Section 5167.12 | Requirements when prescribed drugs are included in care management system.
If prescribed drugs are included in the care management system:
(A) Medicaid MCO plans may include strategies for the management of drug utilization, but any such strategies are subject to the limitations and requirements of this section and the approval of the department of medicaid.
(B) A medicaid MCO plan shall not impose a prior authorization requirement in the case of a drug to which all of the following apply:
(1) The drug is an antidepressant or antipsychotic.
(2) The drug is administered or dispensed in a standard tablet or capsule form, except that in the case of an antipsychotic, the drug also may be administered or dispensed in a long-acting injectable form.
(3) The drug is prescribed by any of the following:
(a) A physician whom the medicaid managed care organization that offers the plan allows to provide care as a psychiatrist through its credentialing process;
(b) A psychiatrist who is practicing at a location on behalf of a community mental health services provider whose mental health services are certified by the department of mental health and addiction services under section 5119.36 of the Revised Code;
(c) A certified nurse practitioner, as defined in section 4723.01 of the Revised Code, who is certified in psychiatric mental health by a national certifying organization approved by the board of nursing under section 4723.46 of the Revised Code;
(d) A clinical nurse specialist, as defined in section 4723.01 of the Revised Code, who is certified in psychiatric mental health by a national certifying organization approved by the board of nursing under section 4723.46 of the Revised Code.
(4) The drug is prescribed for a use that is indicated on the drug's labeling, as approved by the federal food and drug administration.
(C) The department shall authorize a medicaid MCO plan to include a pharmacy utilization management program under which prior authorization through the program is established as a condition of obtaining a controlled substance pursuant to a prescription.
(D) Each medicaid managed care organization and medicaid MCO plan shall comply with sections 5164.091, 5164.7511, 5164.7512, and 5164.7514 of the Revised Code as if the organization were the department and the plan were the medicaid program.
Available Versions of this Section
- September 29, 2013 – House Bill 59, 130th General Assembly [ View September 29, 2013 Version ]
- August 31, 2016 – Amended by House Bill 116, 131st General Assembly [ View August 31, 2016 Version ]
- July 1, 2017 – Amended by Senate Bill 319, 131st General Assembly [ View July 1, 2017 Version ]
- September 29, 2017 – Amended by House Bill 49, 132nd General Assembly [ View September 29, 2017 Version ]
- April 5, 2019 – Amended by Senate Bill 265, 132nd General Assembly [ View April 5, 2019 Version ]
- October 17, 2019 – Amended by House Bill 166, 133rd General Assembly [ View October 17, 2019 Version ]
- September 18, 2020 – Amended by House Bill 11, 133rd General Assembly [ View September 18, 2020 Version ]