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:
- 2023 Annual Report Comprehensive Instructions and Attestation (PDF)
- 2023 Annual Report Narrative Response (PDF)
- 2023 Annual Report Data Collection (Excel)
- 2023 Annual Report Network Structure (Excel)
- 2023 Annual Report Revenue by Service Category (Excel)
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
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.
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.
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:
- claims processing, retail network management, or payment of claims to pharmacies for dispensing prescription drugs;
- clinical or other formulary or preferred drug list development or management;
- 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;
- patient compliance, therapeutic intervention, or generic substitution programs;
- disease management for prescription drug benefits;
- drug utilization review or prior authorization for drug benefits;
- adjudication of appeals or grievances related to prescription drug coverage;
- contracting with and or managing the relationship with network pharmacies including mail service pharmacy agreements; and
- 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.
“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”.
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.
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.
Yes, the term health plan covers Medicare Part D plans.
Each entity seeking to register as a PBM must submit an application via the DFS Portal (see “Registration” section above).
Yes, a PBM applying to register shall pay to the superintendent a non-refundable registration application fee of $4,000 with its registration application.
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
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.
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.
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.
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].