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A pharmacy benefits manager is a third-party administrator (TPA) of prescription drug programs for insurers and employers who pay a fee to the PBM for their services. PBMs are primarily responsible for developing and maintaining the formulary, contracting with pharmacies, negotiating discounts with drug manufacturers and rebates, etc. PBMs manage health care plans for commercial insurance plans, self-insured employer plans, Medicare Part D plans, state government employee health plans and Medicaid managed care organization plans.
Yes, there are companies providing PBM services in South Carolina but they are currently licensed as TPAs.
It creates a new PBM license and establishes other requirements for PBMs. It also authorizes the South Carolina Department of Insurance to promulgate regulations to enforce the provisions of the new law.
Yes. Regulation 69-77, Pharmacy Benefit Managers, is the new regulation promulgated to implement the provisions of Act No. 48 of 2019 regarding the licensure and regulation of pharmacy benefit managers.
The PBM license application window is October 1, 2020- December 1, 2020. Detailed instructions for PBM licensure is available on the PBM webpage on the South Carolina Department of Insurance website. PBM licenses will become effective on January 1, 2021.
The PBM will not be authorized to operate in the state of South Carolina until proper licensure is obtained. An unlicensed PBM is subject to a fine of up to $10,000 per Section 38-2-30 of the S.C. Code of Laws of 1976, as amended.
No. The PBM Application Requirements Checklist is for internal use only, but can function as a guide for all required documents necessary to obtain a PBM license and to ensure approval is granted in the most efficient manner.
Yes, applications and fee payments can be submitted via the NIPR website. The supplemental application can be found on NIPR’s State Specific Requirements page and on the Department’s PBM webpage. Once completed the application and supporting documents may be uploaded electronically via NIPR’s Attachment Warehouse.
Yes, the PBM can download the paper application from the Department website. Applications can be emailed to the Office of PBM Oversight and fee payments can be mailed to :
Attn: Office of PBM OversightSouth Carolina Department of Insurance1201 Main Street Suite 1000Columbia, SC 29201
Fee payments can be made by check and made out to the: South Carolina Department of Insurance
Once the license becomes active, an email notification will be sent to each entity with a copy of their PBM license. PBMs can also print their license on the StateBasedSystem.com.
Each entity should review the definition of PBM and make a determination that every function the entity performs falls solely under the PBM license. If the entity performs additional functions that fall outside of the definition of PBM, then the entity may fall outside of the PBM license authority, and the TPA license would be required in addition to the PBM License.
PBMs can complete the PBM Information Change Form and submit it to the Department.