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
- Elixir RX Solutions LLC
- Express Scripts
- Independent Health's Pharmacy Benefit Dimensions LLC
- OnePoint Patient Care
- Oscar Insurance Company
- Prodigy Care Services LLC
- 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 have observed or learned of a business practice or individual conduct that you believe may violate Iowa insurance, securities, or regulated industries law, and you are not the consumer involved in or affected by the practice or conduct, you may advise the Iowa Insurance Division of your concerns and request investigation by completing this form.
If you need assistance, please contact the Iowa Insurance Division.