Form PBM "Pharmacy Benefit Manager License Application" - Kentucky

What Is Form PBM?

This is a legal form that was released by the Kentucky Department of Insurance - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2021;
  • The latest edition provided by the Kentucky Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PBM by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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Download Form PBM "Pharmacy Benefit Manager License Application" - Kentucky

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Form PBM (02/2021)
For Office Use Only
Check appropriate box for license
_____________
Amt. Rec’d
requested:
Resident License
_____________
Date Rec’d
Non-Resident License
. _____________
Identify Home State:
Tracking No
_________________________
COMMONWEALTH OF KENTUCKY
_____________
Cashier:
Identify Home State License #:
DEPARTMENT OF INSURANCE
(if applicable)
P. O. Box 517
___________________
Frankfort, Kentucky 40602-0517
email: DOI.AgentLicensingMail@ky.gov
http://insurance.ky.gov
Ph. 502-564-6004
Fax 502-564-6030
(PLEASE PRINT OR TYPE)
PHARMACY BENEFIT MANAGER LICENSE APPLICATION
New License Application
Renewal Application
Section 1 – Demographic Information
Entity Name
Incorporation/Formation Date (MM/DD/YY)
FEIN
If assigned, National Producer Number (NPN)
State of Domicile
UR Registration #:
List any other assumed, fictitious, alias or trade names under which you are doing business or intend to do business.
Address of Home Office
City
State
ZIP Code
Business Address (Physical Street)
City
State
ZIP Code
Phone Number (include extension)
Fax Number
Business E-Mail Address
Business Website Address
(
)
-
(
)
-
Mailing Address
P.O. Box
City
State
ZIP Code
Listing of entities/individuals for which the PBM provides services (within Kentucky only):
Applicant Background Information
Attach a full explanation and/or the requested information for questions below as an attachment to this application. Failure to provide the required attachments
or any omissions may result in the denial of this application.
□ □
Has the applicant been refused a registration, license or certification to act as (or provide the services of) a
YES
NO
Pharmacy Benefit Manager, Pharmacy Benefit Management Plan, Pharmacy Benefits Processor, Third Party
Administrator, Third Party Provider, etc., or has any registration, license or certification to act as such been
denied, suspended, revoked or non-renewed for any reason by any state or federal entity? (Attach specific
details separately.)
□ □
Has the applicant ever been found liable in any lawsuit or arbitration proceeding involving allegations of fraud,
illegal or dishonest activities in connection with the administration of pharmacy benefit management services?
YES
NO
(Attach specific details separately.)
□ □
Has the applicant had a business relationship with an insurance company terminated for any alleged fraudulent,
illegal or dishonest activities in connection with the administration of pharmacy benefit management services?
YES
NO
(Attach specific details separately.)
□ □
Has the applicant, parent company or any company or organization controlling the operation of the Pharmacy
Benefit Manager experienced any data security breaches or HIPAA security breaches? (If YES please attach all
YES
NO
pertinent information concerning any data security breach. Any future data security breach must be reported
immediately to the Kentucky Department of Insurance.)
□ □
Does the applicant own, operate or affiliate with any pharmacy located outside of Kentucky that ships, mails or
delivers in any manner, controlled substances, prescription or legend drugs or devices into Kentucky?
YES
NO
Page 1 of 4
Form PBM (02/2021)
For Office Use Only
Check appropriate box for license
_____________
Amt. Rec’d
requested:
Resident License
_____________
Date Rec’d
Non-Resident License
. _____________
Identify Home State:
Tracking No
_________________________
COMMONWEALTH OF KENTUCKY
_____________
Cashier:
Identify Home State License #:
DEPARTMENT OF INSURANCE
(if applicable)
P. O. Box 517
___________________
Frankfort, Kentucky 40602-0517
email: DOI.AgentLicensingMail@ky.gov
http://insurance.ky.gov
Ph. 502-564-6004
Fax 502-564-6030
(PLEASE PRINT OR TYPE)
PHARMACY BENEFIT MANAGER LICENSE APPLICATION
New License Application
Renewal Application
Section 1 – Demographic Information
Entity Name
Incorporation/Formation Date (MM/DD/YY)
FEIN
If assigned, National Producer Number (NPN)
State of Domicile
UR Registration #:
List any other assumed, fictitious, alias or trade names under which you are doing business or intend to do business.
