"Pharmacy Benefit Manager Application" - Utah

Pharmacy Benefit Manager Application is a legal document that was released by the Utah Insurance Department - a government authority operating within Utah.

Form Details:

  • Released on October 22, 2019;
  • The latest edition currently provided by the Utah Insurance Department;
  • 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 Utah Insurance Department.

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UTAH INSURANCE DEPARTMENT
PHARMACY BENEFIT MANAGER APPLICATION
_____ Initial Application _____ Renewal Application
Legal Name of Applicant: __________________________________ FEIN#: ________________________________
Business Location:
Street: ___________________________________________________________
City, State, Zip: ____________________________________________________
Email Address: ____________________________________________________
Contact person: Name: __________________________________________________________________
Title: ____________________________________________________________
Phone number: ___________________________________________________
Email Address: ____________________________________________________
Name of the Pharmacy Benefit Manager affiliation: ___________________________________________________
Contact person: Name: __________________________________________________________________
Title: ____________________________________________________________
Phone number: ___________________________________________________
Email Address: ____________________________________________________
The following information must accompany the application:
1. Payment of a non-refundable $1,050 fee, ($1,000 license fee plus $50 E-commerce fee, See R590-102-18)
2. The names of all individuals who serve as a director, president, chief executive officer or senior executive officer
of the Pharmacy Benefit Manager.
3. A completed biographical affidavit for each person listed under number 2. above. The form is found at:
https://www.naic.org/documents/industry_ucaa_form11.pdf?90
If there have been no changes since the previous primary or renewal application was filed, mark: “No Change”.
_____ No Change.
If a new biographical affidavit(s) is attached mark _____ See Attachment(s)
I hereby certify, under penalty of perjury, that all of the information submitted in this application including
attachments is true and complete. I am aware that submitting false information or omitting pertinent or other
material information in connection with this application is grounds for license revocation or denial of a license and
may subject me to civil or criminal penalties.
I further certify that I grant permission to the Commissioner to verify information with any federal, state or local
government agency, current or former employee or insurance company.
__________________________________ __________________________________________ ______________
Signature
Printed Name
Date
Any material change in the information submitted in an application shall be reported to the department within 30
days after the day on which the information changes. (See 31A-46-202(2)(b))
Revised 10/22/19
UTAH INSURANCE DEPARTMENT
PHARMACY BENEFIT MANAGER APPLICATION
_____ Initial Application _____ Renewal Application
Legal Name of Applicant: __________________________________ FEIN#: ________________________________
Business Location:
Street: ___________________________________________________________
City, State, Zip: ____________________________________________________
Email Address: ____________________________________________________
Contact person: Name: __________________________________________________________________
Title: ____________________________________________________________
Phone number: ___________________________________________________
Email Address: ____________________________________________________
Name of the Pharmacy Benefit Manager affiliation: ___________________________________________________
Contact person: Name: __________________________________________________________________
Title: ____________________________________________________________
Phone number: ___________________________________________________
Email Address: ____________________________________________________
The following information must accompany the application:
1. Payment of a non-refundable $1,050 fee, ($1,000 license fee plus $50 E-commerce fee, See R590-102-18)
2. The names of all individuals who serve as a director, president, chief executive officer or senior executive officer
of the Pharmacy Benefit Manager.
3. A completed biographical affidavit for each person listed under number 2. above. The form is found at:
https://www.naic.org/documents/industry_ucaa_form11.pdf?90
If there have been no changes since the previous primary or renewal application was filed, mark: “No Change”.
_____ No Change.
If a new biographical affidavit(s) is attached mark _____ See Attachment(s)
I hereby certify, under penalty of perjury, that all of the information submitted in this application including
attachments is true and complete. I am aware that submitting false information or omitting pertinent or other
material information in connection with this application is grounds for license revocation or denial of a license and
may subject me to civil or criminal penalties.
I further certify that I grant permission to the Commissioner to verify information with any federal, state or local
government agency, current or former employee or insurance company.
__________________________________ __________________________________________ ______________
Signature
Printed Name
Date
Any material change in the information submitted in an application shall be reported to the department within 30
days after the day on which the information changes. (See 31A-46-202(2)(b))
Revised 10/22/19