This rule governs the bureau's
reimbursement of opioid prescriptions used to treat acute, subacute, and
chronic pain in a work related injury or occupational disease.
(A)
Definitions.
For purposes of this rule:
(1)
"Acute pain,"
"chronic pain," "morphine equivalent dose (MED)," and "subacute pain" have the
same meanings as defined in rule
4731-11-01 of the
Administrative Code.
(2)
"OARRS" means the "Ohio Automated Rx Reporting System"
drug database established and maintained pursuant to section
4729.75 of the Revised
Code.
(3)
"Opioid" has the same meaning as "opioid analgesic" as
defined in section 3719.01 of the Revised
Code.
(B)
Reimbursement for opioid prescriptions used to treat a
work related injury or occupational disease is limited to claims in which
current best medical practices as implemented by rules
4731-11-13
and
4731-11-14
of the Administrative Code and this rule are followed.
The bureau will not reimburse for any
further prescriptions for opioids if the applicable criteria of rules
4731-11-13
and
4731-11-14
of the Administrative Code and this rule are not met. A prescriber's failure to
comply with these rules may be subject to peer review by the bureau of workers'
compensation pharmacy and therapeutics (P&T) committee pursuant to rule
4123-6-21.2 of the Administrative Code, the bureau of workers' compensation
stakeholders' health care quality assurance advisory committee (HCQAAC)
pursuant to rule 4123-6-22 of the Administrative Code, or other peer review
committee established by the bureau, or subject to decertification pursuant to
rule 4123-6-02.7 of the Administrative Code.
(C)
Opioid
utilization for acute pain.
Reimbursement for ongoing opioid
prescriptions for acute pain will only be provided when the prescriber has both
complied with rule
4731-11-13
of the Administrative Code and has documented in the medical record the
appropriateness and safety of the medication in the same manner as in
paragraphs (A) and (B) of rule
4731-11-14
of the Administrative Code.
(D)
Opioid
utilization for subacute and chronic pain.
(1)
Ongoing
reimbursement for opioid prescriptions for subacute and chronic pain will only
be provided when the prescriber has complied with rule
4731-11-14
of the Administrative Code.
(2)
In addition to
paragraph (D)(1) of this rule, when prescribing opioids at or above an average
daily dose of fifty MED per day, the prescriber must complete and document in
the patient records:
(a)
A validated risk assessment, not less than every three
months; and
(b)
Urine drug screens, with frequency based upon the
results of the validated risk assessment and upon presence or absence of
aberrant behaviors or other indications of substance misuse, abuse, substance
use disorder, or diversion.
(E)
Paragraph (D) of
this rule does not apply when the opioid is prescribed for an injured worker in
the situations described in paragraph (H) of rule
4731-11-14
of the Administrative Code.
Replaces:4123-6-21.7.
Notes
Ohio Admin. Code 4123-6-21.7
Effective:
9/1/2020
Five Year Review (FYR) Dates:
05/01/2025
Promulgated
Under: 119.03
Statutory
Authority: 4121.12,
4121.121,
4121.30,
4121.31,
4121.44,
4121.441,
4123.05
Rule
Amplifies: 4121.12,
4121.121,
4121.44,
4121.441
Prior
Effective Dates: 10/01/2016