hb915_00

As Introduced

136th General Assembly

Regular Session H. B. No. 915

2025-2026

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.