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As Introduced
136th
General Assembly
Regular
Session
H. B. No. 192
2025-2026
Representatives Barhorst, Fischer
Cosponsors: Representatives McClain,
Gross, Dean, Johnson, Mullins, Odioso
A
BILL
To
amend
section
3902.50
and to enact sections 3902.75, 3902.76,
and
3959.151 of the Revised Code
to
limit insurer accreditation requirements for pharmacies, to implement
drug cost reporting requirements for pharmacy benefit managers, and
to name this act the Community Pharmacy Protection Act.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section
1.
That
section
3902.50
be amended and sections 3902.75, 3902.76,
and
3959.151 of the Revised Code be enacted to read as follows:
Sec.
3902.50.
As
used in sections 3902.50 to
3902.72
3902.76
of
the Revised Code:
(A)
"Ambulance" has the same meaning as in section 4765.01 of
the Revised Code.
(B)
"Clinical laboratory services" has the same meaning as in
section 4731.65 of the Revised Code.
(C)
"Cost sharing" means the cost to a covered person under a
health benefit plan according to any copayment, coinsurance,
deductible, or other out-of-pocket expense requirement.
(D)
"Covered" or "coverage" means the provision of
benefits related to health care services to a covered person in
accordance with a health benefit plan.
(E)
"Covered person," "health benefit plan," "health
care services," and "health plan issuer" have the same
meanings as in section 3922.01 of the Revised Code.
(F)
"Drug" has the same meaning as in section 4729.01 of the
Revised Code.
(G)
"Emergency facility" has the same meaning as in section
3701.74 of the Revised Code.
(H)
"Emergency services" means all of the following as
described in 42 U.S.C. 1395dd:
(1)
Medical screening examinations undertaken to determine whether an
emergency medical condition exists;
(2)
Treatment necessary to stabilize an emergency medical condition;
(3)
Appropriate transfers undertaken prior to an emergency medical
condition being stabilized.
(I)
"Health care practitioner" has the same meaning as in
section 3701.74 of the Revised Code.
(J)
"Pharmacy benefit manager" has the same meaning as in
section 3959.01 of the Revised Code.
(K)
"Prior authorization requirement" means any practice
implemented by a health plan issuer in which coverage of a health
care service, device, or drug is dependent upon a covered person or a
provider obtaining approval from the health plan issuer prior to the
service, device, or drug being performed, received, or prescribed, as
applicable. "Prior authorization requirement" includes
prospective or utilization review procedures conducted prior to
providing a health care service, device, or drug.
(L)
"Unanticipated out-of-network care" means health care
services, including clinical laboratory services, that are covered
under a health benefit plan and that are provided by an
out-of-network provider when either of the following conditions
applies:
(1)
The covered person did not have the ability to request such services
from an in-network provider.
(2)
The services provided were emergency services.
Sec.
3902.75.
(A)
As used in sections 3902.75 and 3902.76 of the Revised Code:
(1)
Notwithstanding section 3902.50 of the Revised Code, "health
plan issuer" has the same meaning as in section 3922.01 of the
Revised Code but also includes an auditing entity, as defined in
section 3901.81 of the Revised Code.
(2)
"Pharmacy" has the same meaning as in section 4729.01 of
the Revised Code and also includes a dispensing physician.
(B)
A health plan issuer that offers, issues, or administers a health
benefit plan that covers pharmacy services, including prescription
drug coverage, shall not require a pharmacy, as a condition of
participation in the health plan issuer's network, to meet
accreditation standards or certification requirements that are
inconsistent with or in addition to those of the state board of
pharmacy.
(C)
In addition to any other remedies provided by law, any covered person
or pharmacy affected by a violation of this section may file a formal
complaint with the superintendent of insurance.
Sec.
3902.76.
(A)
The superintendent of insurance shall evaluate any complaint filed
under section 3902.75 of the Revised Code.
(B)(1)
If the superintendent determines, based on a complaint by a covered
person or pharmacy or other information available to the
superintendent, that a health plan issuer or one or more of the
health plan issuer's intermediaries has violated section 3902.75 of
the Revised Code, the superintendent shall do both of the following:
(a)
Issue a notice of violation to the health plan issuer or intermediary
that clearly explains the violation;
(b)
Impose an administrative penalty on the health plan issuer or
intermediary of one thousand dollars for each violation.
(2)
Each day that a violation of section 3902.75 of the Revised Code
continues after the health plan issuer or intermediary receives
notice of violation under division (B)(1)(a) of this section is
considered a separate violation for the purposes of the
administrative penalty under division (B)(1)(b) of this section.
