"Pharmacy Benefit Manager Annual Report Form" - Kentucky

Pharmacy Benefit Manager Annual Report Form is a legal document that was released by the Kentucky Department of Insurance - a government authority operating within Kentucky.

Form Details:

  • Released on June 1, 2017;
  • The latest edition currently provided by the Kentucky Department of Insurance;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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

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(Ed. 6/2017)
Kentucky Department of Insurance
Pharmacy Benefit Manager Annual Report
PBM Name:__________________
PBM License No.: _____________
Reporting Period:______________
CLAIM & APPEAL REPORT
Total drug claims in Kentucky adjudicated subject to
maximum allowable cost pricing:
Total maximum allowable cost appeals received from
Kentucky entities:
Maximum allowable cost appeals granted for Kentucky
entities:
Maximum allowable cost appeals denied for Kentucky
entities:
Number of payments adjusted based on granted appeals
(whether initial appeal or entities reversing and
resubmitting following a granted appeal):
Total dollar amount of adjusted payments to contracted
for granted appeals:
__________________________________
________________
Signature of Authorized Representative for PBM
Date
__________________________________
________________
Printed Name
Phone
(Ed. 6/2017)
Kentucky Department of Insurance
Pharmacy Benefit Manager Annual Report
PBM Name:__________________
PBM License No.: _____________
Reporting Period:______________
CLAIM & APPEAL REPORT
Total drug claims in Kentucky adjudicated subject to
maximum allowable cost pricing:
Total maximum allowable cost appeals received from
Kentucky entities:
Maximum allowable cost appeals granted for Kentucky
entities:
Maximum allowable cost appeals denied for Kentucky
entities:
Number of payments adjusted based on granted appeals
(whether initial appeal or entities reversing and
resubmitting following a granted appeal):
Total dollar amount of adjusted payments to contracted
for granted appeals:
__________________________________
________________
Signature of Authorized Representative for PBM
Date
__________________________________
________________
Printed Name
Phone