173-71-01.1 Administrator.

(A) Except as provided in paragraph (B) of this rule, ODA shall administer the best Rx program.

(B) ODA may enter into a contract with any person under which the person serves as the administrator of the best Rx program.

(1) If ODA chooses to enter into such a contract, before entering into the contract, ODA shall issue a request for proposals from persons seeking to be considered. ODA shall follow the process outlined by section 125.071 of the Revised Code for selecting one of the persons seeking to become the administrator.

(2) Subject to divisions (B)(5) and (B)(6) of section 173.721 of the Revised Code, ODA may delegate to the person awarded the contract any of ODA’s powers or duties specified in sections 173.71 to 173.91 of the Revised Code or any other provision of the Revised Code pertaining to the best Rx program. The terms of the contract shall specify the extent to which the powers or duties are delegated to the administrator. Accordingly, ODA shall include the following terms in the contract:

(a) To the extent delegated by ODA, the administrator shall determine the eligibility of any applicant to the best Rx program by reviewing that application upon submission of the application to the administrator in accordance with section 173.76 of the Revised Code and rule 173-71-02 of the Administrative Code:

(i) Whenever the administrator determines that an applicant is ineligible to participate in the best Rx program, the administrator shall provide the applicant with information authorized by ODA on how to apply again and how to contact the administrator for assistance; or,

(ii) Whenever the administrator determines that an applicant is eligible to participate in the best Rx program, the administrator shall distribute information from ODA along with the participant’s best Rx card. The administrator shall distribute information on topics including, but not limited to, the following:

(a) General program information, such as the benefits of best Rx, how to use the card, and how to submit notification changes in address or family composition;

(b) Information on participating terminal distributors; and,

(c) Information on how to contact the administrator for assistance.

(b) The administrator shall process every claim submitted by any participating pharmacy in accordance with rule 173-71-08 of the Administrative Code;

(c) The administrator shall process each payment made by a manufacturer under a manufacturer agreement entered into in accordance with rule 173-71-06 of the Administrative Code, including, but not limited to, the reimbursement of a participating pharmacy, the preparation of an invoice for a participating drug manufacturer, and reconciliation to assure accuracy;

(d) The administrator shall retain and safeguard all hard-copy or electronic records related to the best Rx program throughout the contract period and for no less than six years following the termination of the contract or until the resolution of any outstanding audit or investigation, whichever is later. If the administrator chooses to enter into a contract with another person to offer the drug mail-order system, the administrator shall include a term in the contract with the other person that requires the other person to retain and safeguard all hard-copy or electronic records related to the drug mail-order system throughout the contract period and for no less than six years following the termination of the contract or until the resolution of any outstanding audit or investigation, whichever is later;

(e) The administrator shall submit any report or information to ODA that is requested by ODA;

(f) The administrator shall produce any records related to the best Rx program when requested by ODA;

(g) The administrator shall agree to any audit by the auditor of state, ODA, or any person designated by ODA, including an audit requested by a participating drug manufacturer that is approved by ODA in accordance with section 173.82 of the Revised Code;

(h) The administrator shall maintain identifying information of participants, former participants, and applicants to the best Rx program in confidentiality in accordance with sections 173.90 and 173.91 of the Revised Code and rule 173-71-09 of the Administrative Code;

(i) The administrator shall provide information and assistance to any applicant to the best Rx program, to any participant of the best Rx program, and to any other interested party through multiples avenues, including, but not limited to, the operation of a toll-free telephone line;

(j) The administrator shall provide information and assistance to participating pharmacies, including the operation of a toll-free call center, twenty-four hours a day, seven days a week. This is not to be confused with the resolution of a grievance which is handled by the ombudsman;

(k) In accordance with division (B) of section 173.86 of the Revised Code, ODA shall use money in the best Rx administration fund to pay the administrative costs of the best Rx program associated with services delegated by ODA to the administrator. ODA shall base the payment to the administrator, in part, or in whole, on the volume of transactions processed in claims submitted to the administrator by participating pharmacies and the drug mail-order system;

