Ohio Code 1751.691 – Prior authorization requirements or other utilization review measures as conditions of providing coverage of an opioid analgesic
(A) As used in this section:
Terms Used In Ohio Code 1751.691
- Another: when used to designate the owner of property which is the subject of an offense, includes not only natural persons but also every other owner of property. See Ohio Code 1.02
- Contract: A legal written agreement that becomes binding when signed.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Corporation: means a corporation formed under Chapter 1701. See Ohio Code 1751.01
- Health insuring corporation: means a corporation, as defined in division (H) of this section, that, pursuant to a policy, contract, certificate, or agreement, pays for, reimburses, or provides, delivers, arranges for, or otherwise makes available, basic health care services, supplemental health care services, or specialty health care services, or a combination of basic health care services and either supplemental health care services or specialty health care services, through either an open panel plan or a closed panel plan. See Ohio Code 1751.01
- state: means the state of Ohio. See Ohio Code 1.59
(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 is 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) An individual or group health insuring corporation policy, contract, or agreement that is delivered, issued for delivery, or renewed in this state and covers prescription drugs shall contain 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 c are 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 health insuring corporation 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 a health insuring corporation 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.