5101:3-9-09 Consumer co-payments for certain pharmacy medications.

(A) Consumers eligible for the medicaid program as defined in paragraph (B) of this rule will pay a three dollar co-payment for prescription medications not found in appendix A to rule 5101:3-9-12 of the Administrative Code, and a two dollar co-payment for selected trade name drugs as indicated in appendix A to rule 5101:3-9-12 of the Administrative Code.

(B) Consumers subject to co-payment for medications are identified as adults eligible under the medicaid program, age twenty-one and over. Co-payment requirements as contained in this rule are also subject to the provisions of rules 5101:3-1-09 and 5101:3-1-60 of the Administrative Code.

(C) Exclusions to the co-payment requirement for prescription medications as described in paragraph (A) of this rule are described in rule 5101:3-1-09 of the Administrative Code and as follows:

(1) Children. Prescriptions for medications given to eligible consumers under twenty-one years of age are excluded from co-payment. The Ohio department of job and family services (ODJFS) identifies those eligible consumers who are under age twenty-one through the ODJFS recipient master file (RMF) and excludes them from co-payment at the time the medication is dispensed. In the event that there is a dispute concerning the consumer's age, and the RMF and the client registry information system-enhanced (CRIS-E) are found to be in error, the consumer may be refunded any paid co-payment in accordance with rule 5101:3-1-60.2 of the Administrative Code.

(2) Pregnant women. Prescriptions for medications given to eligible pregnant women are excluded from co-payment during the woman's pregnancy and the post-partum period. The post-partum period is the immediate post-partum period that begins on the last day of pregnancy and extends through the end of the month in which the sixty day period following termination of pregnancy ends. Pregnant women may declare their pregnancy or their sixty day post-partum period at the time their prescription medication is dispensed and they will not be charged a co-payment for their medication.

(3) Institutionalized individuals. Prescriptions for medication given to any eligible consumer who is a resident in a long term care facility are excluded from co-payment. ODJFS identifies residents of long term care facilities (those living in nursing facilities (NFs) and intermediate care facilities for the mentally retarded (ICFs-MR) as defined in section 5111.20 of the Revised Code) through the RMF and excludes them from co-payment at the time the medication is dispensed.

(4) Hospice care. Prescriptions for medication given to any eligible consumer who is receiving hospice care are excluded from co-payment. ODJFS identifies consumers who are receiving hospice care in accordance with Chapter 5101:3-56 of the Administrative Code.

(5) Family planning. Prescriptions for medication given to an eligible consumer of child-bearing age for the purposes of family planning are excluded from co-payment. ODJFS identifies medications that qualify as family planning services in appendix A to rule 5101:3-9-12 of the Administrative Code and the ODJFS pharmacy point-of-sale vendor will exempt these medications from co-payment.

(6) Emergency services. Medications administered to an eligible consumer during emergency care provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily part or organ, are not subject to co-payment.

(7) Medications administered to an eligible consumer during a medical encounter provided in a hospital, clinic, office, or other facility, when the medication is a part of the evaluation and treatment of the condition, are not subject to co-payment.

(D) Prescriptions for medication given to an eligible consumer during a medical encounter provided in the emergency department or other hospital setting, clinic, office, or other facility as a result of the evaluation and treatment of the condition, to be filled at a pharmacy located at the facility or at an outside location, are subject to co-payment under the conditions described in paragraphs (A) and (B) of this rule.

(E) No provider of pharmacy services may deny medication to a consumer because the consumer is unable to pay the co-payment, if the consumer is eligible for medicaid coverage of the medication. Consumers who are unable to pay their co-payment may declare to the provider their inability to pay and obtain the medication without paying their co-payment. Consumers who declare their inability to pay remain liable for the co-payment. The provider may bill the consumer for the co-payment or request payment for a prior uncollected co-payment. The provider may not deny subsequent medications that may be covered by medicaid based on a consumer's failure to pay prior co-payments except as described in paragraph (B)(5) of rule 5101:3-1-09 of the Administrative Code.

(F) In accordance with rule 5101:3-1-08 of the Administrative Code, providers are expected to take reasonable measures to ascertain any third-party resource available to the consumer and to file a claim with that third party. ODJFS shall reimburse the difference between the third party payment and the medicaid calculated allowable minus the applicable co-payment as defined in paragraph (A) of this rule.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 02/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.0112
Rule Amplifies: 5111.01 , 5111.02 , 5111.0112 , section 309.10 of Am.
Sub. HB 1 of the 128th General Assembly Prior Effective Dates: 1/1/04, 1/1/06