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Pharmacy Benefit Managers

Pharmacy Benefit Managers
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Statutes and Regulations

Statutes

Insurance Law Article 29 and Section 280-a of the Public Health Law authorize the Department to regulate Pharmacy Benefit Managers (PBM) operating in New York through registration, licensure, examination, and reporting.

Regulations

Related regulations can be viewed in the free access online version of the New York Codes, Rules and Regulations (NYCRR) maintained by Thomson Reuters.

Proposed regulations, including those adopted on an emergency basis, can be found on our Regulatory and Legislative Activities page.

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.”

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

 

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

1027

CAPITAL RX

 

1188

CARELON RX, INC.

 

1256

CAREMARK, L.L.C.

 

1255

CAREMARKPCS HEALTH, L.L.C.

 

1229

CAREMARKPHC, L.L.C.

 

1248

CIGNA HEALTH AND LIFE INSURANCE COMPANY

CIGNA PHARMACY MANAGEMENT

1224

CITIZEN'S RX 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

1276

ENVOLVE PHARMACY SOLUTIONS, INC.

 

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.

 

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.

 

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.

 

1057

PRODIGY CARE SERVICES LLC

 

1218

PROGYNY, INC.

 

1279

RADIANT SERVICES, LLC

 

1198

RXBRIDGE, LLC

 

1243

SERVE YOU CUSTOM PRESCRIPTION MANAGEMENT, INC.

SERVE YOU RX

1278

SMITH HEALTH, INC.

SMITHRX

1300

SOUTHERN SCRIPTS, LLC

 

1236

TMESYS, LLC

 

1164

TOWERS ADMINISTRATORS LLC

RXSENSE ADMINISTRATORS LLC

Annual Report

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.

Public Notice

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

FAQs

Frequently Asked Questions for Pharmacy Benefit Managers Regarding Mandatory Registration and Licensing with NYS Department of Financial Services Pursuant to Insurance Law §§ 2902, 2903, 2905, and 2906.


Mandatory 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.

Who is required to file?
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Every PBM operating in New York prior to December 31, 2023 is required to register with the Department.

Under the statute a “pharmacy benefit manager” 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 register.

 

What are pharmacy benefit management services?
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Under the statute PBM services means 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”.

Is an entity that provides pharmacy benefit management services exclusively in the workers’ compensation industry required to file with 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 register.

Is a PBM that provides services exclusively for self-insured plans required to file with the Department as a PBM?
+

Yes, self-insured plans are health plans under the statute, therefore an entity that provides PBM services to a self-insured health plan must register.

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

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.

Who can enforce the violation, penalty and damages provision of Insurance Law § 2902(b)?
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After notice and a hearing, the superintendent is authorized to enforce the violations, penalty and damages provision located in § 2902(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 registered under this section, they should notify the Department by email at [email protected] and the Department will review and take any appropriate enforcement action.


Mandatory Licensing FAQ’s

When is a PBM required to obtain a license?
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PBMs operating in New York on or after January 1, 2024 will be required to obtain a license to continue or begin performing pharmacy benefit management services in New York. PBMs currently operating in New York are only required to be registered with the Department from now through December 31, 2023, and are not currently required to be licensed with the Department. All registrations expire on December 31, 2023.

The Department plans to issue further guidance prior to the time that PBMs are required to be licensed in New York. Such guidance will detail what will be required during the licensing process, and the Department will be publishing regulations clarifying what will be required for issuance and maintenance of a license from the Department. The Department intends to provide the opportunity to apply for and obtain a license well in advance of the January 1, 2024 deadline.

Where can I find the PBM license application?
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Each entity seeking licensure as a PBM must submit an application to the Department electronically. The Department will provide access to the electronic license application on or about September 1, 2023. If you would like an email notification when the system becomes live, email [email protected] and request notification.

How long is a license valid for?
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Every license expires 36 months from the date it was issued and may be renewed for an additional 36 months upon the filing and approval of an application to renew. Every license expires 36 months from the date it was issued and may be renewed for an additional 36 months upon the filing and approval of an application to renew.

Is there a fee for filing a license application?
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Yes, a PBM applying for licensure shall pay to the superintendent a non-refundable license application fee of $24,000.

Report a Violation

Any corporation, firm, association, or person may file a verified complaint about a PBM with the Department by email at [email protected]. A copy of the complaint may be shared with the PBM.

The Department will provide additional direction on the complaint process in future guidance.

Contact Us

Send an email to [email protected].