Pharmacy Benefit Manager Name: FEIN:  
PBM License Number:  
Address:   City:  
State:   Zip:  

Responsible Party for the Pharmacy Benefit Manager license:
Name:  
Telephone Number:  
Email:  

All Network Name(s) administered in Kansas:

Number of counties in the service area: 

List of Counties in Service Area:
Allen  Anderson  Atchison  Barber  Barton  Bourbon  Brown  Butler   Chase  Chautauqua  Cherokee  Cheyenne  Clark  Clay  Cloud  Coffey  Comanche  Cowley  Crawford   Decatur  Dickinson  Doniphan  Douglas  Edwards  Elk  Ellis  Ellsworth  Finney  Ford  Franklin  Geary   Gove  Graham  Grant  Gray  Greely  Greenwood  Hamilton  Harper  Harvey  Haskell  Hodgeman  Jackson   Jefferson  Jewell  Johnson  Kearny  Kingman  Kiowa  Labette  Lane  Leavenworth  Lincoln  Linn  Logan   Lyon  Marion  Marshall  McPherson  Meade  Miami  Mitchell  Montgomery  Morris  Morton  Nemaha   Neosho  Ness  Norton  Osage  Osborne  Ottawa  Pawnee  Phillips  Pottawatomie  Pratt  Rawlins  Reno   Republic  Rice  Riley  Rooks  Rush  Russell  Saline  Scott  Sedgwick  Seward  Shawnee  Sheridan   Sherman  Smith  Stafford  Stanton  Stevens  Sumner  Thomas  Trego  Wabaunsee  Wallace  Washington   Wichita  Wilson  Woodson   Wyandotte

Number of in-network affiliated pharmacies in Kansas: 
  List all affiliated pharmacies:

Number of independent in-network pharmacies in Kansas: 
  List all independent pharmacies:

Provide the number of complaints* made by pharmacies concerning the applicant’s network that the applicant has received in the previous 12 months: 

Provide the number of complaints* made by patients concerning the applicant’s network that the applicant has received in the previous 12 months: 
*“Complaints” includes those in writing, by phone, email, or other electronic methods.

In providing the following information, submit responses in a written narrative form.

1. Describe the process for determining the reasonableness of patient access to pharmacies based on distance from the patient's residence. Include a description of the mix of mail-order and physical store locations and identify whether any affiliates are included in the calculation.
2. Do the contracts with the PBM require patients to use pharmacies that are directly or indirectly owned by the PBM, including all new prescriptions, refills, or specialty drugs, regardless of day supply?
3. Does the PBM impose limits, including quantity limits or refill limits, on an independent pharmacy’s access to medications that differ from those existing from the PBM affiliates?
4. Describe how the PBM's certification or accreditation requirements are used as a determinant of network participation.
5. Identify whether there are different standards for independent pharmacies and affiliates of your entity. If so, please describe the differences and how they are applied.
6. Describe how often accreditation requirements change.
7. Describe any sub-networks for specialty drugs.

Name and Title of Submitter:
Submitter's Telephone Number:
Submitter's Email:
Signature:   Date: 07/27/2024
 By checking this box, I affirm that the information I have provided is true and correct. I understand that action may be taken against my license upon finding the information provided in this form is incorrect or misleading.