Prescription medications are a necessary, albeit expensive component of any self-insured workers’ compensation program. Unfortunately, injured workers are often prescribed unnecessary prescription drugs which can lead to dangerous health conditions and increased complexity of workers’ compensation claims. Physicians continue to prescribe and dispense opioids which are the most expensive therapy class in workers’ compensation. Studies show that injured workers with longer-term opioid prescriptions result in three times longer disability than for injured workers with similar injuries who did not receive opioid prescriptions. In the world of workers’ compensation, the medical benefits portion of a claim may be open for a number of years or even a lifetime of an injured worker. As the years progress, prescription medications become a bigger portion of the medical expense which is especially true if the injured worker has become dependent or addicted to opioid medication to control pain. In short,  increasing use of prescription medications imposes unique challenges on self-insured workers’ compensation programs.

What, if anything, can be done to control these escalating costs? By closely monitoring their workers’ compensation claims, self-insured employers can help control prescription medication costs and drive better overall workers’ compensation claims outcomes. In fact, the Ohio Administrative Code (O.A.C.) §4123-6-21.1  sets forth the procedures whereby self-insured employers can unilaterally terminate reimbursement for ongoing prescription medications under specific circumstances by:

  • Providing written notice to the injured worker, their authorized representative and the physician who is prescribing the medication that the self-insured employer will be obtaining a review from an independent physician to address the necessity and appropriateness of the continued use of prescription medications.
  • The written notice must inform all parties to the claim and the prescribing doctor that they have twenty one days to provide additional information justifying the need for ongoing medications.
  • The employer must wait until the twenty one days elapses before sending the documents  (including the information provided on behalf of the injured worker) to an independent doctor to review and address the issue of the medical rationale, necessity and appropriateness of the current prescription drugs.

In the event the independent physician reviewer’s report indicates that the prescription drugs are not necessary or appropriate for the treatment of the conditions allowed in the workers’ compensation claim, the employer may terminate the reimbursement for the medications upon receipt of the report, unless the drug is in a class that requires a “weaning-off” period as set forth in the appendix to O.A.C. §4123-6-21.5, or such other date as agreed to by the prescribing physician and the self-insuring employer. The employer must provide all parties and the prescribing doctor with a copy of the independent physician’s report and written notice of its decision to terminate. The employer must also advise the parties that the injured worker has the right to request a hearing before the Industrial Commission.

Please keep in mind that self-insuring employers may continue to deny INITIAL requests for a drug as not being reasonably related to, or medically necessary for the treatment of the allowed conditions in the claim in accordance with Paragraph J of O.A.C. §4123-6-21.1.

Based on the foregoing, Ohio self-insured employers should regularly review their workers’ compensation claims which have continuing prescription bills and implement the foregoing procedures to control their claim costs.

If you have any questions regarding the termination of reimbursement of prescription medications, please contact Maris McNamara or any of Frantz Ward’s other workers’ compensation attorneys.