Rule 4123-6-21.6 | `First fill of outpatient medications.
(A) In accordance with division (B) of section 4123.66 of the Revised Code, the administrator has established a program to make immediate payment, under the circumstances set forth in this rule, for the first fill of prescription drugs for medical conditions identified in an application for compensation or benefits under section 4123.84 or 4123.85 of the Revised Code that occurs prior to the date the administrator issues an initial determination order under division (B) of section 4123.511 of the Revised Code.
(B) The appendix to this rule shall constitute the complete list of medications, and the maximum quantity of such medications, that are approved for reimbursement by the bureau for first fill prior to issuance of an initial determination order. Except as otherwise provided in paragraph (C) of this rule, drugs not listed in the appendix to this rule are not eligible for reimbursement by the bureau under the first fill program.
(C) Notwithstanding paragraph (B) of this rule, in cases of medical necessity supported by clinical documentation and evidence of need the bureau may, with prior authorization, reimburse for the first fill of medications that are eligible for reimbursement under rule 4123-6-21.3 of the Administrative Code but are not listed in the appendix to this rule.
(D) Reimbursement of outpatient medications by the bureau under the first fill program shall be subject to the following limitations:
(1) Approval for reimbursement of medications under the first fill program will be limited to the quantity limits listed in the appendix to this rule, and no refills will be approved;
(2) With the exception of antivirals, antiretrovirals, and antibiotics, approval for reimbursement of medications under the first fill program will be limited to one drug per therapeutic drug class listed in the appendix to the rule;
(3) Extemporaneous compounded prescriptions are not eligible for reimbursement by the bureau under the first fill program.
(E) Pharmacy providers shall be reimbursed for dispensing drugs under this rule in the manner described in rule 4123-6-21 of the Administrative Code provided that the prescriber, or their agent has indicated the prescription is for a work related injury and signed the prescription blank. A pharmacist or pharmacy intern who receives a telephone prescription may also write and sign that it is work related on the prescription.
(F) If a claim in which the first fill of outpatient medication was reimbursed by the bureau pursuant to this rule is ultimately disallowed in a final administrative or judicial order, and if the employer is a state fund employer who pays assessments into the surplus fund account created under section 4123.34 of the Revised Code, the payment for outpatient medication made pursuant to this rule shall be charged to and paid from the surplus fund account and not charged through the state insurance fund to the employer against whom the claim was filed.
Last updated February 1, 2023 at 9:02 AM