New York’s Drug Formulary is In Effect

Nancy Grover

Albany, NY (WorkersCompensation.com) – The much anticipated — or dreaded —drug formulary for the New York workers’ compensation system took effect this month. Stakeholders have expressed concerns and some confusion and were not entirely sure the formulary would be launched by today’s deadline until the N.Y. Workers’ Compensation Board affirmed the implementation shortly before the formulary went into effect.

As of Dec. 5, “all new prescriptions for injured workers in New York State must be listed within the NY WC Formulary unless an alternative medication has been approved through the NYS Workers’ Compensation Board’s new prior authorization process,” the Board announced. “Effective December 5, 2019, the electronic prior authorization process will be available to registered providers and carriers/self-insured employers through the Board’s Medical Portal.”

New York joins the 12 other states with workers’ compensation drug formularies. New York’s formulary is “a most interesting entrant,” said Lisa Anne Bickford, director of Government Relations for Coventry, in a webinar yesterday. “There’s Phase A, Phase B, and a perioperative phase,” that dictate what medications are allowed when. “There is second line therapy [drugs], which are only allowed when other drugs have been ineffective.” ‘Special considerations’ apply to medications such as opioids.

Then there are what Bickford called “branded generics, branded versions of previously existing generics redone.” For example, a medication that has been available in 7.5 mg has been redone in a 5 mg dose. “This is the first effort I’ve seen to do this.”

There’s also a multi-tiered prior authorization process. And an online portal for preauthorization.

“For our part, we can confirm that the Pharmacy Benefit Manager and Claims Administrator portions of the portal are up,” said David Price, director of Government Affairs for Preferred medical. “I haven’t seen the prescriber side of the Medical Portal first-hand, other than as it was shown in the WCB’s training materials.”

The prior authorization process includes three levels:

  • First level review. The provider submits a request to the insurer, self-insured employer or the pharmacy benefits manager and the request must be approved, partially approved or denied within 4 calendar days.
  • Second Level Review. The prescriber requests a review of a partial approval or denial, from the carrier’s physician.
  • Third Level Review. The provider seeks a review of the carrier physician’s denial or partial approval by the workers’ compensation board’s medical director’s office.

“We were able to get set up as the PBM/Level 1 reviewer for our N.Y. clients without issue,” Price said. “I know that our clients also have Level 2 reviewers set up and (to my knowledge) there was no issue in setting those accounts up.

“The good news is that we’re ready,” Price continued. We’ve assumed that we’ll see Level 1 requests coming in as of December 5, and the Board has been very responsive to questions that have popped up along the way. While we don’t expect any technical issues with requests coming through the WCB’s Medical Portal, we’ll certainly be looking out for any potential issues, and I suspect that the Board is ready to address any issues – and to answer questions – as they arise.”

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