Pharmacy Benefits Manager Complaint Form

Pharmacy Name:
Mailing Address:
City: State: Zip:
Telephone:: Fax: Email:
NCPDP:
Contact:
Contact Telephone: Fax: Email:
Pharmacy Benefits Manager (PBM) compliant is about:
PBM Mailing Address:
PBM City: PBM State: PBM Zip:
PBM Phone Number: PBM Contact Person:

Type of Issue:Please describe in detail on additional sheets if required and provide all supporting documentation.

License- See Section 59A-61-3, NMSA 1978:
Maximum Allowable Cost (MAC) - See Section 59A-61-4, NMSA 1978:
Contract - See Section 59A-61-5, NMSA 1978:
Audit - See Section 59A-61-6, NMSA 1978:

The information contained within is confidential and shall not be disclosed or otherwise provided to anyone not a party to the complaint except the Office of the Superintendent of Insurance. .