Ohio Admin. Code 4123-6-21.3 - Outpatient medication formulary
(A) The administrator hereby adopts the
formulary indicated in the appendix to this rule, developed with the
recommendation of the bureau's pharmacy and therapeutics committee.
(B) Except as otherwise provided in paragraph
(F) of this rule, the formulary indicated in the appendix to this rule shall
constitute the complete list of medications that are approved for reimbursement
by the bureau for the treatment of a work related injury or disease in an
allowed claim when dispensed to an injured worker by a registered pharmacist
from an enrolled outpatient pharmacy provider.
(C) The formulary indicated in the appendix
to this rule also contains specific reimbursement, prescribing or dispensing
restrictions that have been placed on the use of listed drugs. The formulary
will be reviewed and updated as necessary. The most current version will be
electronically published by the bureau.
(D) The administrator will consider current
medical literature and best practices and the recommendations of the bureau's
pharmacy and therapeutics committee when making additions, deletions, or
modifications of coverage of medications listed in the formulary.
(E) The bureau shall provide an expedited
review process for clinically or therapeutically unique medications when
necessary.
(F) Notwithstanding
paragraph (B) of this rule, in cases of medical necessity supported by medical
documentation and evidence of need the bureau may reimburse for:
(1) New drugs approved for use in the United
States by the food and drug administration (FDA) on or after the effective date
of the formulary, and for new indications approved by the FDA on or after the
effective date of the formulary for existing drugs that are not on the
formulary, with prior authorization, for a period not to exceed one hundred
eighty days from the adjudication date of the first prescription for the
requested drug.
(2) Antineoplastic
drugs prescribed for treatment of an allowed cancer condition in a
claim.
(3) Antiretroviral drugs
prescribed for:
(a) Treatment of an allowed
condition of human immunodeficiency virus in a claim; or
(b) Post exposure treatment in an allowed
claim or pursuant to section
4123.026 of the Revised
Code.
(G)
Notwithstanding the appendix to this rule, in cases of medical necessity
supported by medical documentation and evidence of need the bureau may
reimburse for new dosage forms or strengths approved by the FDA on or after the
effective date of the formulary for existing drugs that are on the formulary,
with prior authorization, for a period not to exceed one hundred eighty days
from the adjudication date of the first prescription for the requested drug.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 09/01/2011, 02/01/2012, 09/01/2012, 04/01/2013, 01/02/2014, 09/01/2014, 05/01/2015, 12/01/2015, 01/01/2017, 10/01/2017, 05/01/2018, 01/10/2019, 06/01/2019, 09/01/2020, 04/01/2021, 08/01/2021, 02/01/2022, 08/01/2022, 02/01/2023, 08/01/2023
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(A) The administrator hereby adopts the formulary indicated in the appendix to this rule, developed with the recommendation of the bureau's pharmacy and therapeutics committee.
(B) Except as otherwise provided in paragraph (F) of this rule, the formulary indicated in the appendix to this rule shall constitute the complete list of medications that are approved for reimbursement by the bureau for the treatment of a work related injury or disease in an allowed claim when dispensed to an injured worker by a registered pharmacist from an enrolled outpatient pharmacy provider .
(C) The formulary indicated in the appendix to this rule also contains specific reimbursement, prescribing or dispensing restrictions that have been placed on the use of listed drugs. The formulary will be reviewed and updated as necessary. The most current version will be electronically published by the bureau.
(D) The administrator will consider current medical literature and best practices and the recommendations of the bureau's pharmacy and therapeutics committee when making additions, deletions, or modifications of coverage of medications listed in the formulary.
(E) The bureau shall provide an expedited review process for clinically or therapeutically unique medications when necessary.
(F) Notwithstanding paragraph (B) of this rule, in cases of medical necessity supported by medical documentation and evidence of need the bureau may reimburse for:
(1) New drugs approved for use in the United States by the food and drug administration (FDA) on or after the effective date of the formulary, and for new indications approved by the FDA on or after the effective date of the formulary for existing drugs that are not on the formulary, with prior authorization , for a period not to exceed one hundred eighty days from the adjudication date of the first prescription for the requested drug.
(2) Antineoplastic drugs prescribed for treatment of an allowed cancer condition in a claim.
(3) Antiretroviral drugs prescribed for:
(a) Treatment of an allowed condition of human immunodeficiency virus in a claim; or
(b) Post exposure treatment in an allowed claim or pursuant to section 4123.026 of the Revised Code.
(G) Notwithstanding the appendix to this rule, in cases of medical necessity supported by medical documentation and evidence of need the bureau may reimburse for new dosage forms or strengths approved by the FDA on or after the effective date of the formulary for existing drugs that are on the formulary, with prior authorization , for a period not to exceed one hundred eighty days from the adjudication date of the first prescription for the requested drug.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 09/01/2011, 02/01/2012, 09/01/2012, 04/01/2013, 01/02/2014, 09/01/2014, 05/01/2015, 12/01/2015, 01/01/2017, 10/01/2017, 05/01/2018, 01/10/2019, 06/01/2019, 09/01/2020, 04/01/2021, 08/01/2021, 02/01/2022, 08/01/2022, 02/01/2023