2019 Ohio Revised Code
Title [39] XXXIX INSURANCE
Chapter 3923 - SICKNESS AND ACCIDENT INSURANCE
Section 3923.851 - Prior authorization requirements or other utilization review measures as conditions of providing coverage of an opioid analgesic prescribed for treatment of chronic pain; exceptions.
(A) As used in this section:
(1) "Benzodiazepine" has the same meaning as in section 3 719.01 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 3 719.01 of the Revised Code.
(5) "Prescriber" has the same meaning as in section 4 729.01 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 policy of sickness and accident insurance or a public employee benefit plan that is delivered, issued for delivery, or renewed in this state and covers prescription d rugs 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 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 sickness and accident insurer or public employee benefit plan 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 m ore 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 m g 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 sickness and accident insurer or public employee benefit plan 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.
Added by 131st General Assembly File No. TBD, SB 319, §1, eff. 4/6/2017.
Related Legislative Provision: See 131st General Assembly File No. TBD, SB 319, §7.
