Pharmacy Benefits Manager (PBM) Initial Application for a Certificate of Registration
INSTRUCTIONS: CONNECTICUT PHARMACY BENEFITS MANAGER (PBM) CERTIFICATE OF REGISTRATION (INITIAL)
To apply for an initial certificate of registration as a pharmacy benefits manager (PBM) in Connecticut, use the form discussed in this article. This document can be obtained from the website of the government of Connecticut.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 1: The first page contains general instructions.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 2: On the first four blank lines of the second page, enter your tax identification number or federal employer identification number, your business address, your mailing address (if different) and your phone number.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 3: The next section concerns contact information to be used in future correspondence. Enter the name of your contact person, their title, a mailing address, phone and fax numbers, and an email address.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 4: Enter the name and a description of the controlling company or organization.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 5: Enter the business address and, if different, the mailing address of the controlling company or organization.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 6: The next question requires you to indicate whether any suspension, sanction or disciplinary action has been taken against the PBM in any state during the last ten years. If yes, provide an explanation.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 7: The first question on the third page requires you to indicate whether any suspension, sanction or disciplinary action has been taken against the controlling company or organization during the last ten years. If yes, provide an explanation.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 8: Describe the PBM service area.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 9: Enter the number of total enrollees served by the PBM both nationwide and in Connecticut.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 10: List all entities on whose behalf the PBM has contracts or agreements to provide pharmacy benefit services to Connecticut enrollees.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Initial) Step 11: Complete the rest of the form as instructed.
Pharmacy Benefits Manager (PBM) Renewal Application for a Certificate of Registration
INSTRUCTIONS: CONNECTICUT PHARMACY BENEFITS MANAGER (PBM) CERTIFICATE OF REGISTRATION (RENEWAL)
To apply for a renewal of your registration certificate as a Connecticut pharmacy benefits manager (PBM), use the document discussed in this article. This application can be obtained from the website of the government of Connecticut.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 1: The first page contains general instructions for completion of this form.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 2: On the first five blank lines of the second page, enter the name of the PBM, its registration number, its tax identification number or federal employer identification number, its business address, its mailing address (if different) and its phone number.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 3: The question below asks if any suspension, sanction or disciplinary action has been taken against the PBM in any state. If yes, provide an explanation.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 4: The question below asks if any suspension, sanction or disciplinary action has been taken against the controlling company or organization in any state. If yes, provide an explanation.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 5: Describe the PBM service area.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 6: Enter the total number of enrollees served by the PBM both nationwide and solely in Connecticut.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 7: At the top of the third page, list all entities on whose behalf the PBM has contracts or agreements to provide benefit services to Connecticut enrollees.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 8: The remainder of the third page is a checklist of required attachments to be submitted with this form.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 9: The fourth page concerns your financial security requirement. Calculate your surety bond as instructed.
Connecticut Pharmacy Benefits Manager (PBM) Certificate Of Registration (Renewal) Step 10: The fifth page is a certificate of accuracy which must be completed by the CEO. Enter their name on the first blank line, their location on the second blank line, their signature on the third blank line, and the date on the fourth blank line.