Ohio Admin. Code 4123-6-21.7 - Reimbursement of opioids in the treatment of pain for a work related injury or occupational disease

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