5160-9-01. Eligible providers of pharmacy services and cost of dispensing survey

(A) Provider types eligible for payment for pharmacy services:

(1) A "pharmacy provider" designation and provider number can be obtained by a "terminal distributor of dangerous drugs," as defined in section 4729.01 of the Revised Code, who also:

(a) Has a valid drug enforcement agency (DEA) registration; and

(b) Has a pharmacist as the "responsible person," as defined in rule 4729-5-11 of the Administrative Code; and

(c) Complies with eligible provider rules 5160-1-17 to 5160-1- 17.11 of the Administrative Code and signs a provider agreement with the Ohio department of medicaid (ODM).

(2) A "hospital" provider acting as a pharmacy in accordance with paragraphs (A)(1)(a) to (A)(1)(c) of this rule can obtain a "pharmacy" specialty designation and bill for self-administered take-home drugs.

(3) "Clinic" providers that have a valid medicaid provider agreement and have met the criteria under the Revised Code to personally furnish pharmaceuticals but are not eligible to become a "pharmacy provider" as defined in paragraph (A)(1) of this rule, are eligible to apply for a "pharmacy" specialty designation and bill for self-administered take-home drugs.

(B) Provider types described in paragraph (A) of this rule are required to submit a complete response to the cost of dispensing survey conducted according to section 5164.752 of the Revised Code.

(1) A complete response to the cost of dispensing survey includes supplying complete information about the terminal distributor for, at the least, all of the following categories:

(a) Demographics;

(b) Number of prescriptions dispensed annually, broken out by medicaid fee-for-service and other payers and including a total volume for the location;

(c) Sales and cost of goods sold;

(d) Direct expenses;

(e) Overhead expenses; and

(f) Certification that the person who submits the survey believes the information to be true, correct, and complete.

(2) Providers that do not submit a complete response to the cost of dispensing survey may be paid a lower professional dispensing fee (PDF) in accordance with paragraph (E)(1) of rule 5160-9-05 of the Administrative Code.

(3) Newly-enrolled providers shall be assigned to the dispensing fee described in paragraph (E)(1)(b)(vi) of rule 5160-9-05 of the Administrative Code, unless the provider received the new provider number due to a change in ownership. In that situation, the department shall use the number of prescriptions reported by the previous owner to determine the PDF. In a situation other than a change of ownership, a provider is newly-enrolled if the date of approval of an application to enroll as a provider, or the date of approval of a pharmacy specialty designation, is less than ninety days prior to the distribution of the most recently-conducted cost of dispensing survey. The date of approval is not the effective date of the provider agreement or specialty designation when the effective date is made retroactive by ODM.

(4) If a provider experiences a change in prescription volume during the first nine months following the implementation of a PDF category significant enough that it would result in the provider falling into a different PDF category, the provider may submit a written request with supporting documentation to ODM, no later than the thirtieth day of April of the first year, requesting assignment to a different category. If the supporting documentation justifies an adjustment, ODM will assign a new PDF category effective the first day of July for the second year.

(5) Providers that did not submit a complete response to the cost of dispensing survey conducted in 2016 may submit an attestation of the number of prescriptions filled in the provider's most recently completed fiscal year or other twelve-month period beginning no earlier than January 1, 2015. The attestation shall follow the format posted on the ODM website athttp://pharmacy.medicaid.ohio.gov.

Effective: 4/1/2017
Five Year Review (FYR) Dates: 01/13/2017 and 04/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.752
Prior Effective Dates: 4/7/77, 9/19/77, 12/21/77, 12/30/77, 7/8/78, 10/1/78, 5/9/86, 11/1/86, 10/1/87, 2/1/88, 1/13/89 (Emer), 4/13/89, 6/1/89, 7/1/94, 10/1/97, 2/3/00 (Emer), 5/1/00, 4/14/05, 8/2/11