Ohio Code 3959.20 – Prohibited acts regarding cost-sharing, pharmacy claims for reimbursement, fees
(A) As used in this section:
Terms Used In Ohio Code 3959.20
- Administrator: includes a pharmacy benefit manager. See Ohio Code 3959.01
- pharmacy: means a pharmacy located in this state participating in either the network of a pharmacy benefit manager or in a health care or pharmacy benefit plan through a direct contract or through a contract with a pharmacy services administration organization, group purchasing organization, or another contracting agent. See Ohio Code 3959.01
- Pharmacy benefit manager: includes the state pharmacy benefit manager selected under section 5167. See Ohio Code 3959.01
- Plan: means any arrangement in written form for the payment of life, dental, health, or disability benefits to covered persons defined by the summary plan description and includes a drug benefit plan administered by a pharmacy benefit manager. See Ohio Code 3959.01
(1) “Cost-sharing” means the cost to an individual insured under a health benefit plan according to any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements imposed by the plan.
(2) “Health benefit plan” and “health plan issuer” have the same meanings as in section 3922.01 of the Revised Code.
(3) “Pharmacy audit” has the same meaning as in section 3901.81 of the Revised Code.
(4) “Pharmacy benefit manager” and “administrator” have the same meanings as in section 3959.01 of the Revised Code.
(B) No health plan issuer, pharmacy benefit manager, or any other administrator shall require cost-sharing in an amount, or direct a pharmacy to collect cost-sharing in an amount, greater than the lesser of either of the following from an individual purchasing a prescription drug:
(1) The amount an individual would pay for the drug if the drug were to be purchased without coverage under a health benefit plan;
(2) The net reimbursement paid to the pharmacy for the prescription drug by the health plan issuer, pharmacy benefit manager, or administrator.
(C)(1) No health plan issuer, pharmacy benefit manager, or administrator shall retroactively adjust a pharmacy claim for reimbursement for a prescription drug unless the adjustment is the result of either of the following:
(a) A pharmacy audit conducted in accordance with sections 3901.811 to 3901.814 of the Revised Code;
(b) A technical billing error.
(2) No health plan issuer, pharmacy benefit manager, or administrator shall charge a fee related to a claim unless the amount of the fee can be determined at the time of claim adjudication.
(D) The department of insurance shall create a web form that consumers can use to submit complaints relating to violations of this section.