Effective: October 17, 2019
Latest Legislation: House Bill 166 - 133rd General Assembly
(A) If the department of medicaid includes prescribed drugs in the care management system as authorized under section 5167.05 of the Revised Code, the medicaid director, through a procurement process, shall select a third-party administrator 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 of the following:
(1) Accept applications from entities seeking to become the state pharmacy benefit manager;
(2) Establish eligibility criteria an entity must meet in order to become the state pharmacy benefit manager;
(3) Select and contract with a single state pharmacy benefit manager;
(4) Develop a master contract to be used by the director when contracting with the state pharmacy benefit manager, which shall prohibit the state pharmacy benefit manager from requiring a medicaid recipient to obtain a specialty drug from a specialty pharmacy owned or otherwise associated with the state pharmacy benefit manager.
(C) A prospective state pharmacy benefit manager shall disclose to the director all of the following during the procurement process:
(1) Any activity, policy, practice, contract or arrangement of the state pharmacy benefit manager that may directly or indirectly present any conflict of interest with the pharmacy benefit manager's relationship with or obligation to the department or a medicaid managed care organization;
(2) All common ownership, members of a board of directors, managers, or other control of the pharmacy benefit manager (or any of the pharmacy benefit manager's affiliated companies) with any of the following:
(a) A medicaid managed care organization and its affiliated companies;
(b) An entity that contracts on behalf of a pharmacy or any pharmacy services administration organization and its affiliated companies;
(c) A drug wholesaler or distributor and its affiliated companies;
(d) A third-party payer and its affiliated companies;
(e) A pharmacy and its affiliated companies.
(3) Any direct or indirect fees, charges, or any kind of assessments imposed by the pharmacy benefit manager on pharmacies licensed in this state with which the pharmacy benefit manager shares common ownership, management, or control; or that are owned, managed, or controlled by any of the pharmacy benefit manager's affiliated companies;
(4) Any direct or indirect fees, charges, or any kind of assessments imposed by the pharmacy benefit manager on pharmacies licensed in this state
(6) Any financial terms and arrangements between the pharmacy benefit manager and a prescription drug manufacturer or labeler, including formulary management, drug substitution programs, educational support claims processing, or data sales fees.
(D) The director shall select a provisional state pharmacy benefit manager not later than July 1, 2020.
(1) Once a provisional state pharmacy benefit manager has been selected, full implementation of the entity as the state pharmacy benefit manager shall be subject to that entity's demonstrated ability to fulfill the duties and obligations of the state pharmacy benefit manager as illustrated through a readiness review process established by the director. Any entity failing to complete the readiness review process shall be deemed as having not met the criteria of the review process. The selected entity shall not enter into contracts with the department or medicaid managed care organizations as the state pharmacy benefit manager before the date on which the entity has satisfactorily completed the readiness review process.
(2) If the director determines that, for reasons beyond the director's control, selection of a provisional state pharmacy benefit manager cannot occur before July 1, 2020, the director shall notify the joint medicaid oversight committee of the reasons for the delay and identify the steps the director is taking to complete the selection as expeditiously as possible.
Structure Ohio Revised Code
Chapter 5167 | Medicaid Managed Care
Section 5167.01 | Definitions.
Section 5167.03 | Care Management System.
Section 5167.031 | Recognition of Pediatric Accountable Care Organizations.
Section 5167.05 | Inclusion of Prescribed Drugs in Care Management System.
Section 5167.051 | Coverage of Services Provided by Pharmacist.
Section 5167.10 | Authority to Contract With Managed Care Orgainizations.
Section 5167.102 | Use of Providers to Render Care to Enrollees.
Section 5167.103 | Performance Metrics; Publication.
Section 5167.11 | Managed Care Organization Contract to Provide Grievance Process.
Section 5167.12 | Requirements When Prescribed Drugs Are Included in Care Management System.
Section 5167.122 | Disclosure of Sources of Payment.
Section 5167.123 | Medicaid Mco Contracts With 340b Program Participants.
Section 5167.14 | Data Security Agreements for Managed Care Organization's Use of Drug Database.
Section 5167.15 | Chiropractic Services.
Section 5167.16 | Home Visits and Cognitive Behavioral Therapy.
Section 5167.171 | Uniform Prior Approval Form for Progesterone.
Section 5167.173 | Community Health Worker Services or Services Provided by Public Health Nurse.
Section 5167.18 | Identification of Fraud, Waste, and Abuse.
Section 5167.20 | Reference by Managed Care Organization to Noncontracting Participant.
Section 5167.201 | Payment of Nonsystem Provider for Emergency Services.
Section 5167.21 | Payments to Skilled Nursing Facility.
Section 5167.22 | Recoupment of Overpayment.
Section 5167.221 | Assessment of Recoupment Efforts.
Section 5167.24 | Third-Party Administrator as Single Pharmacy Benefit Manager.
Section 5167.241 | State Pharmacy Benefit Manager Contract; Payment Arrangements.
Section 5167.243 | Quarterly Reports.
Section 5167.244 | Violations; Penalty.
Section 5167.245 | Appeals Process.
Section 5167.26 | Records for Determining Costs.
Section 5167.30 | Managed Care Performance Payment Program.
Section 5167.31 | Financial Incentive Awards.
Section 5167.32 | Improving Integrity of Care Management System.
Section 5167.33 | Strategies Regarding Payment to Providers.
Section 5167.34 | Immunity From Liability.
Section 5167.40 | Appointment of Temporary Manager.
Section 5167.45 | Information About Medicaid Recipients' Races, Ethnicities, and Primary Languages.
Section 5167.47 | Compliance With Federal Mental Health and Addiction Parity Laws.