October 7, 2015
House Bill 64 recently amended Ohio Revised Code Chapter (ORC) 3959. The relevant code sections amended by House Bill 64 are ORC 3959.111 and ORC 3959.12 and these changes took effect on September 29, 2015.

Pursuant to these changes, Pharmacy Benefit Managers (PBMs) must now be in compliance with the following requirements in Ohio:
  • PBMs must obtain and maintain a third party administrator (TPA) license.
  • PBMs must provide their contracted pharmacies current pricing information on Maximum Allowable Cost (MAC).
  • PBMs must provide pharmacies access to an appeals process.
  • PBMs must disclose to plan sponsors if using multiple MAC pricing lists.

It is important to note that House Bill 64 also expands the Ohio Insurance Department's authority to impose penalties on TPAs for specified violations of law.

Per the Ohio Insurance Department, current TPA licensees are not required to take any action with respect to their TPA license until the regular renewal date of June 30, 2016.

Ohio is just one of a growing number of states in recent years which statutorily require PBMs to be licensed as TPAs in their respective states.

Our Insurance and Health Care team includes attorneys who were former in-house counsel for TPAs, PBMs, as well as attorneys who were formerly insurance regulators.

Because of our experience with representing TPAs and PBMs, we are able to help our clients avoid paying for the “learning curve” incurred by companies or attorneys who are not familiar with TPAs and PBM’s regulatory and compliance needs.