5167.01 Definitions.

As used in this chapter:

(A) "Affiliated company" means an entity, including a third-party payer or specialty pharmacy, with common ownership, members of a board of directors, or managers, or that is a parent company, subsidiary company, jointly held company, or holding company with respect to the other entity.

(B) "Care management system" means the system established under section 5167.03 of the Revised Code.

(C) "Controlled substance" has the same meaning as in section 3719.01 of the Revised Code.

(D) "Dual eligible individual" has the same meaning as in section 5160.01 of the Revised Code.

(E) "Emergency services" has the same meaning as in the "Social Security Act," section 1932(b)(2), 42 U.S.C. 1396u - 2(b)(2).

(F) "Enrollee" means a medicaid recipient who participates in the care management system and enrolls in a medicaid MCO plan.

(G) "ICDS participant" has the same meaning as in section 5164.01 of the Revised Code.

(H) "Medicaid managed care organization" means a managed care organization under contract with the department of medicaid pursuant to section 5167.10 of the Revised Code.

(I) "Medicaid MCO plan" means a plan that a medicaid managed care organization, pursuant to its contract with the department of medicaid under section 5167.10 of the Revised Code, makes available to medicaid recipients participating in the care management system.

(J) "Medicaid waiver component" has the same meaning as in section 5166.01 of the Revised Code.

(K) "Network provider" has the same meaning as in 42 C.F.R. 438.2.

(L) "Nursing facility services" has the same meaning as in section 5165.01 of the Revised Code.

(M) "Part B drug" means a drug or biological described in section 1842(o)(1)(C) of the "Social Security Act," 42 U.S.C. 1395u(o)(1)(C).

(N) "Pharmacy benefit manager" has the same meaning as in section 3959.01 of the Revised Code.

(O) "Practice of pharmacy" has the same meaning as in section 4729.01 of the Revised Code.

(P) "Prescribed drug" has the same meaning as in section 5164.01 of the Revised Code.

(Q) "Prior authorization requirement" has the same meaning as in section 5160.34 of the Revised Code.

(R) "Provider" means any person or government entity that furnishes services to a medicaid recipient enrolled in a medicaid MCO plan, regardless of whether the person or entity has a provider agreement.

(S) "Provider agreement" has the same meaning as in section 5164.01 of the Revised Code.

(T) "State pharmacy benefit manager" means the pharmacy benefit manager selected by and under contract with the medicaid director under section 5167.24 of the Revised Code.

(U) "Third-party administrator" means any person who adjusts or settles claims on behalf of an insuring entity in connection with life, dental, health, prescription drugs, or disability insurance or self-insurance programs and includes a pharmacy benefit manager.


Amended by 133rd General Assembly File No. TBD, HB 166, §101.01, eff. 10/17/2019.

Amended by 132nd General Assembly File No. TBD, HB 145, §1, eff. 2/8/2018.

Amended by 132nd General Assembly File No. TBD, HB 49, §101.01, eff. 9/29/2017 (Vetoed).

Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.