Address of Home Office
City
State
ZIP Code
Business Address (Physical Street)
City
State
ZIP Code
Phone Number (include extension)
Fax Number
Business E-Mail Address
Business Website Address
(
)
-
(
)
-
Mailing Address
P.O. Box
City
State
ZIP Code
Listing of entities/individuals for which the PBM provides services (within Kentucky only):
Applicant Background Information
Attach a full explanation and/or the requested information for questions below as an attachment to this application. Failure to provide the required attachments
or any omissions may result in the denial of this application.
□ □
Has the applicant been refused a registration, license or certification to act as (or provide the services of) a
YES
NO
Pharmacy Benefit Manager, Pharmacy Benefit Management Plan, Pharmacy Benefits Processor, Third Party
Administrator, Third Party Provider, etc., or has any registration, license or certification to act as such been
denied, suspended, revoked or non-renewed for any reason by any state or federal entity? (Attach specific
details separately.)
□ □
Has the applicant ever been found liable in any lawsuit or arbitration proceeding involving allegations of fraud,
illegal or dishonest activities in connection with the administration of pharmacy benefit management services?
YES
NO
(Attach specific details separately.)
□ □
Has the applicant had a business relationship with an insurance company terminated for any alleged fraudulent,
illegal or dishonest activities in connection with the administration of pharmacy benefit management services?
YES
NO
(Attach specific details separately.)
□ □
Has the applicant, parent company or any company or organization controlling the operation of the Pharmacy
Benefit Manager experienced any data security breaches or HIPAA security breaches? (If YES please attach all
YES
NO
pertinent information concerning any data security breach. Any future data security breach must be reported
immediately to the Kentucky Department of Insurance.)
□ □
Does the applicant own, operate or affiliate with any pharmacy located outside of Kentucky that ships, mails or
delivers in any manner, controlled substances, prescription or legend drugs or devices into Kentucky?
YES
NO
Page 1 of 4
Form PBM (02/2021)
Pharmacy Benefit Manager
Section 2 – Service of Process Agent for Pharmacy Benefit Manager
______________________________________________________________________________________________________________________________
Name
Address ________________________________________________________ City _______________________________ State ______________________ ZIP Code _____________
Phone Number (
) _______________________________
E-Mail Address ______________________________________________________________________________
Section 3 –Licensed Administrator Acting on Behalf of the Pharmacy Benefit Manager
According to KRS 304.9-133, a business entity shall have at least one licensed individual with same line of authority and shall have at least one licensed individual designated
List primary licensed contact person(s) responsible for regulatory compliance on behalf of the Pharmacy Benefit Manager:
with the commissioner at all times
.
Name___________________________________________________________________________Official Title_____________________________________
Phone: ____________________________ Email: ______________________________________ NPN or DOI ID#: ________________________________
Name___________________________________________________________________________Official Title_____________________________________
Phone: ____________________________ Email: ______________________________________ NPN or DOI ID#: ________________________________
Name___________________________________________________________________________Official Title_____________________________________
Phone: ____________________________ Email: ______________________________________ NPN or DOI ID#: ________________________________
Section 4 – Individuals Responsible for the Compliance and Conduct of Affairs for Pharmacy Benefit Manager
List all individuals responsible for the compliance/conduct of affairs, including members of the board of directors, board of trustees, executive committee, other
governing board or committee, the principal officers in the case of a corporation, the partners or members in the case of a partnership or association, and any other
person who exercises control or influence over the affairs of the Pharmacy Benefit Manager.
1.
Name___________________________________________________________________________Official Title__________________________________
Address______________________________________________________________Professional Qualifications__________________________________
2.
Name____________________________________________________________________________Official Title_________________________________
Address_____________________________________________________________Professional Qualifications___________________________________
3.
Name___________________________________________________________________________Official Title__________________________________
Address______________________________________________________________Professional Qualifications__________________________________
4.
Name___________________________________________________________________________Official Title__________________________________
Address______________________________________________________________Professional Qualifications_________________________________
5.
Name___________________________________________________________________________Official Title__________________________________
Address______________________________________________________________Professional Qualifications__________________________________
6.
Name____________________________________________________________________________Official Title_________________________________
Address_____________________________________________________________Professional Qualifications___________________________________
7.
Name___________________________________________________________________________Official Title__________________________________
Address______________________________________________________________Professional Qualifications__________________________________
8.
