New York has joined the list of states that have passed a workers’ compensation drug formulary for the prescribing and treatment of injured workers. While states like Texas and Tennessee have opted for the Official Disability Guidelines (ODG), New York took a much different approach and created a state-specific formulary, with features like step therapies and phases of treatment.
The details of the drug formulary are complex, and the timeline is fast approaching. At IWP, we have an experienced team of workers’ compensation professionals who are ready and available to make this transition as smooth as possible for your office.
As we approach the first implementation date, here are the important pieces to know.
The drug formulary is split in two implementation dates:
December 5, 2019: Newly prescribed medications must be formulary medications. Prior authorization is required for any new prescription that is not on-formulary.
June 5, 2020: Refills and renewals are subject to the drug formulary. Prior authorization is required before date of refill or renewal.
The drug formulary itself can be updated by the New York State Workers’ Compensation Board (WCB) at any time. We encourage you to continuously check the WCB’s website for updates.
Drug Formulary Details
Medications that are on the drug formulary do not require prior authorization from the insurer or self-insured employer, however, prior authorization is required for the following:
- Medications not listed on the New York Workers’ Compensation Drug Formulary
- A drug formulary medication when a generic is available
- Combination products, unless listed on the formulary
- Compound medications
- Brand name medications when a generic version is available in a different strength/dose
Prior Authorization Process
When prescribing a medication that requires prior authorization, the prescriber must log onto the New York Workers’ Compensation Board Medical Portal. The medical portal will allow the prescriber, insurer, self-insured employer, and Pharmacy Benefit Manager (PBM) to request and respond to prior authorization submissions electronically and access the drug formulary and medical treatment guidelines.
The prescriber will initially seek prior authorization through a Level 1 review to the insurer/self-insured employer by requesting a specific quantity and number of refills, as well as providing information on why a non-formulary medication should be approved for the injured worker.
The request must be approved, denied, or partially approved within four calendar days – this includes holidays and weekends. The insurer must provide a specific reason for any denials or partial approvals. If the insurer does not respond by the end of the four calendar days, an Order of the Chair will be issued approving the prior authorization request.
If a Level 1 review denial is issued, the prescriber can appeal for a Level 2 review to the insurer’s Physician within ten calendar days. Like a Level 1 review, the insurer’s Physician shall approve, deny, or partially approve within four calendar days. Similar to a Level 1 review, any denial must be accompanied by the specific reasoning of the insurer’s physician. If the Insurer’s Physician does not respond by the end of the four calendar days, an Order of the Chair will be issued approving the prior authorization request.
If a Level 2 review is denial is issued, the prescriber may appeal for a Level 3 review to the Workers’ Compensation Board’s Medical Director’s Office within ten calendar days. The Medical Director’s Office will issue a final and binding decision. Upon a Level 3 denial, the prescriber cannot appeal the decision and the prescriber cannot seek prior authorization on the requested medication again unless there has been a change in the injured worker’s medical condition.
Upon any Level 1, 2 or 3 prior authorization approval, the payer would be liable for payment of the approved medication, however, upon any prior authorization denial, the party can deny payment of the requested medication.
The WCB has issued several materials for prescribers and payers in advance of the first implementation date to answer most frequently asked questions and provide guidance into the medical portal.
In addition to the materials issued by the WCB, IWP is ready to make this transition painless for your office and workers’ comp patients. Our team of clinical pharmacists are available to discuss alternative treatment options and answer any questions you may have related to the New York workers’ compensation drug formulary.