The bureau, or a self-insuring employer with a point-of-service
adjudication system, may establish a coordinated services program (CSP) that
requires an injured worker to obtain prescription medications reimbursed by the
bureau or self-insuring employer from a single designated pharmacy and/or
prescriber.
(A) Placement in a CSP.
(1) The bureau or self-insuring employer with
a point-of-service adjudication system may review an injured worker for
possible placement in a CSP if a review of
his or
her
the claim indicates the injured
worker meets one or more of the following criteria:
(a) Use of three or more different
prescribers to obtain prescriptions of the same or comparable medications per
three month time frame;
(b) Receipt
of prescription drugs from more than two different pharmacies per three month
time frame;
(c) Monthly receipt of
three or more prescriptions including refills for drugs identified by
therapeutic drug class as a narcotic analgesic per three month time
frame;
(d) Monthly receipt of more
than two concurrent narcotic analgesics in the same therapeutic drug class per
three month time frame;
(e) Monthly
receipt of more than two narcotic analgesics in the same therapeutic drug
class, more than one benzodiazepine, and more than one sedativehypnotics per
three month time frame.
(2) Upon identification of an injured worker
meeting one or more of the criteria identified in paragraphs (A)(1)(a) to
(A)(1)(e) of this rule, the bureau or selfinsuring employer with a
point-of-service adjudication system shall obtain a physician review of the
injured worker's most recent twelve months history of prescription medications
reimbursed by the bureau or self-insuring employer.
(3) If, based on this physician review, the
bureau or self-insuring employer with a point-of-service adjudication system
determines that the injured worker's utilization of prescription medications
during this period was at a frequency or in an amount that was not medically
necessary or appropriate under the criteria set forth in paragraphs (B)(1) to
(B)(3) of rule 4123-6-16.2 of the Administrative Code, or was potentially
unsafe, the bureau or self-insuring employer may place the injured worker in a
CSP.
(4) Notwithstanding paragraphs
(A)(1) to (A)(3) of this rule, if the bureau or selfinsuring employer with a
point-of-service adjudication system determines that an injured worker has been
convicted of or pled guilty to an offense under Chapter 2925. of the Revised
Code or any other criminal offense related to the misuse of drugs, the bureau
or self-insuring employer may place the injured worker in a CSP.
(5) Placement in a CSP shall be for an
initial period of eighteen months. The bureau or self-insuring employer with a
point-of-service adjudication system may place the injured worker in the CSP
for additional eighteen month periods in accordance with paragraph (A)(6) of
this rule.
(6) The bureau or
self-insuring employer with a point-of-service adjudication system may evaluate
an injured worker's medication utilization at the conclusion of each eighteen
month period in the CSP. If the bureau or self-insuring employer determines
that the injured worker's medication utilization continues to meet the criteria
set forth in paragraphs (A)(1) to (A)(4) of this rule, the bureau or
self-insuring employer may place the injured worker in the CSP for an
additional eighteen month period.
(7) If an injured worker placed in the CSP
enters a nursing home, residential care/assisted living facility, or hospice
program, the injured worker shall be released from the CSP. If the injured
worker is subsequently discharged from the nursing home, residential
care/assisted living facility, or hospice program during the CSP period, the
bureau or self-insuring employer with a point-of-service adjudication system
may place the injured worker back into the CSP.
(B) Selection of designated pharmacy and/or
prescriber.
(1) An injured worker placed into
a CSP pursuant to paragraph (A)(3) or (A)(4) of this rule shall be given the
opportunity to select a designated pharmacy from a list of participating
pharmacies maintained by the bureau or self-insuring employer. If an injured
worker fails to select a designated pharmacy, or selects a designated pharmacy
that is unable or unwilling to accept the injured worker, the bureau or
self-insuring employer may select a designated pharmacy for the injured
worker.
(2) An injured worker
placed in a CSP pursuant to paragraph (A)(3) or (A)(4) of this rule may only
change from one designated pharmacy to another in the following circumstances:
(a) The designated pharmacy becomes
inaccessible to the injured worker due to relocation or incapacity of the
injured worker or closing of the designated pharmacy,
(b) The designated pharmacy chooses to no
longer participate in the CSP or to provide services to the injured worker in
accordance with paragraph (D) (4) of this rule.
(c) The injured worker requests to be
assigned to another designated pharmacy due to personal preference. Not more
than one change due to personal preference shall be approved in a rolling
twelve-month period.
(3)
An injured worker placed in the CSP pursuant to paragraph (A)(4) of this rule
shall be given the opportunity to select a designated prescriber from among
those bureau certified providers who meet the definition of physician under
paragraph
(D)
(P) of rule
4123-6-01 of the
Administrative Code. If an injured worker fails to select a designated
prescriber, or selects a designated prescriber that is unable or unwilling to
accept the injured worker, the bureau or self-insuring employer may select a
designated prescriber for the injured worker.
(4) An injured worker placed in a CSP
pursuant to paragraph (A)(4) of this rule may only change from one designated
prescriber to another in the following circumstances:
(a) The designated prescriber becomes
inaccessible to the injured worker due to relocation or incapacity of the
injured worker or closing of the designated prescriber's practice,
(b) The designated prescriber chooses to no
longer provide services to the injured worker,
(c) The injured worker requests to be
assigned to another designated prescriber due to personal preference. Not more
than one change due to personal preference shall be approved in a rolling
twelve-month period.
