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Pharmacy Benefit Managers

Pharmacy Benefit Managers
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Registration

PBM registration with the Department is required by June 1 through December 31, 2023. On and after January 1, 2024, licensing with the Department is required.

PBMs should create an account and log in to the secure DFS Portal to register. An application for registration can be started, and then completed in separate portal sessions if needed. After filing, an email receipt will be sent that includes a PDF copy of the completed application.

To get started, visit the DFS Portal, go to "Ask for Apps" and select "Pharmacy Benefit Managers.”

FAQs About Registration and Licensing

Frequently Asked Questions About Mandatory Registration and Licensing Pursuant to Insurance Law §§ 2905 and 2906


Mandatory PBM Registration FAQ's

When is a PBM required to obtain a registration?
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Until December 31, 2023, PBMs are required to apply and obtain a registration prior to performing pharmacy benefit management services on behalf of New York health plans. All registrations expire on December 31, 2023, regardless of when the registration was made. Thereafter, a PBM must apply for and obtain a license from the Department to begin or continue performing pharmacy benefit management services in New York.

Where can I find the PBM registration application?
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Each entity seeking to register as a PBM must submit an application via the DFS Portal (see “Registration” section above).

Is there a fee for filing a registration application?
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Yes, a PBM applying to register shall pay to the superintendent a non-refundable registration application fee of $4,000 with its registration application.

 

Mandatory PBM Licensing FAQ’s

Who is required to obtain a license?
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Under the statute, a “pharmacy benefit manager” (“PBM”) is any entity that performs pharmacy benefit management services (“PBM services”) for a health plan. Critically, the definition applies to entities acting “for a health plan.” The requirement, therefore, does not include individual employees of a PBM nor does it include units/groups/divisions or other groups of employees of a health plan which perform PBM services for that health plan. A health plan that performs PBM services for another health plan, however, would meet the definition of pharmacy benefit manager and would be required to obtain a license.

How do I submit a PBM license application?
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License applications must be submitted through the existing registration portal. The portal has been modified to provide instructions on how to submit the additional documentation required for a license application. All PBMs who are registered with the Department received an email with instructions for submitting a license application. Email [email protected] if you did not receive that email or if you have any questions concerning the application process.

How long is a license valid for?
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Every license is valid for 36 months from the date it was issued. Licenses may be renewed upon the filing and approval of an application that meets the standards for licensing.

Is there a fee for filing a license application?
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Yes, the Insurance Law requires a PBM applying for licensure to pay a fee of $24,000. This fee covers the three-year period for which the license is valid.

What are pharmacy benefit management services?
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Under the statute, PBM services mean the management or administration of prescription drug benefits for a health plan, directly or through another entity.
Any of the following services, individually or in combination, constitute PBM services:

  1. claims processing, retail network management, or payment of claims to pharmacies for dispensing prescription drugs;
  2. clinical or other formulary or preferred drug list development or management;
  3. negotiation or administration of rebates, discounts, payment differentials, or other incentives, for the inclusion of particular prescription drugs in a particular category or to promote the purchase of particular prescription drugs;
  4. patient compliance, therapeutic intervention, or generic substitution programs;
  5. disease management for prescription drug benefits;
  6. drug utilization review or prior authorization for drug benefits;
  7. adjudication of appeals or grievances related to prescription drug coverage;
  8. contracting with and or managing the relationship with network pharmacies including mail service pharmacy agreements; and
  9. drug benefit design, including methods for the controlling of cost of covered prescription drugs.

Therefore, if you have agreed to perform at least one of those functions for a health plan you are performing PBM services.

What is a health plan for these purposes?
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“Health plan” is defined broadly under the statute. It includes any entity that approves, provides, arranges for, or pays or reimburses for prescription drugs. To be covered under the statute a health plan must cover a “substantial number of beneficiaries who work or reside in this state.”

The Department has clarified by regulation that “a substantial number of beneficiaries who work or reside in this state” means “50 percent or more of the beneficiaries of the plan work or reside in New York”.

How do I determine whether 50 percent or more of the beneficiaries of the health plan work or reside in New York?
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A beneficiary of a health plan is considered a New York beneficiary (i.e., someone who works or resides in New York) for purposes of Insurance Law Article 29, Public Health Law section 280-a, and the applicable regulations promulgated thereunder, when any of the following are true:

  1. The health plan is issued by an insurance company that is an authorized insurer under the insurance law, a company organized pursuant to article forty-three of the insurance law, a municipal cooperative health benefit plan established pursuant to article forty-seven of the insurance law, an entity certified pursuant to article forty-four of the public health law, an institution of higher education certified pursuant to section one thousand one hundred twenty-four of the insurance law, the state insurance fund, or the New York state health insurance plan established under article eleven of the civil service law;
  2. The beneficiary’s primary participant of the health plan has or had access to that health plan as a result of working in New York; or
  3. The beneficiary resides in New York.

For purposes of calculating the total number of beneficiaries under a health plan, each primary participant of the health plan and all beneficiaries under each primary participant should be counted as beneficiaries for purposes of calculating the total number of New York and non-New York beneficiaries under the health plan.

Once you have determined which beneficiaries are considered New York beneficiaries, you can then calculate what percentage of the total beneficiaries work or reside in New York.

Is an entity that provides pharmacy benefit management services exclusively in the workers’ compensation industry required to obtain a license from the Department as a PBM?
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Yes. Workers’ compensation plans provide benefits which include payment for prescription drugs. Therefore, the broad definition of health plan in the law which includes any policy or plan that provides prescription drug coverage includes workers’ compensation plans. PBMs that provide services only for workers’ compensation plans in New York must obtain a license.

