§ 5167.12 — Requirements when prescribed drugs are included in care management system

Ohio § 5167.12

• Jurisdiction: Ohio
• Title 51: Public Welfare
• Ch. 5167: Medicaid Managed Care

Text

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 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 section5119.36of the Revised Code;

(c) A certified nurse practitioner, as defined in section4723.01of the Revised Code, who is certified in psychiatric mental health by a national certifying organization approved by the board of nursing under section4723.46of the Revised Code;

(d) A clinical nurse specialist, as defined in section4723.01of the Revised Code, who is certified in psychiatric mental health by a national certifying organization approved by the board of nursing under section4723.46of 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 sections5164.091,5164.10,5164.7511,5164.7512, and5164.7514of the Revised Code as if the organization were the department and the plan were the medicaid program.

Last updated October 20, 2025 at 9:08 AM

Legislative History

Effective: October 3, 2023 | Latest Legislation: House Bill 33 - 135th General Assembly