New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 4 - ACTUARIAL SERVICES
Subchapter 55 - PHARMACY CARDS
Section 11:4-55.2 - Requirement to issue cards

Universal Citation: NJ Admin Code 11:4-55.2

Current through Register Vol. 56, No. 24, December 18, 2024

(a) Each carrier, multiple employer welfare arrangement, or other provider of a health benefits plan that provides pharmacy benefits shall issue, or cause to be issued, to the primary insured a card satisfying the requirements of N.J.S.A. 17B:30-35 et seq. and this section. At the option of the issuer, additional cards may be issued to other persons included under the primary insured's coverage. Such additional cards shall bear the insured's name. The carrier or other provider may contract with an administrator, agent, contractor or other vendor to issue the cards; however, the carrier or other provider shall remain responsible for the proper issuance of the cards and for their compliance with the law.

(b) A card may be issued for pharmacy benefits only ("stand alone card") or may be issued for pharmacy benefits in combination with other benefits ("combined card").

(c) Until such time as State or Federal regulations are adopted pursuant to the "Health Insurance Portability and Accountability Act of 1996," P.L. 104-191, specifying data elements that may be used in place of the information listed below, the following information must, subject to (e) and (f) below, appear on all pharmacy benefits cards:

1. The issuer name, when required for proper claims adjudication;

2. The ANSI identification number (properly labeled), when required for proper claims adjudication;

3. The processor control number (properly labeled), if required by the party adjudicating claims, directing payment of claims or directing the adjudication of claims;

4. The group number (properly labeled), when required for proper claims adjudication;

5. An identification number (properly labeled);

6. The insured's name;

7. A telephone number for providers to call for pharmacy benefits assistance; and

8. Any other information necessary for proper claims adjudication, except for information provided on the prescription as required by law or regulation.

(d) Where information is required to be "properly labeled," the label (for example, "RxBIN") shall be placed close enough to the information so as to identify that information uniquely.

(e) If a combined card is used, the issuer name for pharmacy benefits shall be:

1. The same as for other benefits; or

2. Clearly distinguishable from the issuer name for other benefits.

(f) The identification number, if a combined card is used, shall be the same for pharmacy benefits and all other benefits, or the ID for pharmacy benefits shall be labeled "RxID" rather than "ID."

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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