§§21.3002- 21.3005
The Commissioner of Insurance adopts new §§21.3002 - 21.3005, concerning pharmacy identification cards. Sections 21.3002 21.3004 are adopted with changes to the proposed text as published in the July 14, 2000 issue of the Texas Register (25 TexReg 6649). Section 21.3005 is adopted without changes and will not be republished.
The new sections implement the provisions of Senate Bill (SB) 1237, which amended Texas Insurance Code Article 21.07-6, and added Article 21.53L, 76th Legislature, 1999. The sections establish standardized information that must be included on pharmacy identification cards of enrollees in a health benefit plan containing benefits for prescription drugs. Prior to the enactment of SB 1237, Texas law did not require issuers of health benefit plans or pharmacy benefit managers (PBMs) or other administrators to issue pharmacy identification cards or to include standardized information on the pharmacy identification cards, which could result in delays and increased costs in processing pharmacy benefit claims. As a result of SB 1237 and these adopted sections, issuers of health benefit plans, administrators, or PBMs are required to issue pharmacy identification cards and are required to include the standardized information on the cards to help eliminate these problems.
Section 21.3002 sets forth definitions. Section 21.3003 sets forth options that issuers of health benefit plans, PBMs, or administrators may use when issuing standard identification cards to enrollees. This section also lists the information that must be included on a standard identification card for the card to comply with Texas law. The section clarifies that issuers of health benefit plans, PBMs, or administrators are not prohibited from including a magnetic strip or other technological component on the card to transmit information electronically, but still requires the standardized information to be physically printed on the card. Section 21.3004 addresses issuance of standard identification cards in situations where an issuer of a health benefit plan uses a PBM or other administrator. This section also requires a PBM or administrator that administers an issuer´s health benefit plan to enter into an agreement with the issuer as to which party will issue the standard identification card to enrollees. Section 21.3005 sets forth effective dates for issuing standard identification cards in accordance with §6 of SB 1237.
In response to comments, the following changes have been made to the sections: A definition of "effective date" has been added at §21.3002(4), and the remaining paragraphs have been renumbered. A definition of "effective date" has been added to clarify that the effective date of coverage is the date that the health benefit plan´s current prescription drug benefit levels became effective, or the date the subscriber´s coverage first became effective, whichever is later. Section 21.3003(b)(3) has been revised to clarify that standard identification cards must contain the name or logo of the administrator or PBM that is administering the pharmacy benefits if different from the health benefit plan. Section 21.3003(b)(6) has been revised by replacing the phrase, " the appropriate person" with " an appropriate person" to clarify that the section does not require the telephone number of a specific person for purposes of obtaining information relating to the pharmacy benefits under the health benefit plan. The revision is also made for consistency with Articles 21.07-6 and 21.53L which use " an" instead of " the." Section 21.3003(b)(7) has been revised to clarify that in addition to the copayments or coinsurance amounts for each benefit level of the formulary, the card may include language such as "variable" to indicate plan designs or limitations not fully reflected in the copayment/coinsurance disclosure. Section 21.3004(c) and (d) has been revised to clarify that the requirements of §21.3005(a) and (b) apply in conjunction with the requirements of §21.3004(c) and (d).
The Commissioner held a public hearing on the proposed sections on September 7, 2000, under Docket No. 2453, at the William P. Hobby Jr. State Office Building, 333 Guadalupe Street in Austin, Texas.
General
Comment: As provided in §2001.030, Government Code, a commenter requested a statement by the department of the principal reasons for and against adoption of the proposed rule.
Agency Response: The department believes that the order adopting the rules sets out the principal reasons for adoption of the rules. The rationale against adopting all, or portions, of the rules are detailed in the Summary of Comments and Agency´s Response to Comments. The principal reason for adopting the proposed rules with changes and for overruling the considerations urged against adoption is that the rules implement the statute and provide flexibility in their implementation where allowed, without placing overly burdensome requirements on those required to comply with the rules. Additionally, many of the concerns raised by commenters have been addressed by the department in the adoption of the rules by making changes to the rules where appropriate. In those instances where changes were not made, the department believed that either the statute directly addressed the commenter´s concerns, or that the change could not be made and still remain within the legislative parameters of SB 1237.
