Section 5164.7511 | Medication synchronization for medicaid recipients.
(A) As used in this section:
(1) "Cost-sharing" means any cost-sharing requirements instituted for the medicaid program under section 5162.20 of the Revised Code.
(2) "Medication synchronization" means a pharmacy service that synchronizes the filling or refilling of prescriptions in a manner that allows the dispensed drugs to be obtained on the same date each month.
(3) "Prescriber" has the same meaning as in section 4729.01 of the Revised Code.
(B) With respect to coverage of prescribed drugs, the medicaid program shall provide for medication synchronization for a medicaid recipient if all of the following conditions are met:
(1) The recipient elects to participate in medication synchronization.
(2) The recipient, the prescriber, and a pharmacist at a pharmacy participating in the medicaid program agree that medication synchronization is in the best interest of the recipient.
(3) The prescribed drug to be included in the medication synchronization meets the requirements of division (C) of this section.
(C) To be eligible for inclusion in medication synchronization for a medicaid recipient, a prescribed drug must meet all of the following requirements:
(1) Be covered by the medicaid program;
(2) Be prescribed for the treatment and management of a chronic disease or condition and be subject to refills;
(3) Satisfy all relevant prior authorization criteria;
(4) Not have quantity limits, dose optimization criteria, or other requirements that would be violated if synchronized;
(5) Not have special handling or sourcing needs, as determined by the medicaid program, that require a single, designated pharmacy to fill or refill the prescription;
(6) Be formulated so that the quantity or amount dispensed can be effectively divided in order to achieve synchronization;
(7) Not be a schedule II controlled substance, opioid analgesic, or benzodiazepine, as those terms are defined in section 3719.01 of the Revised Code.
(D)(1) To provide for medication synchronization under division (B) of this section, the medicaid program shall authorize coverage of a prescribed drug subject to medication synchronization when the drug is dispensed in a quantity or amount that is less than a thirty-day supply.
(2) The requirement of division (D)(1) of this section applies only once for each prescribed drug subject to medication synchronization for the same medicaid recipient, except when either of the following occurs:
(a) The prescriber changes the dosage or frequency of administration of the prescribed drug subject to medication synchronization.
(b) The prescriber prescribes a different drug.
(E)(1) In providing for medication synchronization under division (B) of this section, the medicaid program shall apply a prorated daily cost-sharing rate for a supply of a prescribed drug subject to medication synchronization that is dispensed at a pharmacy participating in the program.
(2) Division (E)(1) of this section does not require the medicaid program to waive any cost-sharing requirement in its entirety.
(F) In providing for medication synchronization under division (B) of this section, the medicaid program shall not use payment structures that incorporate dispensing fees that are determined by calculating the days' supply of drugs dispensed. Dispensing fees shall be based exclusively on the total number of prescriptions that are filled or refilled.
(G) This section does not require the medicaid program to provide to a pharmacy participating in the program or a pharmacist at a participating pharmacy any monetary or other financial incentive for the purpose of encouraging the pharmacy or pharmacist to recommend medication synchronization to a medicaid recipient.
Available Versions of this Section
- August 31, 2016 – House Bill 116 - 131st General Assembly [ View August 31, 2016 Version ]
- March 22, 2020 – Amended by Senate Bill 229 - 132nd General Assembly [ View March 22, 2020 Version ]