Medicaid Laws & Rules for Pharmacies in Ohio

Pharmaceutical laws for Medicaid patients in the state of Ohio changed radically with the passage of SB 154, which took effect in February 2010, according to the Ohio Pharmacists Association. At that point, drug coverage was carved out of Medicaid managed care plans, and all Medicaid recipients were transferred onto the fee-for-service program.

Drug Coverage

• Pharmacists no longer must differentiate between Medicaid consumers when it comes to covered medications. All Medicaid recipients in Ohio have the same drug coverage and prior authorization policies, according to SB 154, because they are now essentially all on the same plan.

Reimbursement and Copay

• With the new law, the Medicaid reimbursement rate for prescriptions is $1.80, down from $3.70. This reimbursement is reduced by the amount the patient pays as a copay. For trade name drugs, Medicaid recipients can expect a copay of $2 in most cases; for drugs which require prior authorization, a $3 copay is standard. Generic drugs are not subject to copays, according to the Ohio Department of Job and Family Services, the state administrator of Medicaid.

  With very few exceptions, a copay may not be charged to a consumer who is under the age of 21, pregnant or in the immediate postpartum period, residing in a nursing home (or similar facility) or receiving hospice care. In addition, copays cannot be charged for family planning items, exempted trade name medications (specified by the state of Ohio), medications administered in a provider setting or to patients who are unable to pay. Future service can be refused, however, to patients who do not pay outstanding balances, as long as this policy is applied to all customers and the patient is duly informed.

Tamper-resistant Prescriptions Required

• Federal regulations regarding tamper-resistant prescriptions apply to all Medicaid consumers in Ohio. According to the U.S. Department of Health and Human Services/Centers for Medicaid and Medicare Services, pharmacies are still permitted to receive prescriptions directly from the prescriber via phone, fax or email.

  Prescription paper used for written prescriptions must have a security element that prevents blank forms from being copied, a feature that prevents erasure or modification, and a counterfeit-prevention feature. These features might include a "void" pantograph, a thermochromatic patch that lightens when it is rubbed, a watermark on the back of the paper, a "quantity" block that cannot be altered and a batch number. If a pharmacist is unsure whether a written prescription meets these requirements, he may obtain a verbal confirmation from the prescriber's office.