Comment: Many commenters generally supported the rules, and believed the statute and rule are beneficial to pharmacists and enrollees. Several commenters recognized the department´s efforts to reduce unnecessary administrative burdens and thereby increase pharmacists' opportunity to ensure quality patient outcomes. Inasmuch as there is a shortage of pharmacists, but more plans, more drugs to dispense, and more prescriptions to fill, several commenters affirmed the necessity of requiring a standard pharmacy benefit card and the resulting benefits.
Agency Response: The department appreciates the commenters´ support.
Comment: Some commenters disagreed generally with the rules and the assertions made in the Public Benefit/Cost Note that there will be no economic impact to persons required to comply with the rules. Other commenters disagreed that the sections will have no adverse economic impact on "issuers of micro (or macro) health benefit plans," administrators, PBMs, and enrollees. One of the commenters cited such costs as retooling of machines, additional machines, and staffing requirements to print and prepare the cards. Another commenter suggested that the Public Benefit/Cost Note should be changed to state that the cost to produce a card and mail it to the enrollee is approximately $1.00 per card. The commenter also stated that if the issuer of the cards has a large enrollee population, the cost of issuing new cards and multiple cards can become extremely expensive, and will eventually impact the cost of services to enrollees.
Agency Response: The department disagrees. The department believes that there will be no adverse economic impact as a result of the rule because any costs are the result of the enactment of SB 1237 which requires issuance of a standard pharmacy card, and also sets forth the items which, at a minimum, must be printed on the card. With respect to the commenter´s concerns about cost, the legislature has mandated that cards be issued. Therefore, it would be inappropriate for the rule to waive the requirement to issue cards as required by the statute. Enrollees were not addressed in the cost note because the cost note, by virtue of the Texas Government Code §2001.024(a)(5)(B), is directed toward persons required to comply with the rule, and enrollees are not persons required to comply with the rule.
Comment: A few commenters expressed concerns about potential added expenses associated with issuing standard identification cards, and suggested that the rule be changed to support issuance of cards on a voluntary, non-mandated basis.
Agency Response: The department disagrees. The card cannot be issued on a voluntary, non-mandated basis because Articles 21.07-6 and 21.53L require pharmacy benefit cards to be issued to "each enrollee."
Comment: One commenter believed that the regulations should recognize and accept the voluntary ID Card Implementation Guide developed by the National Council for Prescription Drug Programs (NCPDP) and thus provide for national standards. This commenter also noted that the NCPDP guide considers some elements required by the rules to be non-mandatory (i.e., dependent information, copayment or coinsurance amounts, and effective date of coverage), whereas the rule requires these items of information. The commenter also stated that the rule should allow compliance with the NCPDP as this would provide flexibility for plans to come into compliance with diverse statutes and regulations across business regions.
Agency Response: The department recognizes the benefit of national standards, but disagrees that the information can be non-mandatory because the requirements of Articles 21.07-6 and 21.53L specifically address the items of information that must, at a minimum, be included on pharmacy benefit cards. Where possible, the department has allowed flexibility in the rule while still implementing the requirements of the articles.
§21.3002(a)(5)
Comment: One commenter suggested changing the definition of "enrollee identification card" to read, "A printed card issued to enrollees of a health benefit plan that includes all necessary information to allow an enrollee to access all coverage under the health benefit plan and for a provider to process any subsequent claims."
Agency Response: The department disagrees with the suggested change because the proposed definition is sufficient to define enrollee identification card. The suggestion could result in either an unnecessary volume of information, or a lack of information, on the card such that the overall intent of the statute is negated.
