Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-8 - Therapeutic and Diagnostic Services
Section 5160-8-52 - Services provided by a pharmacist
Universal Citation: OH Admin Code 5160-8-52
Current through all regulations passed and filed through December 16, 2024
(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.
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