PBM Complaints for change in R/R

Regarding ESI copayment increase.

These instructions are designed to make the process fast, consistent, and simple for pharmacy teams AND your patients.

⚠️IMPORTANT:TDCI does not need hundreds of duplicate complaints.You only need to submit 1–2 strong, well-documented complaints PER PLAN (different BIN / PCN / GROUP).

Below are the complete pharmacy and patient workflows.

💊 PART A — PHARMACY PROCESS

(PBM Contact → Documentation → Submit TDCI PBM Complaint)

A1. Contact ESI’s MAC Appeal Help Desk

📞Call ESI’s MAC Appeal Department:

• 800-711-5672

• 314-684-5606

Ask the representative:

• “Why was reimbursement lowered after an approved MAC appeal?”

• “Why did the patient copay increase after the reversal/rebill?”

• “Was this claim reprocessed under a new deductible/copay/coinsurance phase?”

• “Why was this not billed as the same claim as required under Tennessee PBM Rules (0780-01-95-.04(2))?”

A2. Document EVERYTHING

For each call, write down:

• Date & time

• Representative’s full name (verify spelling)

• Reference/case number

• A short summary of what the rep said

  Keep this with your claim documentation.

A3. File ONE Pharmacy Complaint per PLAN with TDCI

Include:

• Original claim adjudication

• MAC appeal approval

• Rebill adjudication

• Change in pharmacy reimbursement

• Change in patient copay

• Your PBM documentation notes

  
  

Where to file:Tennessee PBM Complaint Form (Pharmacies/covered entities):👉 Visit the Tennessee Department of Commerce & Insurance website → Insurance → Pharmacy Benefits Managers (PBM Complaint Form).

Recommended language to paste into your complaint:

“Tennessee PBM Rules require PBMs to reverse and rebill the same claim (Tenn. Comp. R. & Regs. 0780-01-95-.04(2)), with the ONLY permitted change being the corrected MAC amount under Tenn. Code Ann. § 56-7-3108.  ESI appears to be reprocessing approved appeal claims under NEW deductible/copay phases, increasing patient financial burden and reducing plan liability.This behavior conflicts with Tenn. Code Ann. §§ 56-7-3120, 56-7-3121, and 56-7-2359.”

🧡 PART B — PATIENT PROCESS

(PBM Call → Documentation → Complaint WITH Pharmacy Support)

Patient complaints carry enormous regulatory weight, and pharmacies should help file them.

B1. Patient Calls Their Insurance Provider

📞Have the patient call the number on the back of their insurance card.(If unavailable: 800-282-2881)

The patient should ask:

• “Why did my copay increase after my prescription was ready or picked up?”

• “Was my claim reprocessed under a new deductible/copay phase?”

• “Why did my amount due change after the original clean claim?”

B2. Patient Documents the Call

They should write down:

• Date and time

• Rep name (correct spelling)

• Reference number

• Summary of what was explained

B3. File a TDCI Complaint WITH the Patient

Pharmacies should actively help patients.Here is how:

• Use a store iPad, laptop, or tablet

• Sit with the patient while they fill out the TDCI form

• Stay beside them on speakerphone if needed

• Help them describe the issue clearly and simply

Suggested patient narrative:

“My prescription was ready or already picked up. After the pharmacy appealed pricing, my insurance reprocessed the claim and increased my copay. I am requesting review of why my cost increased after the original clean claim.”

Let patients know:

“I know this takes time, but your complaint is crucial and carries weight with Tennessee regulators.”

Where patients file:TDCI General Insurance Consumer Complaint Portal:👉 Tennessee Department of Commerce & Insurance → Insurance Division → File a Complaint