Last Updated: May 19, 2021
Pharmacy Benefit Manager (PBM)
The type of license required by PBM's is based upon the PBM's responsibilities. If the PBM solicits or collects premiums, effects coverage, or settles claims the PBM must obtain an
Employee Benefit Plan Administrator license. If the PBM administers or manages the pharmacy benefits for an insurer or another entity that provides prescription drug benefits to Wisconsin residents and does not collect premium or affect claims, the PBM must obtain a Pharmacy Benefit Manger license.
“Pharmacy benefit manager" means an entity doing business in this state that contracts to administer or manage prescription drug benefits on behalf of any of the following per
s. 632.865 (1) (c), Wis. Stat.
- An insurer.
- A cooperative, as defined in
s. 185.01 (2).
- Another entity that provides prescription drug benefits to residents of this state.
Exemptions are granted for the following and should be filed using the EBPA/PBM Application for Exemption application:
- The applicant collects only contributions to self-funded employee benefit plans as defined by the Employee Retirement Income Security Act (ERISA) of 1974;
- The applicant does not collect or administer premiums for stop-loss coverage; and
The applicant does not perform any function with respect to a multi-employer welfare arrangement as defined under ERISA.
Applying for a Pharmacy Benefit Manager License
Initial Licensing Requirements
- Apply online at nipr.com
or via paper PBM application. Electronic applications will be available between October – December of 2021 via nipr.com.
- Submit financial statement for the administrator's most recently completed fiscal year, prepared on a generally accepted accounting basis including: assets, liabilities, and net worth (balance sheet); and the results of operations (income statement). NOTE: The financial statements must be those of the applicant. If the financial statements combine the applicant with parent or affiliated entities, they must include a deconsolidating spreadsheet breaking out the applicant's balance sheet and income statement. Statements are not required to be audited.
- Submit a new original performance bond (signed and sealed). Must be sent directly to OCI.
- Pay initial license fee of $100.
- After your application has been approved, you can confirm your new license expiration date by using the License Search at State Based Systems (SBS) .
- Licenses may be printed for free at State Based Systems (SBS).
- Mail an original performance bond to:
OCI Agent Licensing
Attn: PBM License
P.O. Box 7872
Madison, WI 53707-7872
Renew an PBM Entity License
Please Note: Renewal notifications will be sent to the business email address on record for the PBM 60 days prior to the expiration date. Renewal notifications will only be sent via email to the business email address on file.
- Renew annually online by August 1 at nipr.com
or via paper PBM application.
- If any changes in bond coverage, a new original bond (signed and sealed) must be sent directly to OCI.
- Financial statements of the applicant (balance sheet and income statement) for previous completed fiscal year must be submitted via email to email@example.com or be mailed directly to OCI.
- Pay annual renewal fee of $100.
- After your application has been approved, you can confirm your new license expiration date by using the License Search at State Based Systems (SBS).
- Renewed licenses may be printed for free at State Based Systems (SBS).
An administrator shall notify OCI in writing of any of the following within 30 days after the date of the occurrence:
- The cessation of business activities as an administrator. A notification under this subsection shall include the name and address of the custodian of the administrator's business records and the location of those records.
- Any change in the administrator's business mailing address or the location of its business records.
- Formal administrative action in this state or another state by an agency that regulates the business of administrators, insurance, real estate, securities or financial institutions against the administrator or any officer, director, partner or other individual having comparable responsibilities in the corporation or partnership.
- The conviction in this state or another state of a felony or misdemeanor, other than a misdemeanor related to the use of a motor vehicle or the violation of a fish and game regulation, of the administrator or any of the officers, directors, partners or other persons having comparable responsibilities in the corporation or partnership.
Submit a written statement including updates to officers, partners, or owners, address changes, and email to firstname.lastname@example.org.
Name changes require an updated bond to be submitted to the Commissioner's office. Mail a signed and sealed performance bond with the new entity name to OCI.
125 S. Webster St.
Madison, WI 53707
For more information, send an email with inquiries to email@example.com.