PBM Complaint Form
KPhA is collecting data regarding PBM practices in Kansas. Complaints need to originate from Kansas pharmacists or pharmacies, and not from those entities on behalf of individual patients/consumers. Findings will be sent to the Kansas Insurance Department. Please include only one complaint per submission. Thank you.
Name
*
First Name
Last Name
Pharmacy Name
*
Business Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Pharmacy Phone Number
*
Please enter a valid phone number.
E-mail
*
example@example.com
Kansas License Number
*
KPhA Member?
*
Yes
No
General Complaint Information
Rx Bin
*
PCN
*
Name of PBM
Leave blank if unknown
Complaint Category
*
Audit
Claim Denial
Contract Breach
MAC List Pricing Dispute
Payment Delay
Payment of Wrong Rates Signed
Other
If other, please list:
Please enter a description of the complaint. Provide as much information as possible but DO NOT include any details that would constitute a HIPPA violation, including Rx-specific information.
*
0/1000
Please read the following statement:
To the best of my knowledge, the information contained herein is true and accurate. I understand that a copy of this form and any or all of the information attached will be sent to the Kansas Insurance Department for further review.
*
By checking this box, you are providing your electronic signature and agreeing to the statement above.
Submit
Should be Empty: