Ohio Admin. Code 5160-8-52 - Services provided by a pharmacist

(A) Definition. "Pharmacist" has the same meaning as in Chapter 4729:1-1 of the Administrative Code.

(B) Providers. An individual pharmacist may enroll in medicaid as a pharmacist provider.

(C) Coverage.

(1) Payment may be made only for a pharmacist service for which the following criteria are met:

(a) The service is within a pharmacist's scope of practice;

(b) The service is medically necessary in accordance with rule 5160-1-01 of the Administrative Code;

(c) For a service rendered by prescription, the pharmacist provider obtains an order issued by a practitioner having appropriate prescriptive authority and maintains supporting documentation; and

(d) The service is rendered for one of the following purposes:

(i) Managing medication therapy under a consulting agreement with a prescribing practitioner pursuant to section 4729.39 of the Revised Code;

(ii) Administering immunizations in accordance with section 4729.41 of the Revised Code; or

(iii) Administering medications in accordance with section 4729.45 of the Revised Code.

(2) Nothing in this rule precludes a medicaid managed care organization described in Chapters 5160-26 and 5160-58 of the Administrative Code from paying pharmacists for additional purposes, within scope of practice, including care management services that are rendered by a pharmacist without a consult agreement.

(3) Payment may be made for covered telehealth services in accordance with rule 5160-1-18 of the Administrative Code.

(4) Services may be rendered through a standing order or protocol as described in Chapter 4729. of the Revised Code.

(D) Claim payment.

(1) For a covered pharmacist service rendered at a federally qualified health center (FQHC) or rural health clinic (RHC), payment as an FQHC medical service or an RHC medical service is made in accordance with Chapter 5160-28 of the Administrative Code.

(2) For a covered immunization, injection of medication, or provider-administered pharmaceutical, payment is made in accordance with rule 5160-4-12 of the Administrative Code.

(3) For all other covered pharmacist services, payment is the lesser of the submitted charge or eighty-five per cent of the medicaid maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.

(4) No separate payment will be made for pharmacist services provided in an inpatient or outpatient hospital, emergency department, or inpatient psychiatric facility place of service.

Notes

Ohio Admin. Code 5160-8-52

Effective: 1/17/2021
Promulgated Under: 119.03
Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 1/17/2021