Ohio § 3959.20 Prohibited acts regarding cost-sharing, pharmacy claims for reimbursement, fees

Ohio Statutes

§ 3959.20 — Prohibited acts regarding cost-sharing, pharmacy claims for reimbursement, fees

Ohio § 3959.20

Title 39Insurance

Ch. 3959Third-party Administrators

This text of Ohio § 3959.20 (Prohibited acts regarding cost-sharing, pharmacy claims for reimbursement, fees) is published on Counsel Stack Legal Research, covering Ohio primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook

Ohio Rev. Code Ann. § 3959.20 (2026).

Text

(A)As used in this section:

(1)"Cost-sharing" means the cost to an individual insured under a health benefit plan according to any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements imposed by the plan.

(2)"Health benefit plan" and "health plan issuer" have the same meanings as in section3922.01of the Revised Code.

(3)"Pharmacy audit" has the same meaning as in section3901.81of the Revised Code.

(4)"Pharmacy benefit manager" and "administrator" have the same meanings as in section3959.01of the Revised Code.

(B)No health plan issuer, pharmacy benefit manager, or any other administrator shall require cost-sharing in an amount, or direct a pharmacy to collect cost-sharing in an amount, greater than the lesser of either of the following f

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(A) As used in this section:

(1) "Cost-sharing" means the cost to an individual insured under a health benefit plan according to any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements imposed by the plan.

(2) "Health benefit plan" and "health plan issuer" have the same meanings as in section3922.01of the Revised Code.

(3) "Pharmacy audit" has the same meaning as in section3901.81of the Revised Code.

(4) "Pharmacy benefit manager" and "administrator" have the same meanings as in section3959.01of the Revised Code.

(B) No health plan issuer, pharmacy benefit manager, or any other administrator shall require cost-sharing in an amount, or direct a pharmacy to collect cost-sharing in an amount, greater than the lesser of either of the following from an individual purchasing a prescription drug:

(1) The amount an individual would pay for the drug if the drug were to be purchased without coverage under a health benefit plan;

(2) The net reimbursement paid to the pharmacy for the prescription drug by the health plan issuer, pharmacy benefit manager, or administrator.

(C)(1) No health plan issuer, pharmacy benefit manager, or administrator shall retroactively adjust a pharmacy claim for reimbursement for a prescription drug unless the adjustment is the result of either of the following:

(a) A pharmacy audit conducted in accordance with sections3901.811to3901.814of the Revised Code;

(b) A technical billing error.

(2) No health plan issuer, pharmacy benefit manager, or administrator shall charge a fee related to a claim unless the amount of the fee can be determined at the time of claim adjudication.

(D) The department of insurance shall create a web form that consumers can use to submit complaints relating to violations of this section.