Pharmacy Benefits Manager (PBM) License Application

Select one
Are you currently registered in Missouri as a Third Party Administrator?

Demographic Information

Contact Person

Applicant Background Information

If you answer yes to any question, please email a full explanation to regulatory.services@dci.mo.gov. Failure to provide the required information or any omissions may result in the denial of this application.
Has the applicant been refused a registration, license or certification to act as (or provide the services of) a Pharmacy Benefits Manager (“PBM”), Third Party Administrator, etc.?
Has the applicant had any registration, license or certification to act as (or provide the services of) a Pharmacy Benefits Manager (“PBM”) denied, suspended, revoked or non-renewed for any reason by any state or federal entity?
Has the applicant ever been found liable in any lawsuit or arbitration proceeding involving allegations of fraud, illegal or dishonest activities in connection with the administration of pharmacy benefits management services?
Has the applicant had a business relationship with an insurance company terminated for any alleged fraudulent, illegal or dishonest activities in connection with the administration of pharmacy benefits management services?
Has the applicant, parent company or any company or organization controlling the operation of the Pharmacy Benefits Manager ("PBM") experienced any data security breaches or HIPAA security breaches?

Individuals Responsible for the Compliance and Conduct of Affairs for the Pharmacy Benefits Manager ("PBM")

List of all individuals responsible for the compliance/conduct of affairs, including members of the board of directors, board of trustees, executive committee, other governing board or committee, the principal officers in the case of a corporation, the partners or members in the case of a partnership or association, and any other person who exercises control or influence over the affairs of the Pharmacy Benefits Manager ("PBM").

Include name, business address, title and qualifications. This information may also be emailed to regulatory.services@dci.mo.gov.

Proof of registration with the Missouri Secretary of State

Attach proof of registration with the Missouri Secretary of State’s office in order to do business in Missouri
One file only.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Applicant’s Certification and Attestation

On behalf of the Pharmacy Benefits Manager ("PBM"), applicant hereby certifies, under penalty of perjury, that:
 

  1. All of the information submitted in this application and attachments is true and complete and I am aware that submitting false information or omitting pertinent or material information in connection with this application is grounds for license or registration revocation and may subject me and the applicant to civil or criminal penalties.
  2. The applicant grants permission to the Missouri Department of Commerce and Insurance or other appropriate party in the State of Missouri to verify any information supplied with any federal, state or local government agency, or insurance company.
  3. I authorize the Missouri Department of Commerce and Insurance to give any information they may have concerning me, as permitted by law, to any federal, state or municipal agency, or any other organization and I release the Missouri Department of Commerce and Insurance, and any person acting on their behalf, from any and all liability of whatever nature by reason of furnishing such information.
  4. I acknowledge that I understand and comply with the insurance laws and regulations of the State of Missouri.
  5. I acknowledge that I understand that any data security breach or HIPPA security breach must be reported immediately to the Missouri Department of Commerce and Insurance.
  6. I hereby certify that I will furnish any additional information upon request.

Must be signed by an officer, director, or partner of the entity, or member or manager of a limited liability company who has authority to act on behalf of the entity.

Name of officer, director, partner, member or manager

NOTICE

Please DO NOT provide any personal or sensitive information when filling out this form, such as a social security number, credit card, health information, account numbers, etc. 

Once you Submit this data, you will be re-directed to the Official DCI Payment Portal to complete your payment.