Ohio Code 5167.123 – Medicaid MCO contracts with 340B program participants
(A) No contract between a medicaid managed care organization, including a third-party administrator, and a 340B covered entity shall contain any of the following provisions:
Terms Used In Ohio Code 5167.123
- Contract: A legal written agreement that becomes binding when signed.
- Medicaid managed care organization: means a managed care organization under contract with the department of medicaid pursuant to section 5167. See Ohio Code 5167.01
- Provider: means any person or government entity that furnishes services to a medicaid recipient enrolled in a medicaid MCO plan, regardless of whether the person or entity has a provider agreement. See Ohio Code 5167.01
- Third-party administrator: means any person who adjusts or settles claims on behalf of an insuring entity in connection with life, dental, health, prescription drugs, or disability insurance or self-insurance programs and includes a pharmacy benefit manager. See Ohio Code 5167.01
- United States: includes all the states. See Ohio Code 1.59
(1) A payment rate for a prescribed drug that is less than the national average drug acquisition cost rate for that drug as determined by the United States centers for medicare and medicaid services, measured at the time the drug is administered or dispensed, or, if no such rate is available at that time, a reimbursement rate that is less than the wholesale acquisition cost of the drug, as defined in 42 U.S.C. §§ 1395w-3a(c)(6)(B);
(2) A fee that is not imposed on a health care provider that is not a 340B covered entity;
(3) A fee amount that exceeds the amount for a health care provider that is not a 340B covered entity.
(B) The organization, or its contracted third-party administrators, shall not discriminate against a 340B covered entity in a manner that prevents or interferes with a medicaid recipient’s choice to receive a prescription drug from a 340B covered entity or its contracted pharmacies.
(C) Any provision of a contract entered into between the organization and a 340B covered entity that is contrary to division (A) of this section is unenforceable and shall be replaced with the dispensing fee or payment rate that applies for health care providers that are not 340B covered entities.