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Legislation enacted in April 2017 required the New York State Workers' Compensation Board to establish a drug formulary. The New York State Workers' Compensation Drug Formulary (Formulary) is based on a medication's effectiveness and appropriateness for the treatment of illnesses and injuries covered under the Workers' Compensation Law. Full information about the Formulary can be found at NYS Workers’ Compensation Drug Formulary.

To support the Formulary, a prior authorization process for requesting non-Formulary drugs is required. The three-level review process includes:

  • Level 1 Review - is performed by the payer and can be delegated to a Pharmacy Benefit Manager (PBM).
  • Level 2 Review - must be the Carrier’s physician. Please see regulations 441.1 (g) adobe pdf for the definition of the Carrier’s Physician.
  • Level 3 Review - is performed by the Board’s Medical Director’s Office.

The non-Formulary request process is fully electronic. The technology utilized automatically routes the non-Formulary request, and sends an email notification, between the requesting provider and the designated reviewer(s). The payer is responsible for designating and maintaining the Level 1 and Level 2 review contact information. This maintenance will be performed on the Board’s Formulary Administration application.

It should be noted that notifications and routing of prior authorization requests will be at the organization level. The Workload Administrator will receive all submitted prior authorization requests; these requests can then be assigned to a designated reviewer. All submitted requests will be visible via a dashboard that will contain high-level information about each prior authorization request and can be used by the Workload Administrator to assign the request to individual reviewers. Individual reviewers will also use a dashboard to respond to their assigned requests.

There are multiple roles designated within the Board’s Formulary Administration application, they include:

Role Responsibility
Payer User Administrator
  • Create and maintain Level 1 and Level 2 email contacts for routing and notifications
  • Assign users to Level 1 and Level 2 review roles
  • Maintain user administrator and workload administrator
Work Load Administrator
  • Responsible for assigning Prior Authorization Requests for review
PBM User Administrator
  • Assigns users to Level 1 review roles
  • Maintain user administrator and workload administrator
Reviewers
  • Review Level 1 or Level 2 requests (as designated and assigned)

Access

The Drug Formulary Prior Authorization system will be accessed via the Medical Portal. To access the portal users will need a NY.Gov ID. This ID will be provided to the user by the Board as part of the registration process.

Who Should Register for the Drug Formulary Prior Authorization System?

  • Payers - The claim administrator (insurer, self-insured entities, or third-party administrator) or their Pharmacy Benefit Manager if designated. The payer is ultimately responsible for the review of Formulary Prior Authorization. NOTE: A payer may designate a Pharmacy Benefit Manager (PBM) as a Level 1 contact, however the PBM must first complete the online PBM Formulary registration process.

    Organizational profiles for information within the Drug Formulary Administration Application have been built using the existing eClaims Trading Partner information. See Administrator responsibilities for more information.
  • Pharmacy Benefit Managers (PBM) - PBMs may be designated by the payer to review Level 1 Formulary Prior authorization requests. The PBM must register for access prior to a payer designating them as the reviewer.

User Administrator (Payer or PBM) Responsibilities

The User Administrators are responsible for creating and maintaining the required contacts and appropriate users needed to review and respond to Formulary Prior Authorization requests. The User Administrators are required to maintain accurate information within the application. The Formulary Prior Authorization requests will be routed using the contacts and users identified by the Administrator.

Administrator Log-In

Payer User Administrators

The Payer User Administrator is an employee of the insurer, self-insured employer, or Third-party Administrator (TPA). The Payer User Administrator will use the online Formulary Administration application to keep designated contact and user information up to date.

NOTE: The payer organizational profiles have been based on existing eClaims trading partner agreements, therefore the user designated as the eClaims Administrator will be the initial User Administrator for Formulary Administration. It will be this individual’s responsibility to add additional Payer User Administrator(s). It is recommended that multiple individuals be assigned to the role of Payer User Administrator. If an individual is no longer performing user administration for the payer, their access should be removed.

