PBM Related Complaints
The Colorado Division of Insurance (DOI) has authority to enforce statutory requirements regarding Pharmacy Benefit Management Firms (PBMs), as granted by House Bill (HB) 23-1227 Enforce Laws Against Pharmacy Benefit Managers. The DOI assists individuals and pharmacies with concerns related to PBM business practices and conduct that may be in violation of state law. If you if have an issue you would like to submit to the DOI, please review the information outlined below.
Before Submitting a Complaint
Before filing a complaint with the Colorado Department of Insurance (DOI) regarding a Pharmacy Benefit Management (PBM) related-issue, it is recommended you first contact the PBM to resolve the matter. You may want to document phone calls to the company, keep copies of all written communications, and complete all levels of contractual appeals available. If you are still unable to resolve your complaint, you may contact the DOI for assistance.
Instructions to File a PBM Complaint
To file a complaint against a PBM for violation of law or rule, (1) download a pdf copy of this form, (2) fill out this PBM Complaint Form in its entirety and (3) submit it to the DOI via email at dora_pbm_compliance@state.co.us along with any supporting documentation you wish to include.
*Note: You must download a pdf of this PBM Complaint Form to access the fillable sections.
Supporting Documentation
Be sure to include as much relevant information as possible to support the Division’s investigation of your complaint. Depending on the nature of your complaint, the appropriate supporting documents may vary. Please send copies, not originals of:
- Details of any previous contact with the PBM regarding the matter.
- Copies of documents that help verify or explain the problem.
- Copies of invoices, MAC appeals, and communications with the PBM regarding your complaint.
What Happens After I File a PBM Complaint?
Once you file a complaint, the DOI will respond confirming receipt of the complaint. Depending on the circumstance, the DOI may:
- Send an inquiry letter to the PBM communicating the concerns brought to the Division’s attention and request a written response.
- Review the PMB response to the Division’s inquiry to determine if the PBM named in your complaint is performing as required under the law.
You will receive a copy of all correspondence received during the DOI’s review of your complaint as well as a letter explaining our findings. If you have questions, disagree with our findings, or have additional information that was not included with your original complaint, you may submit the information to us for further review. Please understand that our complaints are thoroughly reviewed; however, we may not be able to provide the exact results you desire. We hope through our complaint process we can help you understand the laws that may apply, however, the DOI does not provide legal advice.
What We Can Do
- Provide you with additional information relevant to your complaint file.
- Investigate your complaints against PBMs.
- Submit your complaint to the PBM and require a response to the Colorado Department of Insurance.
- Review the response to determine if the PBM is acting according to appropriate statutes.
- Require corrective action, if we determine that the PBM did not meet the legal requirements of the Act.
What We Cannot Do
- Assist with your PBM complaint if you have involved an attorney.
- Provide legal advice or provide legal representation.
- Intervene on your behalf in a pending lawsuit.
- Determine the facts regarding any other disagreement between you and another party.
- Help resolve PBM complaints or investigate matters that are not subject to the laws of the State of Colorado.