4511

    Prohibition of patient steering: 2024 Act 77

  • Rhode Island

    Complaint form: Insurance Division | Dept. of Business Regulation

    Fair pharmacy audit procedures: R.I. Gen. Laws 5-19.1-35

  • South Carolina

    Complaint form: Form Center • PBM Complaint Form

    Prohibition against retroactive claim adjustments: S.C. Laws 38-71-2230

    Prohibition against adjudication fees: S.C. Laws 38-71-2150 and 38-71-2230

    Fair pharmacy audit procedures: S.C. Laws 38-71-1810 through -1830

    Prohibition of patient steering: S.C. Laws 38-71-2230

    Reimbursement Floor:

    Managed Medicaid: Pharmacy Services Provider Manual (effective Jan. 1, 2026) (in-state independents only)

  • South Dakota

    Complaint form: Division of Insurance Complaint Process

    Prohibition against retroactive claim adjustments: S.D. Laws 58-29E-13

    Prohibition against adjudication fees: S.D. Laws 58-29E (2023 HB 1135)

    Fair pharmacy audit procedures: S.D. Laws 58-29F

  • Tennessee

    Complaint form: Tennessee Insurance: Pharmacy Benefits Managers

    Prohibition against adjudication fees: Tenn. Laws 56-7-3115

    Fair pharmacy audit procedures: Tenn. Laws 56-7-3103

    Prohibition of patient steering: Tenn. Laws 56-7-3120 - incentives

  • Texas

    Complaint form: Pharmacists Resource Page

    Prohibition against retroactive claim adjustments: Tex. Ins. Code 1369.553 & SB 1236 (2025)

    Prohibition against adjudication fees: Tex. Ins. Code 1369.402

    Fair pharmacy audit procedures: Tex. Ins. Code 1369.254 through .266

    Prohibition of patient steering: Tex. Ins. Code Sec. 1369.555 - messaging, marketing

  • Utah

    Complaint form: Information for Consumers | Utah Insurance Department

    Prohibition against retroactive claim adjustments: Ut Code 31A-46-304

    Fair pharmacy audit procedures: Ut Code 58-17b-622

  • Vermont

    Complaint form: Insurance Complaints | Department of Financial Regulation

    Fair pharmacy audit procedures: 18 VSA 3802

    Prohibition of patient steering: 8 V.S.A. § 4089j - mandates, messaging, incentives

  • Virginia

    Complaint form: Virginia SCC - Pharmacy Benefits Mgmt

    Prohibition against adjudication fees: Va. Code 38.2-3467

    Fair pharmacy audit procedures: Va. Code 38.2-3407.15:1

    Prohibition of patient steering: Va. Code 38.2-4312.1 - incentives, penalties

  • Washington

    Complaint form: File a complaint or check your complaint status | Office of the Insurance Commissioner

    Prohibition against retroactive claim adjustments: RCW 48.200.280

    Fair pharmacy audit procedures: RCW 48.200.220 thru 48.200.270

  • West Virginia

    Complaint form: PBM Complaint Form.pdf

    Prohibition against adjudication fees: WV Code 33-51-9

    Fair pharmacy audit procedures: WV Code 33-51-4

    Prohibition of patient steering: WV Code 33-51-11 - incentives, penalties

    Reimbursement Floor:

    Commercial: W.Va. Code §33-51-9€

    State Employee Health Plans: W.Va.Code §5-16-9 

  • Wisconsin

    Complaint form: OCI Types of Complaints

    Prohibition against retroactive claim adjustments: Wis. Stat. 632.865

    Fair pharmacy audit procedures: Wis. Stat. 632.865

  • Wyoming

    Complaint form: PBM Complaints

    Fair pharmacy audit procedures: Wyo. Stat. 26-52-103

    Protection from under reimbursements (decline to dispense): Wyo. Stat. 26-52-104