PBM Registration
"Pharmacy Benefit Manager" means any entity doing business in this state that administers or manages prescription drug benefits, including claims processing services and other prescription drug or device services as defined in section 10-16-122.1, on behalf of any carrier that provides prescription drug benefits to residents of this state, either pursuant to a contract with the carrier or as an entity that is related to, associated by common or other ownership with, or otherwise associated with the carrier (C.R.S.10-16-102(49)).
A PBM does not include:
- A health-care facility licensed or certified by the department of public health and environment pursuant to section 25-1.5-103 (1)(a);
- A provider;
- A consultant who only provides advice as to the selection or performance of a pharmacy benefit management firm; or
- A nonprofit health maintenance organization that offers managed care plans that provide a majority of covered professional services through a single, contracted medical group and that operates its own pharmacies (C.R.S.10-16-102(49)(b)).
Colorado's House Bill (HB) 23-1227 introduced new obligations for all Pharmacy Benefit Managers (PBMs) doing business in Colorado to register annually with the Colorado Division of Insurance (DOI). Colorado Regulation 4-2-97 outlines a registration deadline of 7/1/2024 and provides guidance on the form and manner for PBMs to register with the DOI including required documentation.
PBM Registration Instructions
Colorado's PBM application is hosted through sircon.com/colorado. The DOI will process complete applications only, which includes submitting application form, attaching applicant's organizational and financial documents, completing the attestation, and paying the filing fee in Sircon.
1. Begin Application
To apply for a PBM registration, click the button below.
Next, click “Apply for a License” > “Other Insurance & Non-Insurance Licenses” > Select if you are "Resident/Non-Resident" > Select "Firm" from "Individual/Firm".
Note: If the application is requiring a resident license number and you do not have one, you may enter "00000" to continue.
2. Attach Documentation
The following state-specific documents must be submitted with the application. Documents may be uploaded using the "Upload Documents for Required Items" page at the end of the application.
- State-Specific Required Application Materials
PBM Organizational Documents
- Articles of Incorporation, Articles of Association, and partnership agreements of the PBM;
- A copy of all by-laws or similar documents regulating the conduct or the internal affairs of the PBM; and
- Relevant documentation (policies and procedures) and a detailed explanation that demonstrates the PBM has adopted processes to ensure compliance with the requirements in sections 10-16-122.1, 10-16-122.3, 10-16- 122.4, 10-16-122.5, 10-16-122.6, 10-16-122.7, and 10-16-122.9, C.R.S, including any written policies or procedures describing the appeals or dispute resolution processes between the PBM and a PBM-affiliated pharmacy, as applicable.
Financial and Other Documents
- The most recent year-end financial statement for the PBM;
- A listing of all carriers with which the PBM is contracted to provide pharmacy benefit services in Colorado, including any non-ERISA self-funded or governmental plans;
- The number of projected enrollees or beneficiaries in Colorado to be serviced by the applicant during the upcoming year for all contracted insurers; and
- A listing of any delegated or contracted companies that perform part of the PBM's services.
3. Submit Filing Fee
PBMs are required to provide a $2,500 non-refundable filing fee for all initial and renewal applications. Payment must be collected as part of the application.
Who to Contact for Help
For assistance using Sircon.com, please refer to the "Help" and "FAQ" pages on Sircon.com for information and how-to guides. You may also call Sircon Support at 1-877-846-4430, or request assistance by selecting the "Open a Case" link at the bottom of the website.
For all other questions, please contact the Division of Insurance, PBM Enforcement Section at dora_pbm_compliance@state.co.us.
PBM Related Complaints
The Colorado Division of Insurance (DOI) has authority to enforce statutory requirements regarding Pharmacy Benefit Management Firms (PBMs), as granted by House Bill (HB) 23-1227 Enforce Laws Against Pharmacy Benefit Managers. The DOI assists individuals and pharmacies with concerns related to PBM business practices and conduct that may be in violation of state law. If you if have an issue you would like to submit to the DOI, please review the information outlined below.
Before Submitting a Complaint
Before filing a complaint with the Colorado Department of Insurance (DOI) regarding a Pharmacy Benefit Management (PBM) related-issue, you should first contact the PBM to resolve the matter. Document phone calls to the company, keep copies of all written communications, and complete all levels of contractual appeals available. If you are still unable to resolve your complaint, you may contact the DOI for assistance.
Instructions to File a PBM Complaint
To file a complaint against a PBM for violation of law or rule, (1) download a pdf copy of this form, (2) fill out this PBM Complaint Form in its entirety and (3) submit it to the DOI via email at dora_pbm_compliance@state.co.us along with any supporting documentation you wish to include.
*Note: You must download a pdf of this PBM Complaint Form to access the fillable sections.
Supporting Documentation
Be sure to include as much relevant information as possible to support the Division’s investigation of your complaint. Depending on the nature of your complaint, the appropriate supporting documents may vary. Please send copies, not originals of:
- Details of any previous contact with the PBM regarding the matter.
- Copies of documents that help verify or explain the problem.
- Copies of invoices, MAC appeals, and replies from PBM with your complaint.
What Happens After I File a PBM Complaint?
Once you file a complaint, the DOI will respond to your complaint by doing the following:
- Confirming receipt of the complaint.
- Sending an inquiry letter to the PBM communicating the concerns brought to the Division’s attention and requesting a written response.
- Reviewing the PMB response to the Division’s inquiry to determine if the PBM named in your complaint is performing as required under the law.
- Sending a findings letter containing the Division’s analysis and findings related to the filed complaint.
You will receive a copy of all correspondence received during the DOI’s review of your complaint as well as a letter explaining our findings. If you have questions, disagree with our findings, or have additional information that was not included with your original complaint, you may submit the information to us for further review. Please understand that our complaints are thoroughly reviewed; however, we may not be able to provide the exact results you desire. We hope through our complaint process we can help you understand the laws that may apply.
What We Can Do
- Provide you with additional information relevant to your complaint file.
- Investigate your complaints against PBMs.
- Submit your complaint to the PBM and require a response to the Colorado Department of Insurance.
- Review the response to determine if the PBM is acting according to appropriate statutes.
- Require corrective action, if we determine that the PBM did not meet the legal requirements of the Act.
What We Cannot Do
- Assist with your PBM complaint if you have involved an attorney.
- Provide legal advice or provide legal representation.
- Intervene on your behalf in a pending lawsuit.
- Determine the facts regarding any other disagreement between you and another party.
- Help resolve PBM complaints or investigate matters that are not subject to the laws of the State of Colorado.