Section 5167.12 | Requirements when prescribed drugs are included in care management system.
(A) When contracting under section 5167.10 of the Revised Code with a managed care organization that is a health insuring corporation, the department of medicaid shall require the health insuring corporation to provide coverage of prescribed drugs for medicaid recipients enrolled in the health insuring corporation. In providing the required coverage, the health insuring corporation may use strategies for the management of drug utilization, but any such strategies are subject to divisions (B) and (E) of this section and the department's approval.
(B) The department shall not permit a health insuring corporation to 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 either of the following:
(a) A physician whom the health insuring corporation, pursuant to division (C) of section 5167.10 of the Revised Code, has credentialed to provide care as a psychiatrist;
(b) A psychiatrist practicing at 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.
(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) Subject to division (E) of this section, the department shall authorize a health insuring corporation to develop and implement 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) The department shall require a health insuring corporation to comply with section 5164.7511 of the Revised Code with respect to medication synchronization.
(E) The department shall require a health insuring corporation to comply with section 5164.091 of the Revised Code as if the health insuring corporation were the department.
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 ]