§21.3003(a) & (b)
Comment: Some commenters were concerned about additional costs related to issuing and updating cards, and contended that costs related to the initial and on-going printing, handling, and mailing of these cards are not insignificant. One commenter expressed concern regarding any requirements to continually make changes to the card format, as well as the additional expense for employers, consumers, and health plans as a result.
Agency Response: The department recognizes that there may be costs associated with issuing and updating the cards but notes that those costs are attributable to the statute. Based on legislative history and comments on the rule, it is the department´s determination that the intent of Articles 21.07-6 and 21.53L is to ensure that enrollees possess standardized cards usable by pharmacists to help reduce the time spent submitting claims. The department believes the statute requires the card to be updated whenever the information on the card changes so that pharmacists who need the information have the most current and accurate information possible.
§21.3003(b)(1)
Comment: One commenter supported the need for dependent name and identification code information on pharmacy benefit cards, and noted that some issuers of health benefit plans identify individuals within a family differently than other health benefit plans. This commenter affirmed that this information is required to properly process pharmacy benefits claims, and is needed to reduce the time and cost associated with guessing the information when it is not readily available or apparent from the enrollee, subscriber, or dependent. The commenter also stated that some cards currently in circulation have this information on the card.
Several other commenters expressed concerns or disagreement with the requirement to include enrollee names on the identification cards; to include enrolled dependent names on the cards; or to include either the enrollee or dependent name on the cards. Reasons given by the commenters included: the information is not required by Articles 21.07-6 and 21.53L; only the group number of the enrollee is required by statute; identification cards contain a subscriber/member identification number and the subscriber/member name, but do not always include the name of each covered dependent; requiring the names of dependents on the card does not ensure eligibility at the time the card is presented to the pharmacy, and only electronic transactions can accomplish this; some insurers require the covered individual to self-file for reimbursement, thus the dependent name on the card is not necessary; the dependent name is not always required for benefit adjudication; the requirement creates an unnecessary administrative expense, is costly, and is impractical due to space limitation on the card; is not necessary given current technology; and allows minors to obtain certain drugs directly from a pharmacist.
Agency Response: Articles 21.07-6 and 21.53L require the card to be issued to "each enrollee." The department interprets this language to include enrolled dependents, because at the time SB 1237 was enacted, cards routinely contained, and still contain, both the name and identification number of enrollees. As such, it is the department´s position that the statutes did not expressly address names on the cards because it was assumed de facto. It is also the department´s position that to issue a card without a name could create confusion because a card without a name would not identify who is covered, and could also allow persons who are not covered by the plan to attempt to use the card to improperly access prescription drug benefits to which they are not otherwise entitled. Additionally, commenters stated that pharmacists need the enrolled dependents´ names and corresponding identification codes so that they are not forced to guess what the corresponding codes are for these individuals, a problem the statute is intended to address. The department also recognizes that electronic transactions are used to process claims and to determine eligibility; but for pharmacists to submit a successful electronic claim, pharmacists need both the name and identification code for each enrollee. The sections are written in such a way as to provide the option to either issue two cards containing all names of enrollees including enrolled dependents, or to issue a separate card to each enrollee including enrolled dependents. The department believes this option promotes flexibility. The statute did not provide an exception for insurers that require covered individuals to self-file for claims. Additionally the department´s research reveals no law that expressly prohibits a prescription from being dispensed directly to a minor.
§21.3003(b)(2) & (3)
Comment: A commenter noted that the statutory language of Articles 21.07-6 and 21.53L requires the name and logo of both the health benefit plan providing pharmacy benefits, and the PBM or administrator administering pharmacy benefits in relation to a pharmacy benefit card. The commenter requested clarification regarding use of "if applicable" language in the paragraphs. The commenter interprets the language to allow health benefit plan that contract with a PBM to adjudicate claims online, but retains authority over complaints, to put only the health benefit plan´s name on the card, the identification number of the PBM so that the pharmacist knows who is administering claims payment, and the health benefit plan´s telephone number for complaints.
