The bureau of workers' compensation pharmacy and therapeutics (P&T) committee is hereby created to advise the administrator and the chief medical officer with regard to issues involving medication therapy for injured workers. A list of physician and pharmacist providers, each holding a professional license in good standing, who have agreed to serve on the P&T committee and who would add credibility and diversity to the mission and goals of the committee shall be developed and maintained by the chief medical officer. Providers may also be nominated for inclusion on the list by provider associations and organizations including but not limited to: deans of Ohio's allopathic and osteopathic medical schools, deans of Ohio's colleges of pharmacy, presidents of Ohio's various allopathic and osteopathic medical associations, the Ohio pharmacists association, the Ohio state medical board, and the Ohio state pharmacy board.
(A) The P&T committee shall consist of the bureau pharmacy program director and not more than thirteen nor less than five voting members who shall be licensed physicians and licensed pharmacists representing the diverse group of providers that provide care to the injured workers of Ohio as administered through the bureau. The committee may create any subcommittees that the committee determines are necessary to assist the committee in performing its duties. Any subcommittee recommendations shall be submitted to the P&T committee.
(B) P&T committee members must meet the following requirements:
(1) Each provider must be familiar with issues relating to the prescribing or dispensing of medications in the Ohio workers' compensation system.
(2) Physicians must be a doctor of medicine (MD) or doctor of osteopathic medicine (DO).
(3) Providers must possess significant clinical or administrative experience in health care delivery, including but not limited to pain management, pharmacy practice, medical quality assurance, disease management and utilization review.
(4) Providers must have experience with and an understanding of the concepts of evidence based medicine as well as contemporary best practices in appropriate prescribing, dispensing, and monitoring of outpatient medications.
(5) Providers must not be, or within the previous twenty-four months have been, an employee of any pharmaceutical manufacturer, pharmacy benefits manager, or any non-governmental firm or entity administering state purchased health care program benefits or pharmaceutical rebates.
(C) The appointing authority for members of the P&T committee shall be the administrator or the administrator's designee(s), who shall appoint members of the committee from the list of qualified providers developed and maintained by the chief medical officer. Terms of membership for individual members of the P&T committee shall be for one year. Individuals may be reappointed to subsequent terms as determined by the administrator. Vacated terms shall be filled in a like manner as for the full term appointments and shall be for the remaining term of the vacated member.
(D) The pharmacy program director of the bureau shall be the chairperson of the P&T committee and shall provide notice of meetings to the members and be responsible for the meeting agenda. In addition, the pharmacy program director may be self-designated as an ad hoc member of any subcommittees of the P&T committee; however, the pharmacy program director shall be a voting member of the P&T committee and any subcommittees only in the case of tie votes. The bureau chief medical officer and bureau staff pharmacist may participate in discussions; however, they shall not be voting members.
(E) The P&T committee shall develop and establish bylaws for the organization and operations of the committee and subcommittees, subject to the requirements of this rule and approval by the administrator.
(F) The P&T committee may make such recommendations as it deems necessary to address any issue impacting the bureau related to pharmacy or medication therapeutics. The committee shall be responsible to respond to requests for action on any such issue submitted by the bureau's administrator, chief of medical services, chief medical officer or pharmacy director, including but not limited to:
(1) Development, approval and annual review of a formulary of approved medications.
(2) Development, approval and annual review of a list of non-covered, non-reimbursable medications.
(3) Development and approval of prior authorization criteria.
(4) Review and approval of proposed medication treatment guidelines.
(5) Review and approval of bureau policies and procedures related to drug utilization review or specific medication issues.
(6) Review of the bureau's pharmacy providers' professional performance. The P&T committee shall perform peer review according to generally accepted standards of pharmacy practice and may recommend sanctions as well as termination of any pharmacy provider determined to have consistently failed to meet those standards of care.
(7) Review of any of the bureau's medical providers' medication prescribing patterns and practices. The P&T committee shall perform peer review according to generally accepted standards of medical practice applicable to medication prescribing and may recommend sanctions as well as decertification of any provider determined to have consistently failed to meet those standards of care. Any decertification or sanction of a provider by the bureau pursuant to recommendation of the P&T committee shall be conducted in accordance with rule 4123-6-17 of the Administrative Code.
(8) Review of the performance of the bureau's pharmacy benefit manager and conduct regarding its management of prescription benefit services for the bureau.
(G) The P&T committee shall hold at least three meetings annually. The P&T committee and all subcommittees shall keep written records of the agenda and minutes of each meeting. The records of all committees shall remain in the custody of the chief medical officer.
(H) The P&T committee shall submit an annual report of its activities and recommendations to the administrator. In addition to inclusion in the annual report, all recommendations from the P&T committee and subcommittees shall be submitted to the chief medical officer in a timely fashion upon completion and approval by the respective subcommittees and P&T committee.
(I) Each member of the P&T committee and its respective subcommittees may be paid such fees as approved by the administrator or the administrator's designee. The expenses incurred by the P&T committee and its subcommittees and the fees of their members shall be paid in the same manner as other administrative costs of the bureau.
Five Year Review (FYR) Dates: 08/25/2020
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: 1/10/11, 2/1/12