New Rules for Self-Insured Employers to Unilaterally Terminate Payment for Medications

A recent change to the Ohio Administrative Code (O.A.C.) clarifies the procedure by which employers may unilaterally terminate payment for ongoing prescriptions in claims. Specifically, O.A.C. Section 4123-6-21.1 provides that self-insured employers may terminate payment for prescription medications by:

  1. Notifying the worker, their representative, and the prescribing physician in writing that the employer will be obtaining a review as to the necessity and appropriateness of the medication.
  2. The notice must inform all parties that they have twenty-one days from the receipt of the notice to provide additional information to justify the need for continued use of the medications.
  3. If the review indicates that the medication is not necessary or appropriate, the self-insured employer can unilaterally terminate payment for the medication effective as of the date of the review, with notice to the worker that they have the right to appeal to the Industrial Commission. See O.A.C. §4123-6-21.1(I)

Employers should wait until the 21 day notice period elapses before sending the file out for a review. Under the new rules, if additional information is received within that period from the injured worker or their representative, it must be reviewed by the independent physician before the employer can terminate payment for medications.

Self-Insured employers may deny initial requests for medications as not reasonably related or medically necessary for the allowed conditions in the claim. See O.A.C. §4123-6-21.1(J)

Self-Insured employers in Ohio should take a close look at claims with ongoing prescription bills and consider utilizing these procedures. Medications are often the major cost factor in a workers’ compensation claim.  The BWC adopted these rules after considering the fact that injured workers are often not well served by remaining on medications for years.

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