Agency Response: The department disagrees with the commenter´s interpretation. SB 1237 enacted §19A of Article 21.07-6, which addresses administrators and PBMs, and Article 21.53L which addresses issuers of health benefit plans. The rule implements SB 1237 in its entirety and, as such, addresses all of these entities. The proposed rule attempted to recognize that not all issuers of health benefit plans use the services of an administrator or PBM; hence, use of the "if applicable" language. A purpose of the rule is to provide standard information on a card to allow a pharmacist experiencing claims difficulties to be able to contact the PBM to obtain necessary information to successfully process the claim. Since the PBM adjudicates claims for its client, the issuer of a health benefit plan, it appears that if the pharmacist has technical difficulty processing a claim, the pharmacist will need relevant information to contact the administrator or PBM. As such, an issuer of a health benefit plan that uses an administrator or PBM must include the administrator´s or PBM´s name on the card. To clarify the department´s interpretation, the department changed §21.3003(b)(3). The department also notes that the rule does not prohibit the issuer of a health benefit plan from also including its telephone number for the reporting of complaints.
§21.3003(b)(5)
Comment:Several commenters stated that inclusion of the effective date of coverage on the card will do nothing to accomplish the objectives stated in the statute, is unnecessary, and will increase costs which will be borne by consumers in the form of increased premiums or decreased availability of affordable coverage. A commenter stated that the only date of real value would be the expiration date of the card, which would not be predictable at the time of the card's printing. A few commenters recommended that the paragraph be amended to read, " original effective date" to prevent unnecessary expense of reprinting cards for which eligibility is renewed continuously on a month-to-month or quarterly basis, and noted that technology already allows the pharmacist to determine when eligibility has expired. Other commenters recognized that the effective date is required by the statute, but noted that the information is useless during claims processing as it does not guarantee current or future eligibility and only consumes space on the card.
Agency Response: The department understands the concerns that the effective date is generally not used by pharmacists to process pharmacy claims, but the effective date is required by Articles 21.07-6 and 21.53L. The department has addressed the commenter´s concerns by adding a definition of "effective date" to §21.3002. The definition developed is useful, meets statutory intent, and provides a date that allows one to determine how current the card is.
§21.3003(b)(6)
Comment: One commenter recommended changing this paragraph to prevent any confusion about providing the telephone number of a specific person.
Agency Response: The department agrees, and has changed paragraph (6) to clarify that the telephone number does not refer to a specific person.
Comment: Some commenters suggested changing the language to read as follows: "a telephone number of the appropriate person for purposes of obtaining information and/or technical support relating to the pharmacy benefits provided under the health benefit plan."
Agency Response: The department disagrees with the suggested change and believes the suggestion could cause additional confusion. Such language would not make it clear whether "technical support" was for claims software issues, or technical support for pharmacy claims, or some other purpose.
§21.3003(b)(7)
Comment: Several commenters recommended either deleting the copayment/coinsurance provision or limiting it to generic and brand-name information only. These commenters stated that requiring inclusion of copayment or coinsurance information on the card will be impossible to comply with because of modern, sophisticated benefit designs, as well as impractical to accommodate on a standard sized card. The commenters noted that requiring each level of copayment information for drug formularies is unnecessary because the information is immediately transmitted to the PBM or administrator or health benefit plan electronically, and pharmacists will collect the amounts associated with the electronic response, not the amount on the card. The commenters also objected to the requirement that cards be reissued upon a change in information as people frequently change jobs or relocate, which results in additional costs. Several commenters suggested use of the term "variable" or other similar language in lieu of the current requirement. A commenter stated that inclusion of copayment/coinsurance levels will encourage Texas consumers to gravitate toward mail order service, and in doing so, will penalize Texas retail pharmacists and consumers. The commenter stated that the ability to collect variable copays at the point of sale remains a significant advantage that local retail pharmacists maintain over mail-order pharmacists.
