Section 3957.26 | [Former R.C. 2959.20, amended and renumbered as R.C. 3957.26 by H.B. 229 of the 136th General Assembly, effective 6/30/2026] Prohibited acts regarding cost-sharing, pharmacy claims for reimbursement, fees.
(A) As used in this section and section 3957.27 of the Revised Code:
(1) "Administrator" has the same meaning as in section 3959.01 of the Revised Code.
(2) "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.
(3) "Pharmacy audit" has the same meaning as in section 3901.81 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.
(E) Any pharmacy benefit manager license issued under this chapter may be suspended for a period not to exceed two years, revoked, or not renewed by the superintendent of insurance after notice to the licensee and hearing in accordance with Chapter 119. of the Revised Code, if upon investigation and proof the superintendent finds that the licensee has knowingly violated this section.
Last updated April 17, 2026 at 1:24 PM
Available Versions of this Section
- June 30, 2026 – House Bill 229 - 136th General Assembly [ View June 30, 2026 Version ]