173.742 Drug pricing information verification procedures.

For purposes of section 173.741 of the Revised Code, the department of aging shall obtain verification of drug pricing information from the Ohio’s best Rx program’s consulting pharmacy benefit manager selected under section 173.731 of the Revised Code. The information shall be obtained in accordance with the following procedures:

(A) For brand name drugs, excluding generic drugs marketed under brand names, the department shall submit to the consulting pharmacy benefit manager the formula the department proposes to use to establish the program’s base price for brand name drugs during the year.

The consulting pharmacy benefit manager shall review the formula submitted by the department. In conducting the review, the consulting pharmacy benefit manager shall compare the drug pricing discount percentage included in the department’s formula to the drug pricing discount percentage included in the formula most commonly used by the consulting pharmacy benefit manager to establish part of its payment rate for brand name drugs dispensed by terminal distributors of dangerous drugs other than drug mail order systems. If the formulas are not expressed in equivalent terms, the consulting pharmacy benefit manager shall make all accommodations necessary to make the comparison of the discount percentages.

After conducting the review, the consulting pharmacy benefit manager shall provide information to the department verifying whether the discount percentage included in the department’s formula is more than two percentage points below the discount percentage included in the formula used by the consulting pharmacy benefit manager. The information provided to the department shall be certified by signature of an officer of the consulting pharmacy benefit manager.

(B) For generic drugs, the department shall identify the fifty generic drugs most frequently purchased by Ohio’s best Rx program participants in the immediately preceding year from terminal distributors of dangerous drugs other than the drug mail order system included in the program pursuant to section 173.78 of the Revised Code. The department shall submit to the consulting pharmacy benefit manager the names of the fifty drugs, the number of prescriptions filled for each of the drugs, the formula used to compute the base price for the drugs during the year, and the weighted average base price for the drugs that resulted for the year.

The consulting pharmacy benefit manager shall review the submitted information. In conducting the review, the consulting pharmacy benefit manager shall compare the department’s weighted average base price to the equivalent part of the consulting pharmacy benefit manager’s weighted average payment rate for the same drugs when dispensed by terminal distributors of dangerous drugs other than drug mail order systems. For purposes of the comparison, the department and consulting pharmacy benefit manager shall express the weighted average base price and payment rate in terms of a discount percentage that is taken from the drugs’ average wholesale price, as identified by a national drug price reporting service selected by the department and the consulting pharmacy benefit manager.

After conducting the review, the consulting pharmacy benefit manager shall provide information to the department verifying whether the discount percentage reflected in the department’s weighted average base price for the drugs is more than two percentage points below the equivalent part of the consulting pharmacy benefit manager’s weighted average payment rate for the same drugs. The information provided to the department shall be certified by signature of an officer of the consulting pharmacy benefit manager.

Effective Date: 07-01-2007