CHAPTER 78
UNIFORM PRESCRIPTION DRUG INFORMATION CARD
191—78.1(514L) Purpose. The purpose of this chapter is to implement the use of a uniform prescription drug information card or other technology by the providers of third-party payment or prepayment of prescription drug expenses, by the providers’ contractors or agents and pharmacy benefit managers, and by administrators of the providers and payors. The purpose of the uniform prescription drug information card or other technology is to benefit patients, insurers, pharmacy benefit managers and pharmacists through enhanced patient convenience and processing of claims for prescription benefits, decreased calls to help desks due to missing or incorrect card information, and improved delivery of prescription benefit services to consumers.
191—78.2(514L) Definitions.
“Administrator” or “administrator of the payor” means the claims administrator or administrators to which claims for prescription drug benefits are submitted, processed and adjudicated, and includes pharmacy benefit managers, and excludes administrators for self-funded employer-sponsored health benefit plans qualified under the federal Employee Retirement Income Security Act of 1974.
“BIN number,” “IIN/BIN number,” “BIN,” or “RxBIN” means the ANSI-assigned issuer identification number, or IIN, which was formerly known as the “bank identification number” or “BIN,” and which is identified in the National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide as the “BIN number.” The “Rx” prefix is not required if the same BIN number is used for pharmacy and medical claims submission.
“Card” or “card or other technology for claims processing” means a card or other technology that is issued to insureds, enrollees, and covered individuals. Insureds, enrollees, and covered individuals provide the card to pharmacies to receive prescription drug benefits. Pharmacies use the information, required by Iowa Code chapter 514L to be on the card, for prescription drug claims submission, processing and adjudication with providers, administrators, pharmacy benefit managers or similar entities.
“Cardholder ID” means the cardholder’s unique identification number that is issued by the provider to the insured, enrollee, or covered individual, and which is identified in the National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide.
“Cardholder name” means the cardholder’s first name, middle initial and last name.
“Card issuer identifier number” means the number identified in the National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide as the international identifier for the United States of America, which has not yet been enumerated and may remain blank on cards until such number is determined.
“Card issuer’s name and logo” means the name and identifying mark of the entity issuing the card or other technology, identified in the National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide.
“Consistent with the guide” means that the information and data elements on the card shall conform to the standards set forth in the most recent release of the National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide, except that the address of the pharmacy benefit manager may be excluded and the information and data elements may be placed at different locations on the card as reasonably necessary to accommodate space and logistical needs.
“Group ID number,” “Grp,” or “RxGrp” means the group identification number or group ID number as identified in the National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide. The “Rx” prefix is not required if the same group number is used for pharmacy and medical claims submission.
“Guide” or “National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide” means the most recent document issued by the National Council for Prescription Drug Programs.
“Pharmacy benefit manager” means an entity that receives and processes claims for payment or prepayment for prescription drug expenses from pharmacies and that may issue cards or other technology for prescription claims processing.
“Processor control number,” “PCN,” or “RxPCN” means the processor control number as identified in the National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide. The “Rx” prefix is not required if the same PCN number is used for pharmacy and medical claims submission.
“Provider of third-party payment or prepayment of prescription drug expenses” or “provider” means a provider of an individual or group policy of accident or health insurance or an individual or group hospital or health care service contract issued pursuant to Iowa Code chapter 509, 514 or 514A, a provider of a plan established pursuant to Iowa Code chapter 509A for public employees, a provider of an individual or group health maintenance organization contract issued and regulated under Iowa Code chapter 514B, a provider of a preferred provider contract issued pursuant to Iowa Code chapter 514F, a provider of a self-insured multiple employer welfare arrangement, and any other entity providing health insurance or health benefits which provide for payment or prepayment of prescription drug expenses coverage subject to state insurance regulation.
“Substantially consistent with the guide” means that the location of the uniform prescription drug information on the card or other technology shall conform to the standards set forth in the most recent National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide. The information may be placed at different locations on the card as reasonably necessary to accommodate space and logistical needs.
“Uniform prescription drug information” means the requirements set forth in the most recent National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide, including the data elements information required on the card, such as the content, format and the location.
[ARC 3682C, IAB 3/14/18, effective 4/18/18]
191—78.3(514L) Implementation.
	78.3(1) Cards or other technology for prescription claims processing issued by providers, administrators, pharmacy benefit managers, and other entities shall contain data elements and other required information that is substantially consistent with the most recent National Council for Prescription Drug Programs Pharmacy ID Card Implementation Guide. The location of the data elements and information shall be substantially consistent with the guide, and the cards or other technology shall at a minimum contain the following:
	a. 	The BIN number labeled as “BIN” or “RxBIN.”
	b. 	The processor control number labeled as “PCN” or “RxPCN” if required for claims processing.
	c. 	The group identification number labeled as “Grp” or “RxGrp” if required for claims processing.
	d. 	The card issuer’s identification number if available.
	e. 	The cardholder’s name.
	f. 	The card issuer’s name or logo.
	g. 	The help desk name and telephone number for claims submission, processing and other assistance clearly labeled as “Help Desk” or “Pharmacy Service,” except that this information may be excluded from the card if the name and telephone number is provided electronically in a readable manner to the pharmacy computer at the time of claims processing and submission.
Notwithstanding the foregoing, nothing in this rule shall be interpreted to preclude the inclusion of additional data elements and information.
	78.3(2) If the card or other technology is issued by the provider of third-party payment or prepayment of prescription drug expenses, the provider shall be responsible for issuing the card or other technology in compliance with these rules.
	78.3(3) If the card or other technology is not issued by the provider of third-party payment or prepayment of prescription drug expenses and the card or other technology is issued by an administrator, pharmacy benefit manager, or other entity, the provider and entity shall enter into an agreement as to whether the provider or entity shall be responsible for compliance with these rules.
	78.3(4) For new insureds, enrollees, or otherwise covered individuals, the provider, administrator, pharmacy benefit manager, or other entity responsible for issuing cards or other technology in compliance with these rules shall issue the cards or other technology no later than 30 days after the insured, enrollee, or covered individual becomes eligible for prescription drug benefits.
	78.3(5) The provider, administrator, pharmacy benefit manager, or other entity responsible for issuing cards or other technology shall reissue cards in compliance with these rules at least once per year if the material information required on the cards or other technology under these rules changes. Nothing in these rules shall prevent such entities from issuing cards or other technology more than once per year.
	78.3(6) The data elements and information required on the cards or other technology pursuant to these rules shall be printed in a clear and readable form.
	78.3(7) Nothing in this rule shall prohibit the provider, administrator, pharmacy benefit manager or any other entity required to comply with these rules from issuing a card or other technology containing a magnetic strip or other technological component or device enabling the electronic transmission of information for prescription claims submission, processing, or adjudication, provided that the information required by these rules is printed on the card or other technology in a clear and readable form.
These rules are intended to implement Iowa Code chapter 514L.
[Filed emergency 8/27/03—published 9/17/03, effective 8/27/03]
[Filed ARC 3682C (Notice ARC 3571C, IAB 1/17/18), IAB 3/14/18, effective 4/18/18]