Pharmacy benefit manager reporting form

Pharmacy benefit manager reporting form

PBM | 0126
Instructions
- Under Texas Insurance Code Section 1369.502, the report is due by March 1 of each year.
- More information about this report is located on the pharmaceutical benefits reporting index page.
- All fields marked with * are required and must be filled.
Company information
Company name*
NAIC number
TDI number
Reporting year*
Company address
Company address*
Company city*
Company state*
Company zip*
Contact information
Contact name*
Contact title*
Phone number*
Email address*
example@example.com
This company is a pharmacy benefit manager

Yes, this company is a PBMNo, this company is not a PBM
Release my email address

Yes, TDI may release my email addressNo, TDI may not release my email address
My address is the same as the company address

Yes, my address is the same as the company addressNo, my address is different and I will enter my address below
Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Aggregate rebates, fees, price protection payments, and other payments

All pharmacy benefit managers fill in the information below.
Amount passed to issuers*
Must be a number
Amount passed to enrollees*
Must be a number
Amount retained as revenue*
Must be a number
Total amount collected from pharmaceutical drug manufacturers*
Must be a number and typically this is the sum of the above three amounts.
Should be Empty:

Company information