Pharmacy Benefit Manager (PBM) Complaints
The Colorado Division of Insurance (DOI) has the authority to enforce statutory requirements regarding Pharmacy Benefit Management Firms (PBMs), as granted by HB23-1227, Enforce Laws Against Pharmacy Benefit Managers. The DOI assists providers and pharmacies with concerns related to PBM business practices and conduct that may violate state law. If you have an issue you would like to submit to the DOI, please review the information outlined below.
Definition of a PBM: A "Pharmacy benefit management firm," "pharmacy benefit manager," or "PBM" means any entity doing business in this state that administers or manages pharmacy drug benefits on behalf of any carrier that provides such benefits to Colorado residents. PBMs subject to DOI’s authority may directly contract with a carrier or be related to, share ownership with, or be otherwise associated with a carrier. Entities excluded from this statutory definition can be found in C.R.S § 10-16-102(49)(b).
Before Submitting a Complaint
Before filing a complaint with the Colorado Department of Insurance (DOI) regarding a PBM-related issue:
It is recommended you first contact the PBM to resolve the matter.
You may want to document phone calls to the company, keep copies of all written communications, and complete all levels of contractual appeals available.
If you are still unable to resolve your complaint, you may contact the DOI for assistance.
Instructions to File a PBM Complaint
To file a complaint against a PBM for violation of law or rule, fill out this PBM Complaint Form in its entirety. Once complete, submit it to the DOI via email at dora_pbm_compliance@state.co.us along with any supporting documentation you wish to include.
Supporting Documentation
Be sure to include as much relevant information as possible to support the Division’s investigation of your complaint. The appropriate supporting documents may vary depending on the nature of your complaint. Please send copies, not originals, of:
- Details of any previous contact with the PBM regarding the matter.
- Copies of documents that help verify or explain the problem.
- Copies of invoices, MAC appeals, and communications with the PBM regarding your complaint.
Preserving Access to Rural Independent Pharmacies (HB25-1222)
About HB25-1222
The Division is committed to ensuring that Pharmacy Benefit Managers (PBMs) comply with state laws designed to protect independent pharmacies, as they are critical to delivering health care services to Colorado’s rural communities and vulnerable populations. HB25-1222 became effective January 1, 2026 and provides new protections for rural independent pharmacies, including that it requires PBMs to pay a rural independent pharmacy an amount no less than the National Average Drug Acquisition Cost (NADAC) for the dispensed prescription drug, plus a specified dispensing fee. This provision is codified in section 10-16-122.3(1.5), C.R.S.
Definition of Rural Independent Pharmacy
A rural independent pharmacy is defined in C.R.S. § 10-16-102(59.5) as a pharmacy that is:
- Privately owned by at least one licensed pharmacist; and
- Has no ownership interest in, or affiliation with, a chain pharmacy or a publicly traded prescription drug outlet.
Rural Independent Pharmacy Inquiries & Complaints
If you have concerns that a PBM is not complying with HB25-1222, first contact the PBM. Reach out to the PBM directly about your concerns. Make sure to keep copies of your correspondence with the PBM. If your inquiry to the PBM is unsuccessful or results in a refusal to pay, review the following steps to submit a complaint to the DOI.
File Your Rural Independent Complaint with the DOI
If you are unable to directly resolve your complaint with the PBM, you may submit a complaint to the DOI at dora_pbm_compliance@state.co.us. To help us process your complaint more quickly, please provide the following level of detail:
Confirm You are a Rural Independent Pharmacy
Please include a brief statement in your complaint confirming that your pharmacy meets the criteria for being a rural independent pharmacy. A rural independent pharmacy is defined under statute as a pharmacy that is:
- Privately owned by at least one licensed pharmacist; and
- Has no ownership interest in, or affiliation with, a chain pharmacy or a publicly traded prescription drug outlet.
The Division recommends using the following documents to verify if a pharmacy should be considered a rural independent pharmacy to determine eligibility for the protections available under HB25-1222:
- A current, active Prescription Drug Outlet license issued by the Colorado Department of Regulatory Agencies, Division of Professions and Occupations;
- A current, active Pharmacist License for each pharmacist-owner;
- Articles of Incorporation or Articles of Organization filed with the Colorado Secretary of State; and
- Sworn Affidavits from pharmacist-owners attesting to their ownership interest and lack of affiliation with chain or publicly traded pharmacies.
The following documents can be useful, but are not required, to verify rural independent status.
- A current Sales Tax License issued by the Colorado Department of Revenue;
- A Federal Employer Identification Number (EIN); and/or
- A list of National Provider Identifiers (NPIs) covered under the entity.
Separate by PBM
If you have concerns about multiple PBMs, please file a separate complaint for each PBM or create clearly distinct sections in your complaint description relating to each company.
Provide Representative Claim Examples
Please provide at least one specific claim or transaction example per PBM.
Attach Documentation of PBM Correspondence
Attach any relevant Remittance Advices or correspondence from the PBM that supports your allegation.
What Happens After I File a PBM Complaint?
Once you file a complaint, the DOI will respond, confirming receipt of the complaint. Depending on the circumstance, the DOI may:
- Send an inquiry letter to the PBM communicating the concerns brought to the Division’s attention and request a written response.
- Review the PBM response to the Division’s inquiry to determine if the PBM named in your complaint is performing as required under the law.
- Send a findings letter containing the Division’s analysis and findings related to the filed complaint.
You will receive a copy of all correspondence received during the DOI’s review of your complaint and a letter explaining our findings. If you have questions, disagree with our findings, or have additional information not included with your original complaint, you may submit the information to us for further review. Please understand that our complaints are thoroughly reviewed; however, we may not be able to provide the exact results you desire. We hope through our complaint process, we can help you understand the laws that may apply; however, the DOI does not provide legal advice.
What We Can Do
Provide you with additional information relevant to your complaint file.
Investigate your complaints against PBMs.
Submit your complaint to the PBM and require a response to the Colorado Department of Insurance.
Review the response to determine if the PBM is acting according to appropriate statutes.
Require corrective action, if we determine that the PBM did not meet the legal requirements of the Act.
What We Cannot Do
Assist with your PBM complaint if you have involved an attorney.
Provide legal advice or provide legal representation.
Intervene on your behalf in a pending lawsuit.
Determine the facts regarding any other disagreement between you and another party.
Help resolve PBM complaints or investigate matters not subject to the laws of the State of Colorado.