Current through all regulations passed and filed through September 16, 2024
(A) Medication must
be for treatment of
a work related injury or occupational disease in a claim either allowed by an
order of the bureau or the industrial commission, or recognized by a
self-insuring employer.
(B)
Medication may be prescribed by any treating provider authorized by law to
prescribe such medication.
(C)
Drugs covered in self-insuring employer claims
are limited to those that are approved for human use in the United States by
the food and drug administration (FDA) and that are dispensed by a registered
pharmacist .
(D) A
self-insuring employer may approve and reimburse for various drugs as a part of
a comprehensive treatment plan submitted by the physician of record or a
treating physician when reasonably related to and medically necessary for
treatment of the allowed conditions in the claim, provided that such approval
and reimbursement shall not constitute the recognition of any additional
conditions in the claim even if such drugs are used to treat conditions that
have not been allowed in the claim.
(E) Payment for medications to pharmacy
providers shall include both a product cost component and a dispensing fee
component.
(1) Except as provided in this
paragraph, product cost component shall be the lesser of the following: maximum
allowable cost established under paragraph (N) of this rule,
if applicable, or the average wholesale price (AWP) of the commonly stocked
package size minus fifteen per cent.
(a) For
repackaged brand name medications, the product cost component shall be
calculated using the AWP of the original labeler.
(b) For compounded prescriptions, the product
cost component shall be limited to the lesser of the
the maximum allowable cost, if applicable, for each
ingredient or the AWP of the commonly stocked package size minus fifteen
per cent for each ingredient.
(c)
The maximum product cost component reimbursement for any one
non-sterile compounded prescription will be four
hundred dollars.
(2) The
dispensing fee component for non-compounded prescriptions shall be three
dollars and fifty cents, unless the self-insuring employer has negotiated a
payment rate with the pharmacy provider pursuant to rule
4123-6-46 of the Administrative
Code. Only pharmacy providers are eligible to receive a dispensing
fee.
(3) The dispensing fee
component for non-sterile compounded prescriptions shall be eighteen dollars
and seventy-five cents.
(4) The
dispensing fee component for sterile compounded prescriptions shall be
thirty-seven dollars and fifty cents.
(F) The pharmacy provider is required to bill
medication at their usual and customary charge. The amount paid to the provider
will be the lesser of the provider's usual and customary charge or the
reimbursement allowed as determined in paragraph (E) of this rule, unless the
self-insuring employer has negotiated a payment rate with the provider pursuant
to rule 4123-6-46 of the Administrative
Code. Pharmacy providers are required to submit for billing the national drug
code (NDC) number of the stock bottle from which the dispensed medication is
obtained. Drugs may be dispensed in unit dose packaging, but the NDC number of
the closest comparable bulk package listed in the bureau or vendor payment
system must be used for billing purposes.
(G) The pharmacy provider shall:
(1)
Include prescriber information within bills submitted electronically to the
self-insuring employer or its vendor for payment. The prescriber information
must include the national provider identifier (NPI) or the drug enforcement
administration (DEA) number;
(2) Not pay, allow, or
give, or offer to pay, allow, or give, any consideration, money, or other thing
of value to an injured worker, of to any other person,
firm, or corporation (including but not limited to free or discounted
medications or other goods or services) as an inducement to or in return for
the injured worker ordering or receiving from the provider any medications or
other goods or services for which payment may be made by the self-insuring
employer or its vendor or QHP under Chapter 4121., 4123., 4127., or 4131. of
the Revised Code;
(3) Comply with all applicable billing instructions
contained in the bureau's provider billing and reimbursement manual in effect
on the billed date(s) of service.
(H) Claimant reimbursement for medications
shall be in accordance with rule
4123-6-26 of the Administrative
Code and shall at least be equal to the bureau's established rate for the
medication, unless the self-insuring employer has negotiated a payment rate
with the pharmacy provider utilized by the claimant pursuant to rule
4123-6-46 of the Administrative
Code, in which case the claimant reimbursement shall be at least the rate
negotiated with the provider. Requests for reimbursement must be paid
within thirty days of receipt of the request.
(I) Self-insuring employers must obtain a
drug utilization review from a physician before terminating payment for current
medications, as follows:
(1)
Except as
otherwise provided in paragraph (I)(7) of this rule, before terminating
payment for current medications, the self-insuring employer shall notify all
parties to the claim (including authorized representatives) and the prescribing
physician, in writing, that a physician drug review is being performed, or has
been performed, regarding the necessity and appropriateness of the continued
use of current medications (by therapeutic drug class).
(2) The written notice shall inform all
parties to the claim (including authorized representatives) and the prescribing
physician that they have twenty-one days from receipt of the notice to provide
additional information and/or medical documentation to justify the need for
continued use of the medications (by therapeutic drug class).
(3) The self-insuring employer shall provide
all medically related information regarding the medications to an independent
physician reviewer for review and opinion as to the necessity or
appropriateness of the medications. If the self-insuring employer has obtained
an independent physician reviewer's report prior to sending the notice required
by paragraph (I)(1) of this rule and subsequently receives additional
information and/or medical documentation pursuant to paragraph (I)(2) of this
rule, the self-insuring employer shall provide the additional information
and/or medical documentation to the independent physician reviewer and obtain
an addendum. The independent physician reviewer's report (and addendum, if
applicable) shall address the medical rationale, necessity and appropriateness
of the drug treatment in the control of symptoms associated with the allowed
conditions in the claim.