(5)
All requests for change of designated pharmacy or designated prescriber must be
submitted in writing to the bureau or self-insuring
employer.
(C) Operation
of the CSP.
(1) An injured worker placed in a
CSP pursuant to paragraph (A)(3) or (A)(4) of this rule must obtain covered
prescription medications from the injured worker's designated pharmacy. During
the period the injured worker is placed in the CSP, the bureau or self-insuring
employer shall deny reimbursement for prescription medications obtained from a
pharmacy other than the injured worker's designated pharmacy, except in cases
of emergency as set forth in paragraph (C)(2) of this rule.
(2) Emergency prescription fills shall be
allowed in the following situations:
(a) The
injured worker is unable to get to
his or
her
their designated pharmacy,
(b) The injured worker's designated pharmacy
does not have the prescribed medication in stock.
(3) Emergency prescription fills shall be
limited to a four-day supply. Records of dispensing for emergency prescription
fills are subject to review by the bureau.
(4) An injured worker placed in a CSP
pursuant to paragraph (A)(4) of this rule must obtain all prescriptions for
covered medications from the injured worker's designated prescriber. During the
period the injured worker is placed in the CSP, the bureau or self-insuring
employer shall deny reimbursement for prescriptions written by providers other
than the injured worker's designated prescriber, except:
(a) In cases of emergency as defined in
paragraph
(O)
(F) of rule
4123-6-01 of the
Administrative Code;
(b) With prior
authorization, prescriptions written by a specialist in cases where the injured
worker has been referred to a specialist for
care.
(D)
Pharmacies participating in the bureau's CSP.
(1) The bureau shall maintain a list of
pharmacies participating in the bureau's CSP that are eligible for selection by
an injured worker as a designated pharmacy. To participate in the bureau's CSP,
a pharmacy must meet the following criteria:
(a) The pharmacy must be enrolled with the
bureau and have a signed agreement with the bureau's pharmacy benefits
manager.
(b) The pharmacy must
enter into a CSP agreement with the bureau.
(2) Pharmacies participating in the bureau's
CSP agree to perform the following monitoring activities:
(a) For each injured worker in the bureau's
CSP for whom the pharmacy is the designated pharmacy, the pharmacy shall
conduct a bimonthly review of the injured worker's OARRS report from the Ohio
board of pharmacy (or a similar automated prescription monitoring report from
the injured worker's state of residence).
(b) The pharmacy shall notify the injured
worker's prescribing physician of any critical findings discovered in the
report. Critical findings are indications of any prescription related activity
that could cause harm to the patient, including but not limited to:
(i) Duplication of therapy,
(ii) Excessive doses of concurrent
medications,
(iii) Potential drug
interactions or potentiation of side effects.
(c) The pharmacy shall notify BWC in writing
whenever reports are made under paragraph (D)(2)(b) of this rule.
(d) BWC may request quarterly documentation
of the pharmacy's monitoring activities under paragraphs (D)(2)(a) to (D)(2)(d)
of this rule.
(3)
Pharmacies participating in the CSP may receive compensation from the bureau
under the CSP agreement for services provided as part of the CSP.
(4) Pharmacies participating in the bureau's
CSP may terminate their CSP agreement with the bureau and discontinue their
participation in the bureau's CSP at any time upon not less than thirty days
written notice to the bureau. Pharmacies participating in the bureau's CSP may
discontinue providing services to an individual injured worker at any time upon
not less than thirty days written notice to the bureau, the injured worker, and
the injured worker's authorized representative.
(5) The bureau may terminate the CSP
agreement of a pharmacy participating in the bureau's CSP in accordance with
the terms of the CSP agreement.
(E) Pharmacies participating in a
self-insuring employer's CSP.
(1) A
self-insuring employer with a point-of-service adjudication system who
establishes a CSP shall maintain a list of pharmacies participating in the
selfinsuring employer's CSP that are eligible for selection by an injured
worker as a designated pharmacy. The list of participating pharmacies shall
cover a geographic area sufficient to provide the self-insuring employer's
injured workers with reasonable access to pharmacy providers.
(2) Pharmacies participating in a
self-insuring employer's CSP shall provide not less than thirty days written
notice to an injured worker and the injured worker's authorized representative
prior to discontinuing services to the injured worker.
(F) Disputes.
(1) Decisions by the bureau regarding an
injured worker's placement in the bureau's CSP, assignment of a designated
pharmacy or designated prescriber, or denial of an injured worker's request for
change of designated pharmacy or designated prescriber may be appealed to the
industrial commission in accordance with section
4123.511
of the Revised Code.
(2) Decisions
by a self-insuring employer regarding an injured worker's placement in the
self-insuring employer's CSP, assignment of a designated pharmacy or designated
prescriber, or denial of an injured worker's request for change of designated
pharmacy or designated prescriber shall indicate that the injured worker has
the right to request a hearing before the industrial commission.
Notes
Ohio Admin. Code 4123-6-21.4
Effective:
2/1/2022
Five Year Review (FYR) Dates:
11/12/2021 and
02/01/2027
Promulgated
Under:
119.03
Statutory Authority:
4121.121,
4121.44,
4121.441,
4121.50,
4123.05
Rule
Amplifies:
4121.12,
4121.121,
4121.44,
4121.441,
4121.50,
5164.758,
5167.13
Prior Effective Dates:
06/01/2012