Michigan Department of Insurance and Financial Services (DIFS) Pharmacy Benefit Manager (PBM) Registration
Required Field: PBM Full Legal Name
Required Field: Domicile State
Required Field: Federal Employer Identification Number (FEIN)
Required Field: Do you currently hold a Michigan Certificate of Authority as a Third Party Administrator?
Required Field: Address 1
Required Field: Phone Phone number is not in the correct format.
PBM Primary Contact Person
Required Field: First Name
Required Field: Last Name
Required Field: Address 1
Required Field: Zip Entry must be a number
Required Field: Phone Phone number is not in the correct format.
Required Field: Email Email is not in the correct format.