(4) When
the independent physician reviewer's report (and addendum, if applicable)
indicates the drug treatment is not medically necessary or appropriate for
treatment or in the control of symptoms associated with the allowed conditions
in the claim, the self-insuring employer may terminate reimbursement for the
medications (by therapeutic drug class) effective as of the date of receipt of
the independent physician reviewer's report, or addendum if one is obtained, or
in the case that a drug is in a therapeutic class that requires a "weaning-off"
period, in accordance with the tapering schedules set
forth in the appendix to rule
4123-6-21.5 of the
Administrative Code or such other date as agreed to by the prescribing
physician and self-insuring employer.
(5) In the event the self-insuring employer
terminates reimbursement for the medications as set forth in paragraph (I)(4)
of this rule, the self-insuring employer or its authorized representative shall
provide all parties to the claim (including authorized representatives) and the
prescribing physician with a copy of the independent physician reviewer's
report (and addendum, if applicable) and the self-insuring employer shall
notify the
injured worker and the
injured
worker's representative in writing of its decision to terminate. The
employer's notification to the
injured worker and
injured
worker's representative shall indicate that the
injured
worker has the right to request a hearing before the industrial
commission.
(6) In the event there
is a dispute as to whether the drug treatment is medically necessary or
appropriate for treatment of the symptoms associated with the allowed
conditions in the claim, the disputed matter shall be adjudicated in accordance
with paragraph (K)(5) of rule
4123-19-03 of the Administrative
Code.
(7)
The self-insuring employer may terminate current medications
that have been removed from the bureau's outpatient medication formulary set
forth in the appendix to rule
4123-6-21.3 of the
Administrative Code without obtaining a physician drug review. However, the
tapering schedules set forth in the appendix to rule
4123-6-21.5 of the
Administrative Code would apply.
(J) Self-insuring employers may deny initial
requests for a drug or therapeutic class of drugs as not being reasonably
related to or medically necessary for the treatment of the allowed conditions
in a claim.
(K)
Self-insuring employers may
contract with a pharmacy benefits
manager.
A self-insuring employer utilizing a pharmacy benefits manager may require
pharmacy providers to submit bills for medication by an on-line
point-of-service authorization terminal or a host-to-host link with the
pharmacy benefits manager's established bill
processing system as a condition of reimbursement, and may refuse submission by
paper or by tape-to-tape. Self-insuring employers utilizing a
pharmacy benefits manager may refuse to reimburse any
third-party pharmacy biller that submits pharmacy bills on behalf of a pharmacy
provider or that has purchased pharmacy bills from a pharmacy provider for
subsequent submission to the self-insuring employer for payment.
(L)
Self-insuring employers utilizing a
pharmacy benefits
manager may require prior authorization of drugs or therapeutic classes
of drugs which appear on the bureau's published list of drugs or therapeutic
classes of drugs for which prior authorization is required.
Notwithstanding rule
4123-19-03 of the Administrative
Code, the self-insuring employer shall approve or deny a prior authorization
request within three business days of the request.
(M)
Self-insuring employers utilizing a
pharmacy benefits
manager may apply the following dispensing limitations, adopted by the
bureau, to medications approved and reimbursed by the self-insuring employer:
(1)
The bureau may
publish supply limitations for drugs which represent the maximum number of days
supply that may be dispensed at any one time for a single
prescription.
(2) The bureau may publish maximum prescription
quantities which represent the largest number of units per drug that may be
dispensed at any one time for a single prescription.
(3) Requests submitted
that exceed either the days supply limit or maximum quantity limit shall be
denied; provided, however, that the pharmacy provider may still fill the
prescription up to the days supply limit or maximum quantity limit, as
applicable. Denials may be overridden by the self-insured employer in cases
where medical necessity and appropriateness have been determined.
(4)
Refills of drugs
not scheduled by the DEA requested before eighty per cent of any published days
supply limit has been utilized will be denied.
(5)
Refills of drugs
scheduled by the DEA requested before ninety per cent of any published days
supply limit has been utilized will be denied.
(6)
Denials may be overridden by the self-insured employer for the following
reasons with supporting documentation:
(a)
The injured
worker's pharmacy is submitting an early refill for a shortened days supply to
support synchronizing the filling or refilling of the prescription in a manner
that allows the dispensed drug to be obtained on the same date each
month;
(b)
The injured worker is traveling out of the country and will
be unable to refill medications during that time;
(c)
The injured
worker's pharmacy will be closed for more than two days.
(d) An emergency or disaster, as defined in
division (O) of section
4123.511 of the Revised Code, is
declared by the governor of Ohio or the president of the United
States.
(N) Self-insuring
employers utilizing a
pharmacy benefits manager may
apply the maximum allowable cost list of the
pharmacy benefits
manager.
(O)
Injured workers who request a brand name drug or
whose physician specifies a brand name drug designated by "dispense as written"
on the prescription for a medication for which pharmaceutically and therapeutically equivalent
medications exist, as defined in paragraph
(I) of
rule 4123-6-21
of the Administrative Code, shall be liable for the product cost
difference between the AWP of the dispensed brand name
drug minus fifteen per cent and the established maximum
allowable cost price of the drug product. However, the self-insuring
employer or its vendor may approve reimbursement of the dispensed brand name
drug at the AWP of the drug minus fifteen per cent if the following
circumstances are met:
(1) The injured worker
has a documented, systemic allergic reaction as a
result of taking the generic equivalent which is consistent with known
symptoms or clinical findings of a medication allergy;
or
(2) The
injured worker has been prescribed, and has tried,
another generic equivalent and the intended
therapeutic benefit has not been achieved or an unacceptable adverse event has
occurred.
(P) A self-insuring employer has sufficient grounds to
refuse to pay for the dispensing of drugs and other medications when a pharmacy
provider fails to observe any state or federal law relating to his or her
professional licensure or to the dispensing of drugs and other
medication.
