"Pharmacy Benefits Manager Certificate of Registration - Initial Application Form" - Connecticut

Pharmacy Benefits Manager Certificate of Registration - Initial Application Form is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

Form Details:

  • Released on July 6, 2015;
  • The latest edition currently provided by the Connecticut Insurance Department;
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Download "Pharmacy Benefits Manager Certificate of Registration - Initial Application Form" - Connecticut

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Pharmacy Benefits Manager (PBM)
Certificate of Registration (Initial)
Instructions and Application
Section 38a-479bbb, Connecticut General Statutes requires all Pharmacy Benefits Managers
(PBMs) operating in the State of Connecticut to obtain a certificate of registration. Any new
PBM seeking to do business in Connecticut must first obtain a Certificate of Registration.
The State of Connecticut Insurance Department (the Department) is charged with registering
PBM entities. If you have any questions about your responsibility to register please refer to
C.G.S. §38a-479bbb for more information.
Instructions:
To assure that a PBM certificate of registration is issued timely, the Department requires
that applications be submitted with the $100 nonrefundable application fee by check, made
payable to: Treasurer, State of Connecticut
State of Connecticut
Insurance Department
Pharmacy Benefits Manager Registration
P O Box 816
Hartford, CT 06142-0816
Connecticut law requires that applications for registration be submitted prior to doing
business in the State of Connecticut.
The application must be completed, including all attachments and signed by the CEO of
the PBM entity certifying that all information provided is true and accurate.
Submit your application, attachments via electronic to:
Peter.Nakano@ct.gov
Revised 7/6/2015
PBM Certificate of Registration – Initial Application
Page 1 of 7
Pharmacy Benefits Manager (PBM)
Certificate of Registration (Initial)
Instructions and Application
Section 38a-479bbb, Connecticut General Statutes requires all Pharmacy Benefits Managers
(PBMs) operating in the State of Connecticut to obtain a certificate of registration. Any new
PBM seeking to do business in Connecticut must first obtain a Certificate of Registration.
The State of Connecticut Insurance Department (the Department) is charged with registering
PBM entities. If you have any questions about your responsibility to register please refer to
C.G.S. §38a-479bbb for more information.
Instructions:
To assure that a PBM certificate of registration is issued timely, the Department requires
that applications be submitted with the $100 nonrefundable application fee by check, made
payable to: Treasurer, State of Connecticut
State of Connecticut
Insurance Department
Pharmacy Benefits Manager Registration
P O Box 816
Hartford, CT 06142-0816
Connecticut law requires that applications for registration be submitted prior to doing
business in the State of Connecticut.
The application must be completed, including all attachments and signed by the CEO of
the PBM entity certifying that all information provided is true and accurate.
Submit your application, attachments via electronic to:
Peter.Nakano@ct.gov
Revised 7/6/2015
PBM Certificate of Registration – Initial Application
Page 1 of 7
Pharmacy Benefits Manager (PBM)
Certificate of Registration (Initial)
Instructions and Application
Name of PBM:
PBM Tax Identification Number (TIN/FEIN):
PBM Business Address:
PBM Mailing Address (if different):
PBM Phone Number:
Contact Information (used by the Department for all future correspondence):
Name:
Title:
Mailing Address:
Phone number:
FAX number:
E-mail address:
Name and description of controlling company or organization:
Controlling company’s or organization’s contact name:
Business Address:
Mailing Address (if different):
Revised 7/6/2015
PBM Certificate of Registration – Initial Application
Page 2 of 7
Has any suspension, sanction or disciplinary action been taken against the PBM in Connecticut or any
other state over the past ten years? If so, please provide us with a complete list on an annual basis,
even if the disciplinary action was previously disclosed.
No
Yes
If answered yes, explain:
Has any suspension, sanction or disciplinary action been taken against the controlling company or
organization in Connecticut or any other state over the past ten years? If so, please provide us with a
complete list on an annual basis, even if the disciplinary action was previously disclosed.
No
Yes
If answered yes, explain:
Describe the PBM’s service area:
How many total enrollees are served by the PBM: Nationwide:
Connecticut:
List all entities on whose behalf the PBM has contracts or agreements to provide pharmacy benefit
services to Connecticut enrollees (e.g. Managed Care Organizations):
Revised 7/6/2015
PBM Certificate of Registration – Initial Application
Page 3 of 7
PLEASE SUBMIT THE FOLLOWING AS ATTACHMENTS:
A Certificate from the Secretary of State affirming that the PBM and its controlling
company or organization (if applicable) is in good standing in Connecticut. In addition, for
out of state PBMs, controlling companies or organizations, a certificate that such PBM,
controlling company or organization is in good standing in its state of organization.
A list of the names, addresses, official positions, and professional qualifications of the
persons responsible for conducting the affairs of the PBM. Such people include (1) the
principal officers, partners or association members; (2) all members of the boards of
directors, trustees and executive and governing committees; and (3) any other person
exercising control or influence over the PBM.
A list of the names, addresses, official positions, and professional qualifications of the
persons responsible for operation of the PBM’s controlling company or organization. Such
people include (1) the principal officers, partners or association members; (2) all members
of the boards of directors, trustees and executive and governing committees; and (3) any
other person exercising control or influence over the PBM.
A list of the PBM’s principal owners.
A list of the controlling company’s or organization’s principal owners.
The name and address of the PBM’s agent for service of process in Connecticut.
A contingency plan describing how contracted pharmacy benefit services will be
provided in the event of insolvency.
Copies of PBM certificates of registration or PBM licenses held in other states.
Proof that the PBM meets the surety bond requirements as described in C.G.S Section 38a-
479bbb. The surety bond must be held exclusively for use in paying any outstanding
amounts owed participating members/providers in the event of insolvency or nonpayment.
[Sample bond language is attached.] Please note that the beneficiaries of the surety bond
are the members/providers.
Note: Under no circumstance should the State of Connecticut or the State of Connecticut
Insurance Department be named as the beneficiary.
The most recently concluded fiscal year-end financial statements for the PBM
AND
The most recently concluded fiscal year-end financial statements for the controlling
company or organization.
• Financial statements must include an audit opinion rendered by an independent
certified public accountant (CPA) on the statements stating that they were prepared
in accord with generally accepted accounting principles (GAAP).
Provide the names and addresses of the public accounting firm and internal accountant(s)
preparing or assisting in the preparation of such financial statements.
Revised 7/6/2015
PBM Certificate of Registration – Initial Application
Page 4 of 7
Financial Security Requirement:
Per Connecticut General Statute §38a-479bbb, subsection (c) the financial security amount shall be
“evidence of a surety bond in an amount equivalent to ten (10%) of one month of claims in this state
over a twelve-month average, except such bond shall not be less than twenty-five thousand or more
than one million dollars.”
Enter below the amount of the average monthly Connecticut claims over the last twelve months.
If ten percent (10%) of the monthly average is less than twenty-five thousand dollars ($25,000),
the surety bond shall be in the amount of twenty-five thousand dollars ($25,000). If ten percent
(10%) of the monthly average is greater than one million dollars ($1,000,000), the surety bond
shall be in the amount of one million dollars ($1,000,000).
Calculation of Surety Bond
Period beginning: Month
Day
Year
Period ending:
Month
Day
Year
Total Connecticut claims over the prior twelve months:
$ _____________________________
Average Monthly Claims:
th
(Connecticut business only – one 12
of the total claims in the prior twelve months)
$ _____________________ Multiplied by 10% = Surety Bond amount $ _______________________
Revised 7/6/2015
PBM Certificate of Registration – Initial Application
Page 5 of 7