(C)
Before imposing an administrative penalty under this section, the
superintendent shall afford the health plan issuer or intermediary an
opportunity for an adjudication hearing under Chapter 119. of the
Revised Code. At the hearing, the health plan issuer or intermediary
may challenge the superintendent's determination that a violation
occurred, the superintendent's imposition of an administrative
penalty, or both. The health plan issuer or intermediary may appeal
the superintendent's determination and imposition of an
administrative penalty in accordance with section 119.12 of the
Revised Code.
(D)
An administrative penalty collected under this section shall be
deposited into the state treasury to the credit of the department of
insurance operating fund created by section 3901.021 of the Revised
Code.
Sec.
3959.151.
(A)
As used in this section, "machine-readable format" means a
digital representation of information in a file that can be imported
or read into a computer system for further processing.
"Machine-readable format" includes.XML and.CSV formats.
(B)(1)
Each pharmacy benefit manager shall quarterly provide to the
superintendent of insurance and to the pharmacy benefit manager's
contracted insurers and plan sponsors, including contracted public
employee benefit plans and contracted employers offering a
self-insurance program, an electronic report of all drug claims
processed the previous quarter in a machine-readable format that is
also readable in plain language without the use of software.
(2)
The electronic report provided to an insurer, a plan sponsor, or the
medicaid program shall include an itemized list of the maximum
allowable cost of each drug product from all drug product claims
processed by the pharmacy benefit manager in the previous quarter for
that insurer, that plan sponsor, or the medicaid program. The
electronic report provided to the superintendent of insurance shall
include an itemized list of the actual acquisition cost of each drug
product from all drug product claims processed by the pharmacy
benefit manager in the previous quarter for all insurers and plan
sponsors.
(3)
The itemized list shall notate the following for each drug product:
(a)
If the drug was procured pursuant to the pharmacy benefit manager,
insurer, plan sponsor, or department of medicaid's drug formulary or
list of covered drugs;
(b)
If the drug was procured outside of the drug formulary or list of
covered drugs;
(c)
If the drug is a brand-name drug;
(d)
If the drug is a generic drug;
(e)
If the drug is a specialty drug, including biological products.
(C)(1)
No agreement between a pharmacy benefit manager and an insurer or
plan sponsor, including a service agreement under section 3959.15 of
the Revised Code, that is entered into, amended, or renewed on or
after the effective date of this section shall prohibit disclosure of
any of the information included in the itemized list required by
division (B) of this section.
(2)
Notwithstanding division (B) of this section, a pharmacy benefit
manager is not required to disclose information deemed proprietary or
confidential by a service agreement between the pharmacy benefit
manager and an insurer or plan sponsor that is entered into in
accordance with section 3959.15 of the Revised Code before the
effective date of this section, and in effect on the date the
information would otherwise be submitted as part of the itemized list
required by division (B) of this section.
(D)
No pharmacy benefit manager shall retaliate against a pharmacy in
this state that reports an alleged violation of this section or
exercises a right or remedy under this section, by doing any of the
following:
(1)
Terminating or refusing to renew a contract with the pharmacy without
providing notice to the pharmacy at least ninety days in advance;
(2)
Subjecting a pharmacy to increased audits without providing notice to
the pharmacy and a detailed description of reason for the audit at
least ninety days in advance;
(3)
Failing to promptly pay a pharmacy in accordance with sections
3901.381 to 3901.3814 of the Revised Code.
(E)
If a pharmacy in this state believes that a pharmacy benefit manager
has violated this section, in addition to any other remedies provided
by law, a pharmacy may file a formal complaint and provide evidence
related to the complaint to the superintendent of insurance.
(F)
The superintendent of insurance shall adopt rules in accordance with
Chapter 119. of the Revised Code for the purposes of implementing and
administering this section. Notwithstanding any provision of section
121.95 of the Revised Code to the contrary, a regulatory restriction
contained in a rule adopted by the superintendent in accordance with
this section is not subject to sections 121.95 to 121.953 of the
Revised Code.
Section
2.
That
existing
section
3902.50
of the Revised Code
is
hereby
repealed.
Section
3.
Sections
3902.75 and 3902.76 of the Revised Code, as enacted in this act,
apply to health benefit plans, as defined in section 3922.01 of the
Revised Code, delivered, issued for delivery, modified, or renewed on
or after the effective date of those sections.
Section
4.
Sections
3902.75 and 3902.76 of the Revised Code, as enacted in this act,
apply to contracts between health plan issuers, as defined in section
3922.01 of the Revised Code, and pharmacies entered into, modified,
or renewed on or after the effective date of those sections.
Section
5.
This
act shall be known as the Community Pharmacy Protection Act.