Agency Response: The department agrees in part and disagrees in part. The statutes specify which information, at a minimum, must be on the card. As such, the department has attempted to balance the concerns of space limitations, while at the same time meeting the requirements of the statute. Because the department recognizes that providing all information for all possible plan designs is not feasible, it has changed subsection (b)(7) to clarify that a card may, in addition to disclosing the copayment/coinsurance amount for generic, brand-name and each tier level of the drug formulary, include terminology such as "variable." For example, a plan using a three-tier formulary with $5/$20/$35 copayments but with a dollar limitation of $500 for the first tier, $1000 for the second tier, and $2000 for the third tier would indicate "$5/$20/$35" on the card, and could also include language to reflect limitations or plan designs not fully reflected in the copayment disclosure, such as "Generally $5/$20/$35" or "$5/$20/$35 Subject to Plan Maximums." The department disagrees with the commenter´s contention that inclusion of copayment/coinsurance information on the cards will encourage Texas consumers to switch to mail-order pharmacies. Neither the statute nor the rule changes how claims are processed by pharmacists, and as such, does not create situations that make mail-order pharmacies either more or less attractive to consumers.
Comment:A commenter stated that requiring inclusion of copayment or coinsurance information on the card may encourage fraud against enrollees and insurers, and will encourage circumvention of central profiling and DUR (Drug Utilization Review), thereby precipitating potentially hazardous and costly health consequences. This commenter also stated that inclusion of basic copay information on the card will not result in a more efficient and expeditious processing of claims; will not reduce wait time for enrollees having prescriptions filled; will not increase disclosure of benefits to enrollees; and will not increase the amount of time that pharmacists will be able to spend filling prescriptions and advising patients.
Agency Response: The department does not believe the inclusion of this information on the card will encourage fraud or lead to circumvention of central profiling and DUR. With respect to the commenter´s statements that this information will not result in a more expeditious processing of claims, etc., the department believes the commenter is referring to the Public Benefit/Cost Note contained in the preamble to the proposed rule. The public benefits stated in the Public Benefit/Cost Note refer to the general benefits of the rule as a whole, and are not in reference to any specific item of information required to be included on the card.
§21.3003(b)(8)
Comment: A commenter commended the department for including language in §21.3003(b)(8) that clarifies that the International Identification Number (IIN) is the same as and is often referred to as the Bank Identification Number (BIN). A few commenters stated that requiring use of the BIN before implementation of the federal administrative simplification rule mandated by the Health Insurance Portability and Accountability Act will impose additional unnecessary expenses on plans, employers, and consumers. One commenter noted that some cards currently in circulation already contain this number.
Agency Response: The department appreciates the commenter´s acknowledgment of the BIN. The department does not agree with other commenters that use of the IIN will impose additional unnecessary expenses. Article 21.07-6 requires the IIN, which is the same as the BIN. Additionally, the federal regulations to which the commenters refer have not been finally published.
Comment: A commenter stated concerns about the amount of time it will take for a company to reprogram its information systems to include necessary information for printing the IIN on prescription cards. The commenter stated that each time a company reprograms its information systems to include an element on the card, it is costly and time-consuming. The commenter cited one instance in which a company cited a cost of $32,000 to add the group effective date to the card. Because it will take a company time to reprogram its information systems, the commenter requested that the effective date for the administrator or prescription benefit manager to have its IIN printed on its card be no sooner than September 1, 2000 and applicable to policies delivered or issued for renewal on or after January 1, 2001.
Agency Response: The department disagrees, and directs the commenter to §21.3005 with respect to the commenter´s request to delay the effective date of the rule which incorporates §6 of SB 1237 and sets forth the dates for compliance.
Comment: A commenter suggested adding an additional paragraph (9) as follows: "as applicable, all other information required by the health benefit plan or PBM to bill a health benefit plan."
Agency Response: The department disagrees. The commenter's suggestion could result in an unnecessary volume of information required to be printed on the card. Other commenters have stated concerns about the lack of space on the card available for printing additional items of information not currently included on some cards.
