Pharmacy Benefit Manager-Initial
Initial application for a new PBM will need to be completed electronically at www.sircon.com/indiana. The following state specific items must be attached to the electronic application:
- Applicant'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. PBM will need to seek Commissioner approval if intending to file consolidated financial statements.
- Applicant’s articles of incorporation or other business organization documents.
- Address of each office the applicant maintains in Indiana or a statement affirming the applicant maintains no offices in Indiana.
- List by jurisdiction of each name under which the applicant 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 applicant has operated in the preceding five (5) years.
- 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, together with a chart showing the relationship of the applicant to all affiliates. An affiliate that is an insurance company shall be identified as such.
- 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.
- A statement describing the applicant’s business plan, including the following information: (A) Staffing levels and activities proposed in Indiana and nationwide. (B) Details concerning the applicant’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. (C) A list of all health plans for whom the applicant 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.
A 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.
For questions, contact Connie Wright, Company Admission Coordinator at firstname.lastname@example.org.