Pharmacy Benefit Manager
What is a Pharmacy Benefit Manager (or PBM)?
A Pharmacy Benefit Manager contracts with an insurer or other third-party payor, to manage the prescription drug coverage provided by the insurer or other third-party payor. This includes:
- Processing and payment of claims for prescription drugs
- Performing drug utilization review
- Processing drug prior authorization requests
- Adjudication of appeals or grievances related to prescription drug coverage
- Contracting with network pharmacies
- Controlling the cost of covered prescription drugs
Pharmacy Benefit Managers are required to:
- Update the price and drug information for each list that the PBM maintains every seven business days.
- At the beginning of the term of a contract, on renewal of a contract and at least once during the term of a contract, make available to each network pharmacy the sources used to determine maximum allowable cost pricing.
- Establish a process by which a network pharmacy may appeal its reimbursement for a drug subject to maximum allowable cost pricing.
- Allow a pharmacy services administrative organization that is contracted with the PBM to file an appeal of a drug on behalf of the organization’s contracted pharmacies.
Before applying:
Forms:
Form E-150 Pharmacy Benefit Manager Application
Complete this form to apply for a PBM Certificate of Authority. Answer every question on the application. The form will prompt you for the required attachments. Payment of the application fee of $500 should be made via OPTins. Attach all required documents to the payment record in OPTins. Once the payment and documents have been submitted, send an email with the OPTins confirmation to [email protected].
Complete this form to report the name and title of each individual reflected in the count on Form E-150, Section H, Item 1.
NAIC Form 11: Biographical Affidavit
Must be completed for each person listed on Form E-150-B.