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hb915_00_IN
As Introduced
136th
General Assembly
Regular
Session
H. B. No. 915
2025-2026
Representatives Robinson, Baker
Cosponsors: Representatives
Abdullahi, Brennan, Brownlee, Cockley, Lawson-Rowe, McNally,
Piccolantonio, Rader, Russo, Somani, Synenberg, Tims, Upchurch
To
amend sections 5162.20 and 5167.12 and to enact sections
3902.65
and
5164.094
of the Revised Code
to
require health benefit plans and the Medicaid Program to cover
epinephrine and glucagon for individuals eighteen years of age and
younger and to cap cost sharing for epinephrine and glucagon in any
form.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section
1.
That
sections 5162.20 and 5167.12 be amended and sections
3902.65
and
5164.094
of the Revised Code be enacted to read as follows:
Sec.
3902.65.
(A)
As used in this section:
(1)
"Epinephrine autoinjector" means a device used to
administer epinephrine only in a manufactured dosage form.
(2)
"Glucagon autoinjector" means a device used to administer
glucagon only in a manufactured dosage form.
(B)
Notwithstanding section 3901.71 of the Revised Code, a health benefit
plan issued, amended, or renewed after the effective date of this
section shall cover both of the following for a covered person who is
eighteen years of age or younger:
(1)
Epinephrine in any prescribed form, if considered medically necessary
by the covered person's provider;
(2)
Glucagon in any prescribed form, if considered medically necessary by
the covered person's provider.
(C)
Notwithstanding section 3901.71 of the Revised Code, no health plan
issuer that provides coverage for medically necessary epinephrine or
glucagon autoinjectors, or for epinephrine or glucagon in any other
prescribed form, pursuant to the terms of a health benefit plan
issued, amended, or renewed on or after the effective date of this
section, shall require cost sharing in excess of either of the
following:
(1)
For medically necessary epinephrine or glucagon autoinjectors, sixty
dollars per package containing two autoinjectors, regardless of the
amount or type of epinephrine or glucagon autoinjectors needed to
fill the covered person's prescription;
(2)
For epinephrine or glucagon in any other prescribed form, sixty
dollars per dose equivalent to the dose contained within two
autoinjectors, regardless of the amount or type of epinephrine or
glucagon needed to fill the covered person's prescription.
(D)
The cost-sharing limitations under division (C) of this section apply
regardless of any deductible, copayment, coinsurance, or any other
cost-sharing requirement that would otherwise apply to the covered
person under the health benefit plan.
(E)
This section does not prohibit a health plan issuer from reducing a
covered person's cost-sharing requirement for medically necessary
epinephrine or glucagon autoinjectors to amounts less than those
prescribed by division (C) of this section.
Sec.
5162.20.
(A)
The department of medicaid shall institute cost-sharing requirements
for the medicaid program. The department shall not institute
cost-sharing requirements in a manner that does
either
any
of
the following:
(1)
Disproportionately impacts the ability of medicaid recipients with
chronic illnesses to obtain medically necessary medicaid services;
(2)
Violates section 5164.09 or 5164.10 of the Revised Code
;
(3)
Violates section 5164.094 of the Revised Code
.
(B)(1)
No provider shall refuse to provide a service to a medicaid recipient
who is unable to pay a required copayment for the service.
(2)
Division (B)(1) of this section shall not be considered to do either
of the following with regard to a medicaid recipient who is unable to
pay a required copayment:
(a)
Relieve the medicaid recipient from the obligation to pay a
copayment;
(b)
Prohibit the provider from attempting to collect an unpaid copayment.
(C)
Except as provided in division (F) of this section, no provider shall
waive a medicaid recipient's obligation to pay the provider a
copayment.
(D)
No provider or drug manufacturer, including the manufacturer's
representative, employee, independent contractor, or agent, shall pay
any copayment on behalf of a medicaid recipient.
(E)
If it is the routine business practice of a provider to refuse
service to any individual who owes an outstanding debt to the
provider, the provider may consider an unpaid copayment imposed by
the cost-sharing requirements as an outstanding debt and may refuse
service to a medicaid recipient who owes the provider an outstanding
debt. If the provider intends to refuse service to a medicaid
recipient who owes the provider an outstanding debt, the provider
shall notify the recipient of the provider's intent to refuse
service.
(F)
In the case of a provider that is a hospital, the cost-sharing
program shall permit the hospital to take action to collect a
copayment by providing, at the time services are rendered to a
medicaid recipient, notice that a copayment may be owed. If the
hospital provides the notice and chooses not to take any further
action to pursue collection of the copayment, the prohibition against
waiving copayments specified in division (C) of this section does not
apply.
(G)
The department of medicaid may collaborate with a state agency that
is administering, pursuant to a contract entered into under section
5162.35 of the Revised Code, one or more components, or one or more
aspects of a component, of the medicaid program as necessary for the
state agency to apply the cost-sharing requirements to the components
or aspects of a component that the state agency administers.
Sec.
5164.094.
(A)
The medicaid program shall cover any of the following for an enrollee
who is eighteen years of age or younger:
(1)
Epinephrine in any prescribed form, if considered medically necessary
by the enrollee's provider;
(2)
Glucagon in any prescribed form, if considered medically necessary by
the enrollee's provider.
(B)
The department of medicaid shall not impose cost-sharing requirements
under section 5162.20 of the Revised Code for any prescribed form of
epinephrine or glucagon that are greater than any cost-sharing
requirements instituted under that section for epinephrine or
glucagon in a different prescribed form. Any cost-sharing
requirements instituted for any prescribed form of epinephrine or
glucagon shall comply with the requirements established under section
3902.65 of the Revised Code.
Sec.
5167.12.
If
prescribed drugs are included in the care management system:
(A)
Medicaid MCO plans may include strategies for the management of drug
utilization, but any such strategies are subject to the limitations
and requirements of this section and the approval of the department
of medicaid.
(B)
A medicaid MCO plan shall not impose a prior authorization
requirement in the case of a drug to which all of the following
apply:
(1)
The drug is an antidepressant or antipsychotic.
(2)
The drug is administered or dispensed in a standard tablet or capsule
form, except that in the case of an antipsychotic, the drug also may
be administered or dispensed in a long-acting injectable form.
(3)
The drug is prescribed by any of the following:
(a)
A physician who has registered the physician's psychiatric specialty
with the department;
(b)
A psychiatrist who is practicing at a location on behalf of a
community mental health services provider whose mental health
services are certified by the department of
mental
behavioral
health
and
addiction services
under
section 5119.36 of the Revised Code;
(c)
A certified nurse practitioner, as defined in section 4723.01 of the
Revised Code, who is certified in psychiatric mental health by a
national certifying organization approved by the board of nursing
under section 4723.46 of the Revised Code;
(d)
A clinical nurse specialist, as defined in section 4723.01 of the
Revised Code, who is certified in psychiatric mental health by a
national certifying organization approved by the board of nursing
under section 4723.46 of the Revised Code.
(4)
The drug is prescribed for a use that is indicated on the drug's
labeling, as approved by the federal food and drug administration.
(C)
The department shall authorize a medicaid MCO plan to include a
pharmacy utilization management program under which prior
authorization through the program is established as a condition of
obtaining a controlled substance pursuant to a prescription.
(D)
Each medicaid managed care organization and medicaid MCO plan shall
comply with sections 5164.091,
5164.094,
5164.10, 5164.7511, 5164.7512, and 5164.7514 of the Revised Code as
if the organization were the department and the plan were the
medicaid program.
Section
2.
That
existing sections 5162.20 and 5167.12 of the Revised Code are hereby
repealed.