Section 5164.091 | Coverage for opioid analgesics.
(A) As used in this section:
(1) "Benzodiazepine" has the same meaning as in section 3719.01 of the Revised Code.
(2) "Chronic pain" has the same meaning as in section 4731.052 of the Revised Code.
(3) "Hospice care program" and "hospice patient" have the same meanings as in section 3712.01 of the Revised Code.
(4) "Opioid analgesic" has the same meaning as in section 3719.01 of the Revised Code.
(5) "Prescriber" has the same meaning as in section 4729.01 of the Revised Code.
(6) "Terminal condition" means an irreversible, incurable, and untreatable condition that caused by disease, illness, or injury and will likely result in death. A terminal condition is one in which there can be no recovery, although there may be periods of remission.
(B)(1) With respect to the medicaid program's coverage of prescribed drugs, the department of medicaid shall apply prior authorization requirements or other utilization review measures as conditions of providing coverage of an opioid analgesic prescribed for the treatment of chronic pain, except when the drug is prescribed under one of the following circumstances:
(a) To an individual who is a hospice patient in a hospice care program;
(b) To an individual who has been diagnosed with a terminal condition but is not a hospice patient in a hospice care program;
(c) To an individual who has cancer or another condition associated with the individual's cancer or history of cancer.
(2) When implementing division (B)(1) of this section, the department shall consider either or both of the following, as applicable to the case in which the opioid analgesic is prescribed:
(a) If the course of treatment with the drug continues for more than ninety days, the requirements of section 4731.052 of the Revised Code;
(b) If the morphine equivalent daily dose for the drug exceeds eighty milligrams or the individual is being treated with a benzodiazepine at the time the opioid analgesic is prescribed, the guidelines established by the governor's cabinet opiate action team and presented in the document titled "Ohio Guidelines for Prescribing Opioids for the Treatment of Chronic, Non-terminal Pain 80 mg of a Morphine Equivalent Daily Dose (MED) 'Trigger Point'" or a successor document, unless the guidelines are no longer in effect at the time the opioid analgesic is prescribed.
(C) If the department measures the efficiency, quality of care, or clinical performance of a prescriber, including through the use of patient satisfaction surveys, it shall not penalize the prescriber, financially or otherwise, for deciding not to prescribe an opioid analgesic.
Available Versions of this Section
- April 6, 2017 – Enacted by Senate Bill 319, 131st General Assembly [ View April 6, 2017 Version ]