Responsibilities include:

  1. Maintenance of Organizational Notification Contact Information: The Board strongly recommends this be a shared email address. This address should be kept current as it will be utilized for routing Formulary Prior Authorization requests. This email address for Level 1 reviews may be the same for all associated entities or entered separately. The email address for Level 2 may also be the same for all associated entities or entered separately. As previously noted, the Level 1 and Level 2 email address cannot be the same.
    • Level 1 - Enter/update information in the following fields:
      • Current Email - Displays current email address for the Level 1 contact.
      • Email Should Be - Enter to update the Level 1 email address.
      • Name of PBM - Select the desired Pharmacy Benefit Manager (PBM). PBMs must have completed the PBM registration process before they can be selected by the payer within the Formulary Administration application.
    • Level 2 - Enter/update information in the following fields:
      • Current Email - Displays current email address for the Carrier’s Physician.
      • Email Should Be - Enter to update the Level 2 email address for the Carrier’s Physician.
    • Order of the Chair - Both the claim administrator AND insurance carrier must have emails listed. A notification that an Order of the Chair has been generated, requiring payment of a non-Formulary medication, will be sent to both entities.
  2. Maintenance of User Information - The User Menu will be accessed to add, modify or remove user information for the user types as follows:
    • Level 1 Reviewer - The individual(s) responsible for reviewing Level 1 Formulary Prior Authorization requests. If a payer designates a PBM for Level 1 review, the PBM User Administrator will maintain users within their organization profile that may review requests.
    • Level 2 Reviewer - The individual(s) responsible for reviewing Level 2 Formulary Prior Authorization requests. This must be the Carrier’s physician.
    • Work Load Administrator - The individual(s) responsible for assigning Prior Authorization Requests from the Formulary Dashboard to designated reviewers.
    • Online Administrator - The individual(s) responsible for keeping Formulary contact and user information updated in the online Formulary Administration Application.
    • User Information - Information related to each user includes:
      • Name
      • Address
      • Phone number
      • Email address

PBM User Administrators

PBM User Administrators will use the online Formulary Administration application to maintain and update their organizational and users’ information.

Responsibilities include:

  1. Maintenance of User Information - The User Menu will be accessed to add, modify or remove user information for the user types as follows:
    • Level 1 Reviewer - The individual(s) responsible for reviewing Level 1 Formulary Prior Authorization requests. If a payer designates a PBM for Level 1 review, the PBM User Administrator will maintain users within their organization profile that may review requests.
    • Work Load Administrator - The individual(s) responsible for assigning Prior Authorization Requests from the Formulary Dashboard to designated reviewers.
    • Online Administrator - The individual(s) responsible for keeping Formulary contact and user information updated in the online Formulary Administration Application.
    • User Information - Information related to each user includes:
      • Name
      • Address
      • Phone number
      • Email address

Pharmacy Benefit Manager (PBM) Registration

Online Registration Process

To access the online system to perform Level 1 Formulary Prior Authorization Request reviews, the Pharmacy Benefit Manager (PBM) must first complete an online registration.

All information must be complete and accurate.

  • PBM Organization Information - Enter information in the following fields:
    • Federal Tax Identification Number (FEIN)
    • PBM’s organization name
    • PBM’s address
  • User Information - As part of the registration process, PBMs may also designate; (1) User Administrator(s), (2) Work Load Administrator(s) and (3) Reviewers.
    • User Administrator - Accesses the online Formulary Administration application to add/remove users and to keep the PBM’s information up-to-date. It is recommended that multiple individuals be assigned to the role of PBM User Administrator.
    • Work Load Administrator - Assigns work within the Formulary dashboard.
    • Reviewer - Responds to assigned Level 1 requests within the Formulary Prior Authorization system.
  • Information required for each user includes:
    • Name
    • Address
    • Phone number
    • Email address

Confirmation of Submission to the Board

Upon submission of your registration, a confirmation that it was successfully submitted to the Board will appear in your web browser. If you do not receive confirmation of your submission in your browser, the application was not successfully submitted and you will need to resubmit.

After Application Has Been Submitted

It typically takes three to five business days for the Board to complete the review of a registration. Upon approval, emails will be sent to each user designated in the application with their Ny.gov ID, temporary password, and additional instructions related to their role.

NOTE: Until the Formulary Prior Authorization system becomes available (November 2019) the entering and updating of contacts and users, by the User Administrator (Payer or PBM) in the Formulary Administration application, will be the only functionality available. Updates about the Formulary Prior Authorization system will be posted on the Board’s website; please watch for more information. Additionally, you can subscribe for WCB updates to get notifications by email.

Register

General questions about the formulary should be sent to WCBFormularyQuestions@wcb.ny.gov.

Technical questions on the PBM Formulary Access process can be directed to WCBCustomerSupport@wcb.ny.gov.