A pharmacy benefits manager manages a prescription drug benefit provided by a third-party payor. The pharmacy benefit manager may manage the prescription drug benefit pursuant to a contract or other relationship with a third-party payor and may do so directly or through an intermediary.
TPA CERTIFICATE & TPA ANNUAL REPORT
A PBM doing business in Iowa must obtain a certificate as a third-party administrator (TPA) under Iowa Code chapter 510, and the provisions relating to a third-party administrator pursuant to Iowa Code chapter 510 and Iowa Administrative Code 191-58 shall apply to a pharmacy benefits manager. This includes the requirement to submit an annual TPA report by July 1st of each year. All TPA Annual reports must include the information required in IAC 191-58.11 and must be submitted through OPTins.
PBM QUARTERLY REPORTING
A PBM must provide a quarterly report of all complaints as defined in Iowa Administrative Code rule 191-59.2. Quarterly reports are required for continued registration as a PBM and are due:
- January 31st
- April 30th
- July 31st
- October 31st
Quarterly reports must include all of the information required in Iowa Administrative Code rule 191-59.8 and must be submitted through OPTins. A copy of the quarterly complaint report should be downloaded from OPTins.
COMPLIANCE INQUIRY TEMPLATE
Download the Compliance Inquiry Template, complete, and submit through OPTins by July 31, 2023. Refer to the Division's letter sent June 20, 2023 for additional instructions.
PBM ANNUAL REPORT
A PBM must provide an annual report and include all information in Iowa Code section 510C.2. The report is available on and must be submitted through Optins by February 15th annually. Annual reports are available at: PBM Annual Reports.
HOW TO SUBMIT ALL REPORTS THROUGH OPTins
The Iowa Insurance Division requires use of OPTins (Online Premium Tax for Insurance) for the submission of the PBM annual and quarterly complaint reports as well as for the TPA Annual report. If you do not have an OPTins account, contact the OPTins Marketing Team at optinsmktg@naic.org or call 816-783-8787. Setup of a new account takes 7-10 business days. If you already use OPTins, you do not need to set up a new account; just create a new filing for the TPA annual report and PBM annual and quarterly complaint reports.
All annual reports and quarterly complaint reports must be filed under the company name. If you are submitting a report for more than one company, they MUST BE filed individually.
We ask that you DO NOT mail any paper financial statements, verification forms or check payments to the Iowa Insurance Division. We have transitioned to a completely electronic system for payment and submission of annual reports and fees. Upon remittance by the company, all items are received immediately.
Questions: If further information is needed regarding a report, select the Pharmacy Benefits Manager option from the drop down menu on our Contact page.
PRIOR AUTHORIZATION FORM REQUIRED
Each health carrier, third-party payor, and pharmacy benefits manager is required to create, use, and submit a single prior authorization form to the commissioner for approval.
Such forms which have been approved by the Iowa Insurance Division are listed on the PBM Prior Authorization Forms page.
QUESTIONS & COMPLAINTS
Pharmacies: If you have observed or learned of a business practice or individual conduct that you believe may violate Iowa law, you may advise the Iowa Insurance Division of your concerns and request an investigation by completing this form.
Consumers and Other Stakeholders: If you have a complaint about your pharmacy benefit, you may advise the Iowa Insurance Division of your concerns and request an investigation at by completing this form.
PBMs CERTIFIED IN IOWA
Click here for a listing of certified pharmacy benefits managers in Iowa