Ohio Revised Code Search

...Upon approving an application for a license under this chapter and receiving payment of the associated filing fee, the superintendent of insurance shall grant the applicant a license to operate as a pharmacy benefit manager in this state. The initial license is effective on the date the application is approved by the superintendent and expires annually on the thirtieth day of June. If the initial license application ...

...(A) The superintendent of insurance shall provide a renewal notice to each licensee not later than the first day of May each year. (B) A licensee may renew its pharmacy benefit manager license by applying to the superintendent, in the form and manner prescribed by the superintendent, and paying a renewal fee of three thousand dollars before the date the license expires. A licensee shall not apply for a license rene...

...at any time upon request. Any protected health information received from the request shall be maintained in compliance with all applicable federal and state privacy laws, including the "Health Insurance Portability and Accountability Act of 1996," 42 U.S.C. 1320d, et seq. and the regulations adopted under that act. (D) A pharmacy benefit manager shall account, annually or more frequently, to the plan sponsor for an...

...(A) Upon notice and hearing in accordance with Chapter 119. of the Revised Code, the superintendent of insurance may take any of the actions enumerated in division (C) of this section if the superintendent finds that a licensee has done any of the following: (1) Violated any provision of this chapter, any rule adopted by the superintendent, or any consent agreement or order of the superintendent; (2) Provided inc...

...(A) A pharmacy benefit manager shall notify the superintendent of insurance if the pharmacy benefit manager, or any owner of the pharmacy benefit manager, is subject to administrative action by a government entity having professional, occupational, or financial authority in this or another state while the pharmacy benefit manager holds a license under this chapter. The notice shall be provided not later than thirty d...

...(A) On and after July 1, 2027, no pharmacy benefit manager shall do any of the following: (1) Use plan sponsor funds for any purpose not specifically set forth in writing by the pharmacy benefit manager; (2) Fail to disclose in written solicitation materials and at least once annually to contracted plan sponsors any ownership relationship of five per cent or more between the pharmacy benefit manager and an insure...

...benefit manager and a plan sponsor of a health benefit plan or health plan issuer: (1) The aggregate amount of rebates received by a pharmacy benefit manager; (2) The aggregate amount of rebates distributed by a pharmacy benefit manager to an appropriate plan sponsor of a health benefit plan or health plan issuer; (3) The aggregate amount of rebates passed on to a covered person under the health benefit plan a...

...(A) All information and data acquired by the superintendent of insurance or the department of insurance under this chapter is considered proprietary and confidential under section 3905.24 of the Revised Code and is not a public record under section 149.43 of the Revised Code. (B) On and after July 1, 2027, no pharmacy benefit manager or representative of a pharmacy benefit manager shall cause or knowingly permit th...

...For purposes of licensure, this chapter does not apply to an employer's self-insurance program or fully insured plan to the extent that federal law supersedes, preempts, prohibits, or otherwise precludes its application to such plan.

...On receipt of a notice pursuant to section 3123.43 of the Revised Code, the superintendent of insurance shall comply with sections 3123.41 to 3123.50 of the Revised Code and any applicable rules adopted under section 3123.63 of the Revised Code with respect to a license issued pursuant to this chapter.

... section 3959.01 of the Revised Code, a health insuring corporation or a sickness and accident insurer shall comply with the requirements of this section and is subject to the penalties under section 3959.12 of the Revised Code if the corporation or insurer is a pharmacy benefit manager, as defined in section 3959.01 of the Revised Code. (D) The superintendent may impose a monetary fine against a licensee if, upon ...

...e cost to an individual insured under a health benefit plan according to any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements imposed by the plan. (3) "Pharmacy audit" has the same meaning as in section 3901.81 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 ph...

...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.

...Whoever knowingly violates section 3957.03 of the Revised Code is guilty of a misdemeanor of the fourth degree.

...are provided by a pharmacist or nursing home. (C) "Covered vision services" means vision care services or vision care materials for which a reimbursement is available under an enrollee's health care contract, or for which a reimbursement would be available but for the application of contractual limitations, such as a deductible, copayment, coinsurance, waiting period, annual or lifetime maximum, frequency limitatio...

...es pursuant to the contracting entity's health care contract with the participating provider unless one of the following applies: (a) The third party accessing the participating provider's services under the health care contract is an employer or other entity providing coverage for health care services to its employees or members, and that employer or entity has a contract with the contracting entity or its affilia...

...(A) Each health care contract shall include all of the following information: (1)(a) Information sufficient for the participating provider to determine the compensation or payment terms for health care services, including all of the following, subject to division (A)(1)(b) of this section: (i) The manner of payment, such as fee-for-service, capitation, or risk; (ii) The fee schedule of procedure codes reasonabl...

...(A)(1) If an amendment to a health care contract is not a material amendment, the contracting entity shall provide the participating provider notice of the amendment at least fifteen days prior to the effective date of the amendment. The contracting entity shall provide all other notices to the participating provider pursuant to the health care contract. (2) A material amendment to a health care contract shall...

... by the council for affordable quality healthcare (CAQH) in electronic or paper format for physicians. The department of insurance also shall prepare the standard credentialing form for all other providers and shall make the standard credentialing form as simple, straightforward, and easy to use as possible, having due regard for those credentialing forms that are widely in use in the state by contracting e...

...he terms of the contract for any basic health care services, specialty health care services, or supplemental health care services the provider provided to enrollees starting at the expiration of that ninety-day period until the provider's credentialing application is granted or denied. When the credentialing process of the contracting entity exceeds the ninety-day period, the contracting entity shall sele...

...(A) All remittance notices sent by a payer, whether written or electronic, shall include both of the following: (1) The name of the payer issuing the payment to the participating provider; (2) The name of the contracting entity through which the payment rate and any discount are claimed, if the contracting entity is different from the payer. (B) Division (A) of this section takes effect March 31, 2009.

...The superintendent of insurance shall adopt any rules necessary for the implementation of this chapter.

...(A) A series of violations of this chapter by any person regulated by the department of insurance under Title XVII or Title XXXIX of the Revised Code that, taken together, constitute a pattern or practice of violating this chapter may be defined as an unfair and deceptive insurance practice under sections 3901.19 to 3901.26 of the Revised Code. (B) The superintendent of insurance may conduct a market conduct ...

...a state agency, or federal agency for health care services provided through a program for medicaid or medicare; (B) A contract for payments made to providers for rendering health care services to claimants pursuant to claims made under Chapter 4121., 4123., 4127., or 4131. of the Revised Code; (C) An exclusive contract between a health insuring corporation and a single group of providers in a specific geo...

... following: (1) Offer to a provider a health care contract that includes a most favored nation clause; (2) Enter into a health care contract with a provider that includes a most favored nation clause; (3) Amend or renew an existing health care contract previously entered into with a provider so that the contract as amended or renewed adds or continues to include a most favored nation clause. (B) As used in ...