New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 55 - PHARMACY CARDS › Section 11:4-55.1 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.
"ANSI identification number" means the American National Standards Institute (ANSI) International ID Number assigned to the administrator or pharmacy benefits manager of the health benefits plan. The label for this number is "RxBIN."
"Card" means a card or other technology that functions like a card.
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization authorized to issue health benefits plans in this State.
"Comprehensive pharmacy benefits" means benefits covering prescription drugs on an outpatient basis, irrespective of whether the benefits are provided by a network of participating pharmacies, and irrespective of whether the benefits are in the form of the prescription drugs themselves or are in the form of reimbursement for the cost of the prescription drugs. "Comprehensive pharmacy benefits" shall not mean benefits limited to prescription drugs provided in connection with mandated benefits for specific diseases or conditions.
"Group number" means the group number for the insured. The label for this number is "RxGRP."
"Health benefits plan" means:
1. A health benefits plan that is delivered or issued for delivery in this State by or through a carrier;
2. A plan provided by a multiple employer welfare arrangement; or
3. A plan provided by another benefit arrangement, to the extent permitted by the "Employee Retirement Income Security Act of 1974," Pub. L. 93-406 ( 29 U.S.C. §§
										1001 et seq.), or by any waiver of or other exception to that act provided under Federal law or regulation. "Health benefits plan" shall include prescription-only coverage.
"Health benefits plan" shall not mean:
1. Accident-only insurance;
2. Credit accident and health insurance;
3. Medicare supplement insurance;
4. Medicaid fee-for-service;
5. Disability income insurance;
6. Long-term care insurance;
7. Specified disease insurance;
8. Dental or vision care plan;
9. Hospital indemnity insurance;
10. Coverage issued as a supplement to liability insurance;
11. Medical payments under automobile or homeowners insurance; or
12. Insurance under which benefits are payable without regard to fault and that are statutorily required to be included in a liability policy or equivalent self-insurance program.
"Identification number" or "ID" means the identification number for the insured. This number shall be labeled "ID," except that, in the case of a combined card where the identification number for pharmacy benefits differs from the identification number for other benefits, the number shall be labeled "RxID."
"Insured's name" means the name of the primary insured or, if a separate card is issued for another person included under the primary insured's coverage, the name of the covered person to whom the separate card is issued.
"Issuer name" means the name of the sponsor, carrier, or administrator of the plan (which name may be abbreviated), or the name of a plan of benefits.
"Primary insured" means, in the case of group or individual coverage covering more than one person based on their relationship to an eligible person, such eligible person.
"Processor control number" means the processor control number assigned by the administrator or pharmacy benefits manager. The label for this number is "RxPCN."