N.J. Admin. Code § Tit. 11, ch. 4, subch. 62, APPENDIX, exh. A
I, (Name of Individual Acting on Behalf of the Pharmacy Benefits Manager), hereby certify that with respect to all pharmacy benefits contracts executed or renewed between (Name of Pharmacy Benefits Manager) and a contracted pharmacy located in this State, such contracts comply with the requirements set forth in N.J.S.A. 17B:27F-1 et seq. and N.J.A.C. 11:4-62. I further certify that I am authorized to make this certification on behalf of between (Name of Pharmacy Benefits Manager)..
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment.
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N.J. Admin. Code Tit. 11, ch. 4, subch. 62, APPENDIX, exh. A