A pharmacy benefits manager performs pharmacy benefits management services for an entity offering pharmacy benefits to the entity's customers, managing prescription drug benefits provided by a covered entity under the term and conditions of a contract between the pharmacy benefits manager and the covered entity. A pharmacy benefits manager does not include a health insurer licensed in the state if the health insurer or its subsidiary is providing pharmacy benefits management services exclusively to its own insureds, a public self-funded pool, or a private single employer self-funded plan that provides such benefits or services directly to its beneficiaries.
A pharmacy benefits manager doing business in Iowa must obtain a certificate as a third-party administrator under Iowa Code chapter 510, and the provisions relating to a third-party administrator pursuant to Iowa Code chapter 510 shall apply to a pharmacy benefits manager.
A pharmacy benefits manager must provide to the Iowa Insurance Division a quarterly report of all complaints as defined in Iowa Administrative Code rule 191-59.2. The quarterly report must include all of the information required in Iowa Administrative Code rule 191-59.8. If further information is needed regarding a quarterly complaint report, select the Pharmacy Benefits Manager contact form from the 'category' drop down menu.
A pharmacy benefits manager must also provide an annual report and include all information in Iowa Code section 510C.2. The report is available on and must be filed through Opt-Ins by February 15th annually.
Each health carrier, health benefit plan, and pharmacy benefits manager is required to create, use, and submit a single prior authorization form to the commissioner for approval. The following prior authorization forms have been approved by the Iowa Insurance Division:
- Aetna (Coventry Health)
- Change Healthcare Pharmacy Solutions
- Express Scripts
- Independent Health's Pharmacy Benefit Dimensions LLC
- OnePoint Patient Care
- Oscar Insurance Company
- Sanford Health Plan
- SmartScripts PBM LLC
- Medical Associates
- Serve You Custom Prescription Management, Inc.
- United Healthcare Insurance Company/United Healthcare Plan of the River Valley
Click here for a listing of registered pharmacy benefits managers in Iowa or view the data set below.
If you need assistance, please contact the Iowa Insurance Division.