OSI www PBM – OSI Forms

Pharmacy Benefits Manager Complaint Form

To mail, please send to: Pharmacy Benefit Manager Program Coordinator, 6200 Uptown Blvd. NE, Suite 400, Albuquerque, NM 87110.

Pharmacy Information x

Name of Pharmacy

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Name

Contact Phone Number

Email

PBM Information

Name of PBM

PBM Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Name

Contact Phone Number:

Email

Type 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 at 13.10.30 NMAC. Complaints shall be based on a rule or statute enforced by the New Mexico Office of the Superintendent of Insurance

Enter text

Please attach any documents relevant to your complaint

Max. file size: 8 GB.

Choose file

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. .

CAPTCHA