Ohio Revised Code Search

...ach contract between a pharmacy benefit manager and a pharmacy, the pharmacy shall be given the right to obtain from the pharmacy benefit manager, within ten days after any request, a current list of the sources used to determine maximum allowable cost pricing. In each contract between a pharmacy benefit manager and a pharmacy, the pharmacy benefit manager shall be obligated to update and implement the pricing inform...

...to serve as the single pharmacy benefit manager used by medicaid managed care organizations under the care management system. The state pharmacy benefit manager shall be responsible for processing all pharmacy claims under the care management system. The department of medicaid is responsible for enforcing the contract after the procurement process. (B) As part of the procurement process, the director shall do all ...

...inistrator" includes a pharmacy benefit manager. "Administrator" does not include any of the following: (1) An insurance agent or solicitor licensed in this state whose activities are limited exclusively to the sale of insurance and who does not provide any administrative services; (2) Any person who administers or operates the workers' compensation program of a self-insuring employer under Chapter 4123. of the...

...an issuer, including a pharmacy benefit manager, shall, upon request of a covered person, the covered person's health care provider, or the third-party representative, furnish the following data for any and all drugs covered under a related health benefit plan: (1) The covered person's eligibility information for any and all covered drugs; (2) Cost-sharing information for any and all covered drugs, including a de...

...(A) The state pharmacy benefit manager shall provide to the medicaid director a written quarterly report containing the following information from the immediately preceding quarter: (1) The prices that the state pharmacy benefit manager negotiated for prescribed drugs under the care management system. The price must include any rebates the state pharmacy benefit manager received from the drug manufacturer; (2) Th...

...e Revised Code. (4) "Pharmacy benefit manager" and "administrator" have the same meanings as in section 3959.01 of the Revised Code. (B) No health plan issuer, pharmacy benefit manager, or any other administrator shall require cost-sharing in an amount, or direct a pharmacy to collect cost-sharing in an amount, greater than the lesser of either of the following from an individual purchasing a prescription drug: ...

...U.S.C. 1395u(o)(1)(C). (P) "Pharmacy benefit manager" has the same meaning as in section 3959.01 of the Revised Code. (Q) "Practice of pharmacy" has the same meaning as in section 4729.01 of the Revised Code. (R) "Prescribed drug" has the same meaning as in section 5164.01 of the Revised Code. (S) "Prior authorization requirement" has the same meaning as in section 5160.34 of the Revised Code. (T) "Pro...

...ns shall use the state pharmacy benefit manager selected under section 5167.24 of the Revised Code pursuant to the terms of the master contract entered into under that section. All payment arrangements between the department of medicaid, medicaid managed care organizations, and the state pharmacy benefit manager shall comply with state and federal statutes, regulations adopted by the centers for medicare and medica...

..., including a payer, a pharmacy benefit manager, or a third-party administrator licensed under Chapter 3959. of the Revised Code. (B) "Business day" means any day of the week excluding Saturday, Sunday, and a legal holiday, as defined in section 1.14 of the Revised Code. (C) "Concurrent review" means a claims review within five business days of submission of claims for payment for the provision of dangerous drugs f...

... cost set by the state pharmacy benefit manager for a prescribed drug. All pharmacies participating in the care management system shall use the appeals process to resolve any disputes relating to the maximum allowable cost set by the state pharmacy benefit manager.

...t health care program, pharmacy benefit manager, or other entity that offers health benefit plans, a prescription modified as described in this section, and in accordance with any rules adopted under it, shall be deemed a valid prescription for the drug delivery device.

...t health care program, pharmacy benefit manager, or other entity that offers health benefit plans to provide coverage for a drug in a manner that is inconsistent with the patient's benefit plan.

...No health plan issuer, pharmacy benefit manager, or any other administrator shall prohibit a pharmacy from mailing or delivering drugs to patients as an ancillary service.

...nsuring corporation, a pharmacy benefit manager responsible for handling prior authorization requests, or other payer acting on behalf of the health insuring corporation shall accept and respond to prior prescription benefit authorization requests through a secure electronic transmission using NCPDP SCRIPT standard ePA transactions, and for prior medical benefit authorization requests through a secure electronic tran...

...e Revised Code. (J) "Pharmacy benefit manager" has the same meaning as in section 3959.01 of the Revised Code. (K) "Prior authorization requirement" means any practice implemented by a health plan issuer in which coverage of a health care service, device, or drug is dependent upon a covered person or a provider obtaining approval from the health plan issuer prior to the service, device, or drug being performed, r...

...the insurer or plan, a pharmacy benefit manager responsible for handling prior authorization requests, or other payer acting on behalf of the insurer or plan shall accept and respond to prior prescription benefit authorization requests through a secure electronic transmission using NCPDP SCRIPT standard ePA transactions, and for prior medical benefit authorization requests through a secure electronic transmission usi...

...organization; (g) A pharmacy benefit manager; (h) A third party administrator; (i) Any other person or governmental entity that is, by law, contract, or agreement, responsible for the payment or processing of a claim for a medical item or service for a medical assistance recipient. (2) Except when otherwise provided by the "Social Security Act," section 1862(b), 42 U.S.C. 1395y(b), a person or governmenta...

...(A) The state pharmacy benefit manager shall, on request from the department of medicaid, disclose to the department all sources of payment it receives for prescribed drugs, including any financial benefits such as drug rebates, discounts, credits, clawbacks, fees, grants, chargebacks, reimbursements, or other payments related to services provided for the medicaid managed care organization. (B) Each medicaid manage...

...ms of the master state pharmacy benefit manager contract under section 5167.24 of the Revised Code or section 5167.241 of the Revised Code. Whoever violates those sections is subject to a civil penalty in an amount to be determined by the medicaid director.

...who is the records custodian or records manager or otherwise has custody of the records of that office. The public office shall require that employee to acknowledge receipt of the copy of the public records policy. The public office shall create a poster that describes its public records policy and shall post the poster in a conspicuous place in the public office and in all locations where the public office has branc...

...s: (1) In compliance with the health benefit plan that expressly allows such a practice. Waiver of the deductibles or copayments shall be made only with the full knowledge and consent of the plan purchaser, payer, and third-party administrator. Documentation of the consent shall be made available to the board upon request. (2) For professional services rendered to any other person who holds a certificate or lic...

...As used in this chapter: (A) "Benefit contract" means an agreement, as described in division (A) of section 3921.19 of the Revised Code, under which a fraternal benefit society agrees to provide any benefit set forth in division (A) of section 3921.16 of the Revised Code. (B) "Benefit member" means an adult member of a fraternal benefit society who is designated by the laws or rules of the society to be eligible fo...

...orated or not, conducted solely for the benefit of its members and their beneficiaries and not for profit, operated on a lodge system with ritualistic form of work, having a representative form of government, and providing benefits in accordance with this chapter, is hereby declared to be a fraternal benefit society.

...(A) For purposes of section 3921.02 of the Revised Code, a society is operating on the lodge system if it has a supreme governing body and subordinate lodges into which members are elected, initiated, or admitted in accordance with its laws, rules, and ritual. The subordinate lodges shall be required by the laws of the society to hold regular meetings at least once in each month in furtherance of the purposes of the ...

...921.02 of the Revised Code, a fraternal benefit society has a representative form of government if all of the following apply: (A) The society has a supreme governing body constituted in either of the following ways: (1) As an assembly composed of delegates elected directly by the members or at intermediate assemblies or conventions of members or their representatives, together with other delegates as may be prescr...