§21.3004
Comment: A commenter stated that the amount of information required relating to pharmacy benefits should not negate the purpose of the card which is to provide the plan participant with evidence of insurance that is useful for all providers.
Agency Response: The department recognizes the commenter´s concerns, but believes that the sections do not negate the statutory intent. The department has considered the requirements of the statute and balanced the requirements of the sections with the overall intent of Articles 21.07-6 and 21.53L.
§21.3004(a)
Comment: One commenter stated that currently plans generally issue a single multi-purpose card to subscribers, and requests the flexibility to continue this practice.
Agency Response: Section 21.3004 allows an enrollee identification card to fulfill the requirements of a standard identification card, so long as the required information appears on the enrollee identification card. A single multi-purpose card may be issued so long as it meets the requirements of the statute and rule.
§21.3004(c) & (d)
Comment: A commenter noted that the regulations require health benefit plans and PBMs or administrators to issue pharmacy identification cards within 30 days after the "final step of this rule taking effect." The commenter suggested the department consider allowing implementation to be at the next renewal date of the health benefit plan.
Agency Response: The department understands the commenter´s concerns, but directs the commenter to Article 21.07-6, §19A(c), which sets forth the 30-day requirement. The department also directs the commenter to §6 of SB 1237, and §21.3005(a) and (b), all of which address time frames for issuing cards in compliance with the statute and the rule. The department has changed §21.3004(c) and (d) to clarify that the requirements of §21.3005(a) and (b) apply to §21.3004(c) and (d).
§21.3005(a) & (b)
Comment: One commenter suggested adding language at the end of both subsections (a) and (b) to state, "but at no time later than two years from the effective date of this subsection." Another commenter suggested the department consider proposals that will allow health benefit plans, administrators, and PBMs to issue new cards during the enrollee´s earliest enrollment period. The commenter also noted that it may be necessary to adopt a final compliance date for enrollees that will not cycle through the enrollment process within a reasonable time frame.
Agency Response: The department disagrees. The commenters´ suggested changes are inconsistent with the statute which addresses when new cards must be issued. Section 21.3005(a) and (b) merely implement §6 of SB 1237 to assure consistency between the statute and the rule.
NAMES OF THOSE COMMENTING FOR AND AGAINST THE SECTIONS.
For, with changes: Texas Pharmacy Association; Texas Federation of Drugstores; Texas Association of Life and Health Insurers; Advanced Paradigm, Inc.; Humana Health Plans; Employers´ Health; Lamar Plaza Drugstore; Legend Pharmacies; Texas Association of Health Plans; PCS Health Systems; PAID Prescriptions; BlueCross/BlueShield of Texas; Pharmaceutical Care Management Association; Health Insurance Association of America; Academy of Managed Care Pharmacy; Merck-Medco Managed Care, L.L.C.; a member of the legislature.
Against: An individual.
The sections are adopted under Insurance Code Articles 21.07-6, 21.53L, and §36.001. Article 21.07-6 provides that the commissioner may adopt rules to implement the provisions of the article, and requires the commissioner to adopt standard information to be included on a standard identification card. Article 21.53L provides that the commissioner shall adopt rules necessary to implement the provisions of the article. Section 36.001 provides that the Commissioner of Insurance may adopt rules for the conduct and execution of the powers and duties of the department only as authorized by statute.
§21.3002. Definitions; Pharmacy Identification Cards. The following words and terms, when used in §§21.3002 - 21.3005 of this subchapter shall have the following meanings, unless the context clearly indicates otherwise:
(1) Administrator -- As defined in Insurance Code Article 21.07-6, §1(1), but does not include an administrator for a self-funded employee welfare benefit plan covered by the federal Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §1002(1)(A).
(2) Drug -- As defined in the Texas Pharmacy Act, Occupations Code §551.003.
