Ohio Admin. Code 5160-26-13

Current through all regulations passed and filed through June 10, 2024

Section 5160-26-13 - Managed health care programs: claim billing for pharmaceuticals

Upon implementation of the Ohio department of medicaid's (ODM) single pharmacy benefit manager (SPBM), ODM or its designees will accept provider claim submissions for pharmaceuticals through ODM's managed care entities (MCEs) in the following manner:

(A) Claims for pharmaceuticals that are dispensed by pharmacy providers are billed through ODM's SPBM.

(B) For all other provider types, claims for pharmaceuticals are billed through an MCO, or in accordance with rule 5160-59-03 of the Administrative Code for individuals enrolled in the OhioRISE plan, as applicable.

(C) This rule does not apply to "MyCare Ohio" plans as defined in rule 5160-58-01 of the Administrative Code.

Ohio Admin. Code 5160-26-13

Effective: 10/1/2022
Five Year Review (FYR) Dates: 10/01/2027
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5162.03, 5164.02, 5167.10, 5167.03