173-71-02 Eligibility.

Only an individual who meets the following criteria is eligible to participate in the best Rx program:

(A) The individual is a resident of Ohio;

(B) The individual is one of the following:

(1) An individual who is sixty years of age or older, regardless of family income level and regardless of whether or not the individual has a disability;

(2) An individual who is fifty-nine years of age or younger, regardless of family income level, who has a disability as defined in section 173.06 of the Revised Code; or,

(3) An individual who is fifty-nine years of age or younger whose family income, as determined by section 173.76 of the Revised Code, does not exceed three hundred percent of the federal poverty guidelines, as revised annually by the United States department of health and human services in accordance with section 673(2) of the “Omnibus Budget Reconciliation Act of 1981,” 95 Stat. 511, 42 U.S.C. 9902, as amended;

(C) Except as provided by paragraph (E) of this rule, the individual shall not have coverage for outpatient drugs paid for in whole or in part by any of the following:

(1) A third-party payer, including an employer;

(2) Medicaid;

(3) Children’s health insurance program;

(4) The disability medical assistance program; or,

(5) Another health plan or pharmacy assistance program that uses state or federal funds to pay part or all of the cost of the individual’s outpatient drugs, with the exception of the golden buckeye card and any health benefit plan offered to the employees of state agencies and the eligible dependents of those employees.

(D) The individual shall not have had coverage for outpatient drugs paid for by any of the entities or programs specified in paragraph (C) of this rule during any of the four months preceding the month in which the application for the best Rx program is made, unless any of the following applies:

(1) The individual is sixty years of age or older;

(2) The third-party payer, including an employer, that paid for the coverage filed for bankruptcy under federal bankruptcy laws;

(3) The individual is no longer eligible for coverage provided through a retirement plan subject to protection under the “Employee Retirement Income Security Act of 1974,” 88 Stat. 832, 29 U.S.C. 1001, as amended;

(4) The individual is no longer eligible for the medicaid program, children’s health insurance program, or disability medical assistance program; or,

(5) The individual is either temporarily or permanently discharged from employment due to a business reorganization.

(E) An individual is not subject to paragraph (C) of this rule if the individual has coverage for outpatient drugs paid for in whole or in part by either of the following:

(1) The workers’ compensation program; or,

(2) A medicare prescription drug plan offered pursuant to the “Medicare Prescription Drug, Improvement, and Modernization Act of 2003,” 117 Stat. 2071, 42 U.S.C. 1395w-101, as amended, but only if all of the following are the case with respect to the particular drug being purchased through the best Rx program:

(a) The individual is responsible for the full cost of the drug;

(b) The drug is not subject to a rebate from the manufacturer under the individual’s medicare prescription drug plan; and,

(c) The manufacturer of the drug has agreed to the best Rx program’s inclusion of individuals who have coverage through a medicare prescription drug plan.

Replaces: pt 5101:13-1-02

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: 173.76

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