Is a PBM that provides services exclusively for self-insured plans required to obtain a license from the Department as a PBM?
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Yes, self-insured plans are health plans under the statute, therefore an entity that provides PBM services to a self-insured health plan must obtain a license.

Is a PBM that provides services exclusively for Medicare Part D plans required to be licensed with the Department as a PBM?
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Yes, the term “health plan” covers Medicare Part D plans.

Who can enforce the violation, penalty and damages provision of Insurance Law § 2905(b)?
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After notice and a hearing, the superintendent is authorized to enforce the violations, penalty, and damages provision located in § 2905(b) of the Insurance Law. This provision does not create a private cause of action.

If any health plan, pharmacy or covered individual, or other person believes they have been harmed by a PBM as a result of that PBM acting without being licensed under this section, they should notify the Department by email at [email protected] and the Department will review and take any appropriate enforcement action.

Annual Reporting

An Annual Report must be completed and submitted to the Department by no later than July 1 each year.

Completion and submission of the following items will constitute the second annual report:

The primary contact person listed in the PBM registration application will receive a link to file the Annual Report. If a link is not received, contact the Department.

Pharmacy Benefit Managers Registered in New York

REG NO.

PHARMACY BENEFIT MANAGER NAME

ALSO KNOWN AS (AKA)

1287

A & A Services LLC

Sav-Rx Prescription Services

1286

Alius Health, LLC

 

1315

Alluma LLC

 

1105

American Workers Compensation Prescriptions LLC

AWPRx

1185

AmwINS Group Benefits, LLC

AmWINS Rx

1085

Applied Underwriters, Inc.

 

1274

AscellaHealth LLC

 

1254

Benecard Services, Inc

Benecard PBF

1003

Broadreach Medical Resources, Inc.

 

1331

Cadence Rx, Inc.

 

1027

Capital Rx

 

1188

Carelon Rx, Inc.

IngenioRx, Inc.

1256

Caremark, L.L.C.

CVS Caremark

1255

CaremarkPCS Health, L.L.C.

CVS Caremark

1229

CaremarkPhC, L.L.C.

CVS Caremark

1276

Centene Pharmacy Services, Inc.

Envolve Pharmacy Solutions, Inc.

1248

Cigna Health and Life Insurance Company

Cigna Pharmacy Management

1224

Citizen's Rx LLC

CitizensRx Holdings LLC

1294

Costco Health Solutions, Inc.

 

1107

DST Pharmacy Solutions, Inc.

 

1264

Elixir Rx Solutions, LLC

Elixir

1282

Elixir Rx Solutions, LLC

Elixir Rx

1259

EmpiRx Health, LLC

 

1227

Employee Health Insurance Management, Inc.

EHIM

1292

eviCore healthcare MSI, LLC

eviCore healthcare

1253

Express Scripts, Inc.

 

1179

FairosRx, LLC

 

1201

Fairview Pharmacy Services, LLC

ClearScript

1203

Gateway Health Partners Inc.

 

1316

Global Pharmaceutical Programs, LLC

 

1313

Grane PBM, Inc.

Grane PBM

1165

Health E Systems, LLC

 

1283

Healthcare Highways Rx, LLC

CerpassRx

1263

HealthSmart RX Solutions, Inc.

 

1234

Humana Pharmacy Solutions, Inc.

 

1245

Independent Health's Pharmacy Benefit Dimensions, LLC

 

1241

Integrated Prescription Management, Inc.

 

1260

Lifetime Benefit Solutions, Inc.

LBS

1099

Magellan Rx Management, LLC

Magellan Rx

1267

Matrix Healthcare Services, Inc.

myMatrixx

1082

Matrix Quality Care, Inc.

Araya

1202

MaxorPlus, Ltd.

 

1223

MedImpact Healthcare Systems, Inc.

 

1217

Mitchell International, Inc.

 

1247

MVP Select Care, Inc

 

1021

Navitus Health Solutions, LLC

 

1189

OP Pharmacy, LLC

OnePoint Patient Care

1244

OptumRx, Inc.

Optum Personal Care Benefits

1327

Pharma Force Group LLC

PharmaForce

1291

Pharmacy Risk Management, LLC

Right Rx FL, LLC & US-Rx Care

1280

Pharmapix International, LLC

 

1169

Phoenix Benefits Management, LLC

 

1168

Preferred Medical Network, LLC

 

1299

Prescryptive Health, Inc.

 

1182

ProAct, Inc.

 

1154

Procare Pharmacy Benefit Manager, Inc.

ProCare Rx

1057

Prodigy Care Services LLC

 

1218

Progyny, Inc.

 

1279

Radiant Services, LLC

 

1329

Rightway Healthcare, Inc.

 

1332

Rx Valet, LLC Shield PBM

1198

RxBridge, LLC

 

1309

Scrip World, LLC

Meritain Pharmacy Solutions

1243

Serve You Custom Prescription Management, Inc.

Serve You Rx

1278

Smith Health, Inc.

SmithRx

1300

Southern Scripts, LLC

Liviniti, LLC

1236

Tmesys, LLC

 

1330

True Rx Management Services, Inc.

True Rx Health Strategists

1308

TrueScripts Management Services, LLC

 

1164

Towers Administrators LLC

RxSense Administrators LLC

1323

WINFertility, Inc.

WIN Healthcare

1320

WithMe Health, LLC

 

Contact Us

Have a Question?

Send an email to [email protected].

Submit a Comment

Interested parties and members of the public are invited to comment on PBM issues by email at [email protected].

Report a Violation

Any corporation, firm, association, or person may file a complaint about a PBM with DFS via email to [email protected]. A copy of the complaint may be shared with the PBM.