Name___________________________________________________________________________Official Title__________________________________
Address______________________________________________________________Professional Qualifications__________________________________
(Attach additional sheets if necessary)
Page 2 of 4
Form PBM (02/2021)
Pharmacy Benefit Manager
Section 5 - Administration and Operation: The following documentation must be submitted with this application.
The documentation required to be submitted in this section should be submitted as a Portable Document Format (PDF)
bookmarked document in accordance with the items listed below and submitted to the Department via email to
DOI.PharmacyBenefitManager@ky.gov.
1. Attach a detailed description of the generic drug pricing dispute appeal process to be used by contracted pharmacies,
pharmacy services and administration organizations or group purchasing organization, including the appeals policy
and procedure, pursuant to KRS 304.17A-162 (1) (b).
2. Attach the policy and procedure used for making price updates warranted as a result of an appeal granted under KRS
304.17A-162, including PBM’s means of providing notification to all other contracted pharmacies in the network.
3. Identify the national drug pricing compendia or sources used to obtain drug price data for every drug for which the PBM
establishes a maximum allowable cost to determine the product reimbursement, pursuant to KRS 304.17A-162(3).
4. Identify the location of PBM’s comprehensive list of every drug subject to generic drug pricing, per KRS 304.17A-
162(4).
5. Attach the policy and procedure to be used for updating generic drug pricing every seven days and the PBM’s ability to
provide notification to all contracted pharmacies (KRS 304.17A-162 (6) and (7)).
6. Attach the policy and procedure that ensures that every drug subject to generic drug pricing meets requirements set forth
in KRS 304.17A-162(8) through KRS 304.17A-162(13).
7. Attach the policy and procedure relating to the resolution of generic drug pricing complaints which are filed with the
Kentucky Department of Insurance, including timeframes and sample appeal response letter. Provide a contact
person’s name, address, email, and telephone number for complaints.
8. Attach the Exceptions Policy that allows an enrollee, designee, or prescribing provider to gain access to clinically
appropriate drugs not otherwise covered by the plan, and includes a standard and expedited procedure. (45 CFR
156.122 and KRS 304.17A-535).
9. Provide the policy that explains the process that gives the ability to access prescriptions from an in-network retail, unless
special handling or another reason proves that the prescription cannot be provided by a retail pharmacy. (45 CFR
156.122).
10. Attach the policy explaining any Pharmacy and Therapeutics committee membership standards and duties, including
how often the committee meets, structure, and the decision-making process. (45 CFR 156.122)
11. Provide a listing of any delegated/contracted companies that perform part of the PBM services.
12. Attach proof of financial responsibility in the amount of one million dollars ($1,000,000).
13. Attach proof of a registered agent and office with the Kentucky Secretary of State in accordance with KRS 14A.4-010
14. Attach $1,000 non-refundable fee (KRS 304.9-200(4)), made payable to the Kentucky State Treasurer.
The filing fee must be sent via US post to the address above with a copy of the application form attached to the check.
Page 3 of 4
Form PBM (02/2021)
Pharmacy Benefit Manager
Section 6 - Applicant’s Certification and Attestation
On behalf of the Pharmacy Benefit Manager, applicant hereby certifies, under penalty of perjury, that:
All of the information submitted in this application and attachments is true and complete and I am aware that submitting false information or omitting pertinent or
1.
material information in connection with this application is grounds for license or registration revocation and may subject me and the applicant
to civil or criminal penalties.
The applicant grants permission to the Kentucky Department of Insurance or other appropriate party in the Commonwealth of Kentucky to verify any information
2.
supplied with any federal, state, or local government agency, current or former employer, or insurance company.
I authorize the Kentucky Department of Insurance to give any information they may have concerning me, as permitted by law, to any federal, state or municipal agency,
3.
or any other organization and I release the Kentucky Department of Insurance, and any person acting on their behalf, from any and all liability of whatever nature by
reason of furnishing such information.
I acknowledge that I understand and shall comply with the insurance laws and regulations of Kentucky.
4.
I hereby certify that I will furnish any additional information upon request.
5.
Must be signed by an officer, director, or partner of the entity, or member or manager of a limited liability company who
has authority to act on behalf of the entity:
_____________________________________________________
_______________________________________________
Signature
Date
_______________________________________________________
_________________________________________________
_
Typed or Printed Name
Title
___________________________________________________________________________________________________________________________
Address line 1
___________________________________________________________________________________________________________________________
Address line 2
___________________________________________________________________________________________________________________________
City
State
ZIP
Page 4 of 4
Page of 4