(l) In accordance with division (B)(5) of section 173.721, the administrator shall either offer the drug mail-order system, or else, the administrator shall enter into a contract with another person to offer the drug mail-order system;

(m) The administrator shall not enter into a contract with another person to delegate any power or duty of the best Rx program, except that, in accordance with divisions (B)(5) and (B)(6)(a) of section 173.721 of the Revised Code, if ODA has taken the option to include a term in the contract with the administrator to allow the administrator to enter into a contract with another person to offer the drug mail-order system, in accordance with division (B)(6)(a) of section 173.721 of the Revised Code, the administrator may enter into a contract with another person to offer that service;

(n) The administrator shall not receive verification of drug-pricing information under section 173.742 of the Revised Code or verification of manufacturer-payment information under section 173.814 of the Revised Code from the consulting PBM;

(o) The administrator shall not request the consulting PBM to provide for an audit under section 173.752 of the Revised Code;

(p) The administrator shall not review or use any information contained in or pertaining to an audit provided for by the consulting PBM other than the audit’s findings of whether the consulting PBM provided valid information when providing drug-pricing verification services or manufacturer-payment verification services;

(q) The administrator shall not adopt rules;

(r) The administrator shall not employ a participating pharmacy ombudsman in accordance with division (B)(6)(f) of section 173.721 of the Revised Code;

(s) The administrator shall not charge a fee to any applicant or participant for the submission of applications, for the processing of applications, or for the best Rx card; and,

(t) The administrator shall not charge any participating pharmacy for the submission or processing of any claim.

(3) In exercising powers or performing duties delegated under the contract, the administrator is subject to the same provisions of sections 173.71 to 173.91 of the Revised Code or other provisions of the Revised Code that grant the powers or duties to ODA, to the same provisions of Chapter 173-7 of the Administrative Code, and to any limitations or restrictions that are applicable to or associated with those powers or duties.

(4) Wherever ODA is referred to in sections 173.71 to 173.91 of the Revised Code, in Chapter 173-7 of the Administrative Code, or in another provision of the Revised Code relative to a power or duty delegated to the administrator, both of the following apply:

(a) If ODA has delegated the power or duty in whole to the administrator through a contract entered into between ODA and the administrator, the reference to ODA is, instead, a reference to the administrator; and,

(b) If ODA retains any part of the power or duty that is delegated to the administrator, the reference to ODA is a reference to both ODA and the administrator.

(5) In the contract between ODA and the person seeking to become the administrator, ODA shall include a term that declares that the person is not eligible to be the administrator if being selected as the administrator would create a conflict of interest and that entering into the contract is a written declaration that there is no conflict of interest between ODA and the person seeking to become the administrator. As used in this paragraph, “conflict of interest” means any of the following:

(a) An instance when an employee of ODA involved in selecting the administrator has an ownership interest in the person seeking to become the administrator, unless the local prosecuting attorney and the Ohio ethics commission determines that, in this instance, there is no conflict of interest;

(b) An instance when an employee of ODA involved in selecting the administrator is employed by the person seeking to become the administrator, unless the local prosecuting attorney and the Ohio ethics commission determines that, in this instance, there is no conflict of interest. As used in this paragraph, “employee” means one who is receiving a payment from the person; or,

(c) An instance when an employee of ODA involved in selecting the administrator has an immediate family member has any ownership interests in the person seeking to become the administrator or, when an immediate family member is employed by the person seeking to become the administrator, unless the local prosecuting attorney and the Ohio ethics commission determines that, in this instance, there is no conflict of interest. As used in this paragraph, “immediate family member” means a spouse, parent, parent-in-law, sibling, sibling-in-law, child, child-in-law, grandparent, aunt, or uncle.

Replaces: pt 5101:13-1-06

Effective: 10/04/2007

R.C. 119.032 review dates: 08/31/2011

Promulgated Under: 119.03

Statutory Authority: 173.02, 173.83

Rule Amplifies: 173.721, 173.86

Prior Effective Dates: 11/1/2004, 4/4/07 (Emer.), 7/5/07 (Emer.)