Ohio Code 5167.12 – Requirements when prescribed drugs are included in care management system
If prescribed drugs are included in the care management system:
Terms Used In Ohio Code 5167.12
- Care management system: means the system established under section 5167. See Ohio Code 5167.01
- Certified nurse practitioner: means an advanced practice registered nurse who holds a current, valid license issued under Chapter 4723 of the Revised Code and is designated as a certified nurse practitioner in accordance with section 4723. See Ohio Code 1.64
- Clinical nurse specialist: means an advanced practice registered nurse who holds a current, valid license issued under Chapter 4723 of the Revised Code and is designated as a clinical nurse specialist in accordance with section 4723. See Ohio Code 1.64
- 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
(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 who has registered the physician’s psychiatric specialty with the department;
(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, 5164.10, 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.
Last updated October 6, 2023 at 10:44 AM