Pharmacy Benefit Manager Complaints: Supporting Documentation

When submitting a complaint, be sure to include as much information as possible to support your complaint. This will increase the likelihood of your complaint being successful and prevent unnecessary delays due to requests for additional information. Depending on the nature of your complaint, the appropriate supporting documents may vary. The lists below provide examples of possible supporting documents for each type of complaint. Please note that these examples are not inclusive of all possible items that may be provided as support. Additionally, please ensure that the patient is a resident of Tennessee or an employee in Tennessee, as this is a requirement for submitting a valid complaint.

Reimbursement Appeals

Insurer or PBM failing to pay the dispensing pharmacy at least acquisition cost for medication. T.C.A § 56-7-3108 and T.C.A § 56-7-3206(c)

  • Date the appeal was submitted to PBM and copy of the appeal.
  • Date the invoice was submitted to PBM and copy of the invoice.
  • Copy of the dated PBM response.
  • Was reverse and rebill allowed? Describe and/or show any issues with reverse and rebill.
  • Specify whether an external appeal process was started and when it was submitted.
  • Specify whether patient was a TN resident at the time of fill.
  • Date any additional payment was made if applicable.

Dispensing Fee

Insurer or PBM failing to pay the appropriate dispense fee to a low-volume pharmacy. T.C.A. § 56-7-3206

  • PBM Message showing claim payment details.
  • A listing of Rx #s, group #s, and dates of service for complaints involving multiple claims involving the PBM.
  • Pharmacy claim history detail for member.
  • Signed and dated Low Volume Pharmacy Certification and Proof of Submission to PBM.
  • Specify whether patient was a TN resident at the time of fill

Steering

Insurer or PBM interfering with an insured’s right to choose a contracted pharmacy. T.C.A.§ 56-7-3120.

  • PBM Reject Claim Message - Message rejecting the claim and indicating that the pharmacy was out of network.
  • A listing of Rx #s, group #s, and dates of service for complaints involving multiple claims involving the PBM.
  • Screenshots or copies of electronic messages from PBMs.
  • Pharmacy claim history detail for member.
  • Signed and dated Attestation Form and proof of submission to PBM.
  • Network messaging to pharmacy or member.
  • Rejection notice of pharmacy’s network application.
  • Note that ERISA plans are exempt from steering laws and statutes.

Audits

Insurer or PBM failing to comply with statutory requirements for audits of pharmacy/pharmacist. T.C.A. § 56-7-3103

  • Evidence that the PBM failed to provide written notice at least two (2) weeks prior to conducting an initial on-site audit.
  • Copies of the draft and final audit reports.
  • Evidence of when draft and final audit reports were furnished to the pharmacy.
  • Pharmacy response to draft report and evidence of when the response was submitted to the PBM.

Prompt Pay for Clean Claims

Insurer or PBM failing to provide payment within 30 calendar days for paper claims and 21 calendar days for electronic claims for clean claims defined in the T.C.A. T.C.A. § 56-7-109 and T.C.A. § 56-7-3124

  • Provide date of service (DOS), claim adjudication date if different than DOS, and prescription # for claim(s) in question along with screenshot of adjudicated claim information from operating system.
  • Copies or screenshots of any communications between pharmacy and PBM regarding claim(s) in question.
  • If payment had been received prior to submitting complaint, provide payor, check #, and date on check with copy or screenshot of payment.

Step Therapy

Insurer or PBM failing to provide a step therapy exception. T.C.A. § 56-7-3502

  • A listing of Rx #s, group #s, and dates of service for complaints involving multiple claims involving the PBM.
  • Screenshots or copies of electronic messages from PBMs.
  • Reject Claim Message - Message rejecting the prescribed dosage and instructing the pharmacist to work with doctor to prescribe a lower dosage.
  • Patient history details showing that step therapy was not appropriate. For example, evidence the patient was prescribed an equivalent medication in the past at corresponding dosages, or evidence of past step therapy.
  • Network messaging to pharmacies or members– Any communications from the PBM indicating that an appropriate step therapy exception is not available to a member.

Allowing Disclosures

Insurer or PBM penalizing a pharmacy for (or restricting pharmacy from) disclosing a lower price available for a prescription drug by not using health insurance for prescription purchase. T.C.A. § 56-7-3114

  • A listing of Rx #s, group #s, and dates of service for complaints involving multiple claims involving the PBM.
  • Screenshots or copies of electronic messages from the PBM.
  • Network Messaging- Any communications from the PBM to a pharmacy that instructs the pharmacy to not disclose a lower price available for a prescription drug if a customer chooses not to use their insurance benefits.
  • Any documentation showing that the pharmacy was penalized by the PBM.

Other Complaints

  • A listing of Rx #s, group #s, and dates of service for complaints involving multiple claims involving the PBM.
  • PBM message showing claim payment details or rejecting claim.
  • Pharmacy claim history detail for member.
  • Network messaging to pharmacies or member.
  • Detailed description of the issue that is the cause for filing the complaint.