Pharmacy Benefit Managers
Under Title 18, Chapter 77, Pharmacy Benefit Managers (PBM’s) providing pharmacy benefit services to health benefit plans require licensure to operate in Vermont. PBM’s currently operating in Vermont must be licensed by January 1, 2026, and application materials should be submitted to the DFR by July 1, 2025. All other PBM’s must receive a license before commencing operation in Vermont.
PBMs are defined as an individual, corporation, or other entity, including a wholly or partially owned or controlled subsidiary of a pharmacy benefit manager, that provides pharmacy benefit management services for health benefits. The term “pharmacy benefit manager” does not include:
- A health care facility licensed in this State.
- A health care professional licensed in this State.
- A consultant who only provides advice as to the selection or performance of a pharmacy benefit manager.
- A health insurer to the extent that it performs any claims processing and other prescription drug or device services exclusively for its enrollees; or
- An entity that provides pharmacy benefit management services for Vermont Medicaid.
The purpose of the law is to establish standards and criteria for the licensure and regulation of pharmacy benefit managers providing claims processing services or other prescription drug or device services for health benefit plans by:
- Promoting, preserving and protecting the public health, safety and welfare through effective regulation and licensure of pharmacy benefit managers.
- Promoting the solvency of the commercial health insurance industry, as well as providing for consumer saving and for fairness in prescription drug benefits.
PBM’s seeking licensure with the Department of Financial Regulation shall apply with an initial application for licensure to operate in Vermont and pay a non-refundable application fee of $1,600 and an initial licensure fee of $10,000. The renewal fee is $12,000. Make checks payable to Department of Financial Regulation.
Additional information about the Application, Regulation and FAQ’s may be found at the links below:
Submit applications and supporting materials by email (PDF format). The application fee and licensure/renewal fee should be mailed to the address below.
Department of Financial Regulation
Insurance Division • Company Licensing
89 Main Street • Montpelier, VT 05620
Email: DFR.CompLic@vermont.gov
Green Mountain Care Board Requirements:
An entity that meets the definition of a “Pharmacy Benefit Managers” under Green Mountain Care Board Rule 8.000: Data Submission is required to register with the Green Mountain Care Board as a reporting entity. Registration is required annually, by December 31st.
In addition, all Pharmacy Benefit Managers (PBMs) with customers who are Vermont residents are required to register on an annual basis—by December 31st—with the State of Vermont. Agencies serving 200 or more Vermont resident members must also report claims in Vermont’s All-Payer Claims Database (APCD), called Vermont Health Care Uniform Reporting and Evaluation system, or VHCURES. Agencies serving fewer than 200 Vermont residents must register annually but are not required to report to VHCURES.
Currently both annual registration and VHCURES reporting occurs via Onpoint Health Data, GMCB’s contractor for VHCURES data collection, consolidation, and user support. If you are experiencing problems with the registration or need further information about the process, please contact Onpoint Health Data Systems at vt-support@onpointhealthdata.org or by phone at 207-623-2555.
PBM Disclosure Form - To be completed annually by July 1st.
Under 18 V.S.A. §9472(d), pharmacy benefit managers (PBMs) that provide pharmacy benefit management for health plans in Vermont are required to report to the health insurer, as well as the Department of Financial Regulation (DFR) and the Green Mountain Care Board (GMCB) (collectively, “the State”) on the aggregate amount the pharmacy benefit manager retained on all claims charged to the health insurer for prescriptions filled during the preceding calendar year in excess of the amount the pharmacy benefit manager reimbursed pharmacies. This disclosure form has been developed to provide a standardized and consistent means by which PBMs may implement this statutory requirement with respect the disclosures required to the State. This form does not contemplate nor make recommendations on how PBMs may seek to fulfill their obligation to report this information to the health insurers they conduct business with. For the purposes of this form, the disclosure information provided should be pertinent to:
- Health insurers that are licensed in Vermont.
- PBM services provided to Vermont members only.
- Claims charged for the date range of January 1 to December 31 for the calendar year preceding the July 1 due date for the report.
PBMs should complete this PBM Disclosure Form. This form is due annually on July 1 for the prior calendar year.
Questions regarding this filing or general questions or inquiries related to VHCURES stewardship and governance can be sent to gmcb.data@vermont.gov.