Ohio Code 1751.111 – Standardized prescription identification information – pharmacy benefits to be included
(A)(1) This section applies to both of the following:
Terms Used In Ohio Code 1751.111
- Contract: A legal written agreement that becomes binding when signed.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Corporation: means a corporation formed under Chapter 1701. See Ohio Code 1751.01
- Health care services: means basic, supplemental, and specialty health care services. See Ohio Code 1751.01
- Health insuring corporation: means a corporation, as defined in division (H) of this section, that, pursuant to a policy, contract, certificate, or agreement, pays for, reimburses, or provides, delivers, arranges for, or otherwise makes available, basic health care services, supplemental health care services, or specialty health care services, or a combination of basic health care services and either supplemental health care services or specialty health care services, through either an open panel plan or a closed panel plan. See Ohio Code 1751.01
- Person: includes an individual, corporation, business trust, estate, trust, partnership, and association. See Ohio Code 1.59
- Subscriber: means a person who is responsible for making payments to a health insuring corporation for participation in a health care plan, or an enrollee whose employment or other status is the basis of eligibility for enrollment in a health insuring corporation. See Ohio Code 1751.01
(a) A health insuring corporation that issues or requires the use of a standardized identification card or an electronic technology for submission and routing of prescription drug claims pursuant to a policy, contract, or agreement for health care services;
(b) A person or entity that a health insuring corporation contracts with to issue a standardized identification card or an electronic technology described in division (A)(1)(a) of this section.
(2) Notwithstanding division (A)(1) of this section, this section does not apply to the issuance or required use of a standardized identification card or an electronic technology for submission and routing of prescription drug claims in connection with any of the following:
(a) Coverage provided under the medicare advantage program operated pursuant to Part C of Title XVIII of the “Social Security Act,” 49 Stat. 62 (1935), 42 U.S.C. § 301, as amended.
(b) Coverage provided under medicaid.
(c) Coverage provided under an employer’s self-insurance plan or by any of its administrators, as defined in section 3959.01 of the Revised Code, to the extent that federal law supersedes, preempts, prohibits, or otherwise precludes the application of this section to the plan and its administrators.
(B) A standardized identification card or an electronic technology issued or required to be used as provided in division (A)(1) of this section shall contain uniform prescription drug information in accordance with either division (B)(1) or (2) of this section.
(1) The standardized identification card or the electronic technology shall be in a format and contain information fields approved by the national council for prescription drug programs or a successor organization, as specified in the council’s or successor organization’s pharmacy identification card implementation guide in effect on the first day of October most immediately preceding the issuance or required use of the standardized identification card or the electronic technology.
(2) If the health insuring corporation or the person under contract with the corporation to issue a standardized identification card or an electronic technology requires the information for the submission and routing of a claim, the standardized identification card or the electronic technology shall contain any of the following information:
(a) The health insuring corporation’s name;
(b) The subscriber‘s name, group number, and identification number;
(c) A telephone number to inquire about pharmacy-related issues;
(d) The issuer’s international identification number, labeled as “ANSI BIN” or “RxBIN”;
(e) The processor’s control number, labeled as “RxPCN”;
(f) The subscriber’s pharmacy benefits group number if different from the subscriber’s medical group number, labeled as “RxGrp.”
(C) If the standardized identification card or the electronic technology issued or required to be used as provided in division (A)(1) of this section is also used for submission and routing of nonpharmacy claims, the designation “Rx” is required to be included as part of the labels identified in divisions (B)(2)(d) and (e) of this section if the issuer’s international identification number or the processor’s control number is different for medical and pharmacy claims.
(D) Each health insuring corporation described in division (A) of this section shall annually file a certificate with the superintendent of insurance certifying that it or any person it contracts with to issue a standardized identification card or electronic technology for submission and routing of prescription drug claims complies with this section.
(E)(1) Except as provided in division (E)(2) of this section, if there is a change in the information contained in the standardized identification card or the electronic technology issued to a subscriber, the health insuring corporation or person under contract with the corporation to issue a standardized identification card or an electronic technology shall issue a new card or electronic technology to the subscriber.
(2) A health insuring corporation or person under contract with the corporation is not required under division (E)(1) of this section to issue a new card or electronic technology to a subscriber more than once during a twelve-month period.
(F) Nothing in this section shall be construed as requiring a health insuring corporation to produce more than one standardized identification card or one electronic technology for use by subscribers accessing health care benefits provided under a policy, contract, or agreement for health care services.