4123-6-21.4 Coordinated services program.

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 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 sedative-hypnotics 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 self-insuring 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 self-insuring 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) 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 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) 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 self-insuring 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.

Effective: 06/01/2012
R.C. 119.032 review dates: 06/01/2017
Promulgated Under: 119.03
Statutory Authority: 4121.121 , 4121.44 , 4121.441 , 4121.50
Rule Amplifies: 4121.50 , 5111.085 , 5111.179