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.
Name and Title of Submitter: Submitter's Telephone Number: Submitter's Email: Signature: Date: 12/12/2024 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.