Pharmacy Benefit Manager

The IDOI provides renewal requirements for Certification of Licensure for a Pharmacy Benefit Manager (PBM) under IC 27-1-24.5 and 760 IAC 5.

The annual license renewal process can be completed electronically at www.sircon.com/indiana. The following items must be attached to renew as a PBM:

• Licensee's current audited annual financial statements prepared by an independent certified public accountant in accordance with generally accepted accounting principles (GAAP) reflecting a positive net worth.
• Licensee's articles of incorporation or other business organization documents. (Submit only if there have been changes to the previously submitted documents.)
• Address of each office the licensee maintains in Indiana or a statement affirming the licensee maintains no offices in Indiana. (Submit only if there have been changes to the previously submitted addresses or statement.)
• List by jurisdiction of each name under which the licensee has operated in the preceding five (5) years, including any: (A) alternative names; (B) names of predecessors; and (C) if known, successor business entities; or a statement affirming there are no other names under which the licensee has operated in the preceding five (5) years. (Submit only if there have been changes to the previously submitted list or statement.)
• List identifying the following and indicating percentage of ownership if applicable: (A) Stockholders holding ten percent (10%) or more of the voting securities;  (B) Investors holding a ten percent (10%) or greater interest; (C) Partners; (D) Corporate officers and directors; (E) Trustees; (F) If an association, all of the members; (G) Any affiliates. (Submit only if there have been changes to the previously submitted list.)
• Chart showing the relationship of the licensee to all affiliates. An affiliate that is an insurance company shall be identified as such. (Submit only if there have been changes to the previously submitted chart.)
• NAIC Biographical Affidavits of all of the following: (A) Officers; (B) Directors; (C) Stockholders holding ten percent (10%) or more voting securities; (D) Investors holding ten percent (10%) or greater interest; (E) Partners; (F) Trustees; (G) Members, if an association. (Submit only if there have been changes to the previously submitted NAIC Biographical Affidavits.)
• Statement describing the licensee's business plan, including the following information: (A) Staffing levels and activities proposed in Indiana and nationwide. (B) Details concerning the licensee's capability for providing a sufficient number of experienced and qualified personnel in the areas of pharmacy contracting, prescription drug benefit administration, pharmacy claims processing, prescription drug formulary development, prior authorization determination, prescription drug rebate administration, establishing pharmacy networks, and record keeping. (Submit only if there have been changes to the previously submitted business plan.)
• List of all health plans for whom the licensee provides pharmacy benefit management services in this state and the date the applicant began providing pharmacy benefit management services to each health plan. The list must include the NAIC number of any insurance companies. (Submit only if there have been changes to the previously submitted list.)
• Copy of the written policies and procedures which demonstrate that the applicant has compliant processes established to adhere to the appeals and dispute resolution process as required by IC 27-1-24.5-22 and the requirements for maximum allowable cost pricing set forth in IC 27-1-24.5-22, accompanied by State Form 57243 Pharmacy Benefit Manager Compliance Checklist. (Submit only if there have been changes to the previously submitted policies and procedures.)

For questions, contact the Pharmacy Benefit Manager Division at PBMcompliance@idoi.IN.gov.