• Download the completed PBM Licensing Application
• Upload the PBM application and the following required materials in the upload section to the right.

Required Materials:

• Proof of registration with the Montana Secretary of State’s office.
• A copy of the most recent fiscal year-end audited financial statement of the PBM.
• A list of all health carrier, plan sponsor, and workers’ compensation insurance carrier clients in this state.
• A projection of the number of enrollees and injured workers to be administered by the PBM in this state on an annual basis for each health carrier client, plan sponsor client, and workers’ compensation insurance carrier client.
• A copy of the policies and procedures demonstrating the PBM has established processes to comply with §§ 33-22-170 through 33-22-177, MCA, and § 33-22-180, MCA, concerning maximum allowable costs lists, including the appeals process required under § 33-22-173, MCA.
• Disclosure of any ownership interest, either directly or indirectly or through an affiliate, holding company, or subsidiary, in a pharmacy or mail-order pharmacy that is part of the PBM’s pharmacy network.
• Disclosure of any ownership interest, either directly or indirectly or through an affiliate, holding company, or subsidiary, by a health carrier or workers’ compensation insurance carrier in the PBM or by the PBM in a health carrier or workers’ compensation insurance carrier.
• An NAIC biographical affidavit for each person listed in question 16 of the application.
• Network Adequacy—PBMs must provide an adequate and accessible pharmacy network for the provision of prescription drugs to ensure reasonable proximity of pharmacies to the businesses or personal residences of enrollees and injured workers. Applicants must also submit the following documents for each network as part of their license or license renewal application:

1. PBM Pharmacy Network Adequacy Template

2. Network Adequacy Accessibility Report Example

The regulatory criteria a PBM must provide with its application include:

• The criteria the PBM used to build a pharmacy network, including the criteria used to select pharmacies for participation in the pharmacy network.
• The criteria the PBM used to build any preferred pharmacy network, including the criteria used to place pharmacies in subsets, groups, or tiers.
• The criteria the PBM used to select pharmacies to dispense specialty drugs in the pharmacy network.
• The electronic address of current, accurate, and searchable directory of pharmacies for each pharmacy network.
• The PBM’s process for monitoring and ensuring on an ongoing basis a sufficient and adequate pharmacy network to meet the pharmacist services needs.