(3) Drug formulary -- A list of drugs for which a health benefit plan provides coverage, approves payment, or encourages or offers incentives for physicians or other health care providers to prescribe.
(4) Effective date -- The date that the health benefit plan´s current prescription drug benefit levels became effective, or the date the subscriber´s coverage first became effective, whichever is later.
(5) Enrollee -- A person covered by a health benefit plan.
(6) Enrollee identification card -- A printed card issued to enrollees of a health benefit plan that includes all necessary information to allow an enrollee to access all coverage under the health benefit plan.
(7) Health benefit plan -- As described in Insurance Code Article 21.53L, including a health benefit plan providing coverage for pharmacy benefits only. This definition includes the term, "plan," as defined in Insurance Code Article 21.07-6, §1(6), but does not include a self-funded employee welfare benefit plan covered by ERISA, 29 U.S.C. §1002(1)(A).
(8) Identification code -- Any unique code utilized by an issuer of a health benefit plan, administrator, or pharmacy benefit manager that identifies and differentiates amongst enrollees.
(9) Issuer -- Those entities identified in Insurance Code Article 21.53L, §2(a)(1) - (8).
(10) Pharmacy benefit manager -- As defined in Insurance Code Article 21.07-6, §1(9), but does not include a pharmacy benefit manager for a self-funded employee welfare benefit plan covered by ERISA, 29 U.S.C. §1002(1)(A).
(11) Pharmacy benefits -- Coverage in a health benefit plan for prescription drugs that are ordinarily and customarily dispensed by a pharmacy or pharmacist licensed under the Texas Pharmacy Act, Occupations Code §551.001 et seq.
(12) Standard identification card -- A printed card containing the written information required by §21.3003(b) of this subchapter (relating to Standard Identification Cards).
(13) Subscriber -- The individual who is the contract holder and who is responsible for payment of premiums to the issuer of an individual health benefit plan; or the individual who is the certificate holder and whose employment or membership status, except for family dependency, is the basis for eligibility for enrollment in a group health benefit plan.
§21.3003. Standard Identification Cards.
(a) The issuer of a health benefit plan that provides pharmacy benefits, or a pharmacy benefit manager or administrator issuing standard identification cards to enrollees shall issue standard identification cards as follows:
(1) For a subscriber who is an enrollee, and has no enrolled dependents, a single card shall be issued to the subscriber, with additional cards available upon request.
(2) For a subscriber who is an enrollee, and who has enrolled dependents, either:
(A) a card shall be issued to the subscriber and to each of the enrolled dependents, with additional cards available upon request; or
(B) two cards shall be issued to the subscriber for use by the subscriber and all enrolled dependents, with additional cards available upon request.
(3) For coverage under an individual health benefit plan in which the subscriber is not an enrollee, or for coverage under a group health benefit plan which is continued by an enrollee pursuant to Insurance Code Article 3.51-6, §3B, either:
(A) a card shall be issued to each enrollee, with additional cards available upon request; or
(B) two cards shall be issued for use by all enrollees, with additional cards available upon request.
