November 18, 2020
As you are aware, legislation was signed in 2017 that required the New York State Workers' Compensation Board (Board) to establish a prescription drug formulary. After multiple public comment periods, the Board adopted the New York Workers' Compensation Drug Formulary (Formulary) regulations in May 2019. These regulations required new prescriptions to comply with the Formulary by December 5, 2019, and refill prescriptions to comply by June 5, 2020. Due to the COVID-19 pandemic, the Board moved the date for refill compliance with the Formulary to January 1, 2021.
As with any formulary, providers must have a way to prescribe non-formulary agents to treat worker-specific issues. To accommodate that need, a prior authorization process, using the Board's online Medical Portal, was implemented. To date, there have been nearly 40,000 requests by providers to use non-Formulary medications through the Medical Portal prior authorization process.
As the Board approaches the final step in Formulary implementation, refill compliance, it is taking some additional time to ensure that the Formulary and prior authorization process work for all stakeholders. Thus, the Board is temporarily suspending the January 1, 2021, date for refill compliance, and a new date (likely spring, 2021), will be announced soon. Between now and then, the Board will address feedback from providers and payers; make system and process improvements by aligning with the initial release of the Board's new business information system, OnBoard; and continue outreach and education to key users.
In the meantime, if providers have any difficulty getting needed medications for injured workers, or if payers have questions, please reach out to the Board's Medical Director's Office at firstname.lastname@example.org.
About the Formulary Prior Authorization Process
A full description of the Formulary and the prior authorization process, including two sets of Q&As, are posted on the Board's website. You are encouraged to review the Q&As as a reminder of associated prior authorization requirements and parameters.
To reiterate key points associated with the prior authorization process:
- Before prescribing a non-Formulary medication, a prior authorization request needs to be submitted and approved. Any and all requests for prior authorization must be submitted through the Board's Medical Portal.
- Providers are expected to provide a specific rationale for the need for a non-Formulary medication as part of the prior authorization request. Payers are expected to respond specifically to the provider's rationale. A denial response, such as "the medication is not on the Formulary," is not acceptable, as it is, in fact, the reason that the prior authorization request is being made.
- It is currently the payer's responsibility to communicate the final outcome of a prior authorization request to their pharmacy benefits manager (if one is utilized), so that there are no obstacles for the injured worker when they present at the pharmacy to get their medication.
- Currently, a prescription refill for a non-Formulary medication does not require prior authorization. Any medication that the injured worker has been on in the past year is considered a refill. It should be noted that a change in dosage, either upward or downward, is considered a new prescription and would require prior authorization if it is a non-Formulary medication.
- Formulary medications for established/accepted conditions do not require prior authorization. If a provider writes a prescription for a medication for a non-established/non-accepted body part/condition, the payer should notify the provider that the injured worker has not been accepted for that particular body part/condition.
- Formulary Special Consideration #4 should be used when there are no adopted New York Medical Treatment Guidelines (MTGs) currently in effect. Formulary medications marked with this Special Consideration are considered Formulary in the absence of MTGs, "as clinically indicated for causally related injuries or conditions utilizing accepted standards of medical care."
- While not required at this time, if a provider submits a non-Formulary prior authorization request for a medication refill, or for a medication that is considered Formulary, the payer should review and respond to the request.
Thank you for your ongoing efforts to ensure injured workers in New York State receive the medical care they need.