OSI Events Calendar View our calendar of events Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.This form is ONLY for pharmacies submitting a complaint against a Pharmacy Benefits Manager (PBM). If you are an individual covered by a commercial health plan, please submit a complaint with the OSI Managed Health Bureau here: MHCB Complaint Form. For Medicaid complaints, submit a complaint via the Grievance Intake Form (PDF). For Medicare complaints, submit a complaint via the Medicare Complaint Form. For governmental or group self-insured members, please contact your employer for more information. Thank you.Complainant:Name of Pharmacy submitting Complaint *Pharmacy Contact Name *FirstLastPharmacy Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePharmacy Phone *Pharmacy Email *EmailConfirm EmailPBM:PBM Name *PBM Contact Name *FirstLastPBM Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePBM Phone *PBM EmailType of Issue Please describe the issue in detail. Please include reference to the statute or rule the PBM allegedly violated. For reference, the Pharmacy Benefit Manager Regulation Act is at Section 59A-61-1, et seq., NMSA 1978 and the corresponding rule is 13.10.30 NMAC. Complaints shall be based on a rule or statute enforced by the New Mexico Office of the Superintendent of Insurance.Type of Issue * Address Phone Name Attachments Drag & Drop Files, Choose Files to Upload You can upload up to 10 files. Please attach any documents relevant to your complaint:The information contained within is confidential and shall not be disclosed or other provided to anyone not a party to the complaint except the Office of Superintendent of Insurance.Submit