(b) Each standard identification card issued shall, at all times the card is in effect, include current information as follows:
(1) the enrolled subscriber´s or enrolled dependents´ names and identification codes, as follows:
(A) For cards issued pursuant to subsection (a)(1) of this section, the enrolled subscriber´s name and identification code;
(B) For cards issued pursuant to subsection (a)(2)(A) of this section, the enrolled subscriber´s name and identification code on the enrolled subscriber´s card, and on each enrolled dependent´s card, the name and identification code of the enrolled dependent to whom the card will be issued;
(C) For cards issued pursuant to subsection (a)(2)(B) of this section, the names and identification codes of the enrolled subscriber and the names and identification codes of all the enrolled dependents;
(D) For cards issued pursuant to subsection (a)(3)(A) of this section, on each enrolled dependent´s card, the name and identification code of the enrolled dependent to whom the card will be issued;
(E) For cards issued pursuant to subsection (a)(3)(B) of this section, the names and identification codes of all enrolled dependents;
(2) if applicable, the name or logo of the issuer;
(3) the name or logo of the administrator or pharmacy benefit manager that is administering the pharmacy benefits, if different from the health benefit plan;
(4) as applicable, the group number applicable to the enrollee(s) covered by a group health benefit plan or the policy number or evidence of coverage number applicable to the enrollee(s) covered by an individual health benefit plan;
(5) the effective date of coverage;
(6) a telephone number of an appropriate person for purposes of obtaining information relating to the pharmacy benefits provided under the health benefit plan;
(7) as applicable, the corresponding copayment or coinsurance for generic and brand-name drugs; provided that, if the health benefit plan uses a drug formulary with benefit levels in addition to generic and brand-name prescription drugs, the card shall include the corresponding copayments or coinsurance for each tier level of the drug formulary. In addition to disclosure of each benefit level, the card may include a term such as "variable," to reflect benefit designs not fully revealed by the drug formulary tier disclosure; and
(8) as applicable, the International Identification Number, also known as the Banking Identification Number, assigned to the administrator or pharmacy benefit manager by the American National Standards Institute.
(c) Nothing in this section prohibits the issuer of a health benefit plan, or an administrator or pharmacy benefit manager, from issuing a standard identification card containing a magnetic strip or other technological component enabling the electronic transmission of information, provided that the information required by subsection (b) of this section is printed on the card.
§21.3004. Issuance of Standard Identification Cards.
(a) An issuer of a health benefit plan, or an administrator or pharmacy benefit manager, is not required to issue a standard identification card in addition to an enrollee identification card if:
(1) the enrollee identification card contains the information required by §21.3003(b) of this subchapter (relating to Standard Identification Cards); and
(2) the enrollee identification card is issued in accordance with §21.3003(a) of this subchapter and subsections (c) and (d) of this section.
(b) Pursuant to subsection (a) of this section, if a standard identification card is required to be issued, and an administrator or pharmacy benefit manager administers a health benefit plan of an issuer, the administrator or pharmacy benefit manager and the issuer shall enter into an agreement as to which entity will issue the standard identification card in accordance with this subchapter.
(c) Subject to §21.3005(a) and (b) of this subchapter (relating to Previously Issued Identification Cards), when an administrator or pharmacy benefit manager for a health benefit plan is designated or required to issue a standard identification card, the administrator or pharmacy benefit manager shall issue the standard identification card in accordance with this subchapter not later than the 30th calendar day after the date the administrator or pharmacy benefit manager receives notice from the issuer, or from the health benefit plan, that the enrollee is eligible for the pharmacy benefits.
(d) Subject to §21.3005(a) and (b), if [
If] the issuer of a health benefit plan is required to issue a standard identification card, the issuer of the health benefit plan shall issue the standard identification card in accordance with this subchapter not later than the 30th calendar day after the enrollee is eligible for pharmacy benefits.
§21.3005. Previously Issued Identification Cards.
(a) If an enrollee holds an enrollee identification card or other card used by the enrollee to access pharmacy benefits, and such card was both in effect on September 1, 1999, and includes the information required by §21.3003(b)(4), (5), (6), and (8) of this subchapter (relating to Standard Identification Cards), an administrator or pharmacy benefit manager for a health benefit plan is not required to issue a new standard identification card pursuant to this subchapter that contains all the information required by §21.3003 (b)(1) (8) until coverage under the health benefit plan is modified or until a new card is issued to enrollees, whichever occurs first.
(b) If an enrollee holds an enrollee identification card, or other card used by the enrollee to access pharmacy benefits, and such card was both in effect on September 1, 1999, and includes the information required by §21.3003(b)(4) (6), an issuer of a health benefit plan issuing its own identification card is not required to issue a new standard identification card pursuant to this subchapter that contains all the information required by §21.3003(b)(1) (8) until coverage under the health benefit plan is modified or until a new card is issued to enrollees, whichever occurs first.