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Subject Number 046-1371 Update: Effective Date of Formulary Refills and Renewals

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The Drug Formulary portions of this Subject Number have been superseded by Subject Number 046-1444 Adopted Amendments to 12 NYCRR 441.1, 441.2, 441.3, and 441.5 (Formulary Update and Medical Marijuana Clarification) released September 10, 2021.

February 16, 2021

Due to the COVID-19 pandemic, the Chair has delayed the effective date of section 441.3 of the New York Workers’ Compensation Drug Formulary (Drug Formulary) governing refills and renewals of medications. The new effective date for refills and renewals shall be June 7, 2021.

Insurers, self-insured employers and third-party administrators (payer) must notify health care providers and claimants (in accordance with the procedure set forth in section 441.3 of 12 NYCRR) of the new effective date on or before April 1, 2021. These notifications must be in the format prescribed by the Chair. Please see Injured Worker Formulary Notification and Provider Formulary Notification for the required format. On or after June 7, 2021, all refills or renewals of prescriptions must use a Drug Formulary medication unless prior authorization has been obtained before the date of the refill or renewal.

Opioid Prior Authorization Requests (PAR) and Tapering. When a PAR is submitted to continue opioids beyond the recommendations contained in the Workers’ Compensation Board’s New York Non-Acute Pain Medical Treatment Guidelines (MTGs), the payer should not deny such PAR on the basis that such prescription is not consistent with the Non-Acute Pain MTGs. Instead, the payer should grant or partially grant the PAR. This protects the claimant from the medical consequences from an abrupt stop of a long-term prescription.

In these cases, as more fully set forth in Subject Number 046-892, the payer may file a Request for Further Action by Carrier/Employer (Form RFA-2) with the box checked to request a hearing on the issue of opioid weaning.

Additionally, when a payer partially grants a PAR, the health care provider may seek Level 2 or Level 3 review of the partial grant when clinically indicated.

Clarissa M. Rodriguez