Legislation enacted in April 2017 required the New York State Workers’ Compensation Board to establish a drug formulary. The New York Workers’ Compensation Drug Formulary (Drug Formulary) is based on a medication’s effectiveness and appropriateness for the treatment of illnesses and injuries covered under the Workers’ Compensation Law.
The Drug Formulary drug list designates drugs as either “Phase A”, “Phase B” or “Perioperative.” Additionally, some drugs are listed as second-line therapy (2nd line) and may only be used when other drugs associated with the phase of treatment have been deemed ineffective. Drugs not listed on the Drug Formulary are considered non-formulary.
Formulary drugs do not require prior authorization. Prior authorization from the insurer or self-insured employer is required for:
- Drugs not listed on the Drug Formulary;
- A formulary brand name drug, when a generic is available;
- Combination products, unless specifically listed in the Drug Formulary;
- A brand name drug when a generic version with the same active ingredient(s) is commercially available in a different strength/dosage (e.g., a generic drug available in 5 mg and 10 mg, but brand name drug available in 7.5 mg would be considered non-formulary and could only be dispensed via prior authorization.); and
- Compounded drugs.
Application of the Drug Formulary
The Drug Formulary sets forth drugs in three lists: Phase A, Phase B and Perioperative. These three lists of drugs are considered formulary and can be prescribed per the following framework. For more detailed information about Phase A, Phase B and the Perioperative drugs, can be found in the New York State Workers’ Compensation Drug Formulary – Current Version.
Phase A Drug List
Drugs on this list may be prescribed and dispensed subject to the following:
- Within the first 30 days following an injury or illness or until the insurer accepts the claim or the Board establishes a claim, whichever occurs sooner.
- For up to a 30-day supply.
Phase B Drug List
Drugs on this list may be prescribed and dispensed subject to the following:
- After 30 days following an accident or injury or when the carrier has accepted the claim or the Board has established a claim, whichever occurs sooner.
- For up to a 90-day supply.
- When a body part or illness has been accepted (with or without liability) or established, drugs must be prescribed in accordance with, as applicable, the Workers’ Compensation Board’s adopted New York Medical Treatment Guidelines (MTGs).
- Phase B drugs designated as “2nd line” may be prescribed and dispensed following an unsuccessful trial of a first-line drug prescribed in accordance with Phase B and, as applicable, the adopted MTGs.
Perioperative Drug List
Drugs listed on the Perioperative Drug List may be prescribed/dispensed when:
- The drug is prescribed during the perioperative period (four days before through four days following surgery).
Drugs designated as “2nd line” may be prescribed and dispensed following a trial of a first-line drug prescribed in accordance with Phase B and, as applicable, the adopted MTGs.
Some drugs are marked with a Special Consideration indication. These include:
- “Not to exceed a single seven (7) day supply” – meaning that a specific formulary drug can be prescribed and dispensed one time only without a prior authorization, for a maximum of a seven-day supply, during the phase of the Drug Formulary under which it is contained (e.g., controlled substances);
- “For the prescribed course of therapy” – meaning that a specific formulary drug can be prescribed and dispensed, during the applicable phase of the Drug Formulary, for the quantity indicated by the provider (e.g., antibiotics);
- “Short acting only” – meaning that a specific formulary drug can only be prescribed and dispensed for the short-acting formulation of the product; and
- “As clinically indicated for causally related injuries or conditions utilizing accepted standards of medical care” – meaning that the item can be prescribed and dispensed when there is no adopted MTGs for the established/accepted body part or condition, and/or for a condition directly associated with an established/accepted body part, but not specifically addressed in the MTGs. (e.g., treatment of a post-operative infection following a knee replacement).
A medical provider must obtain prior authorization before prescribing or dispensing a drug other than as described in the Application of the Formulary section (see above), or when prescribing:
- A drug not listed on the Drug Formulary,
- A formulary brand name drug, when a generic is available,
- Combination products, unless specifically listed on the Drug Formulary,
- A brand name drug when a generic version containing the same active ingredient(s) is commercially available in a different strength/dosage, or
- A compounded drug.
If prior authorization is not obtained prior to the dispensing of the drug, the insurer or self-insured employer may deny payment.
Prior Authorization Process
A prior authorization request (PAR) is submitted by the provider as a Medication PAR through OnBoard, which may incorporate up to three levels of review. Detailed information is available about OnBoard on the health care provider's OnBoard Overview page and Medication PAR submission training page.
Level 1 Review
After the provider submits the Medication PAR in OnBoard, the Level 1 review has these requirements and time frames:
- The Medication PAR should include the quantity to be prescribed and the number of refills or the duration of the prescription. In no event may a request exceed 365 days.
- The insurer, self-insured employer or pharmacy benefits manager shall approve, partially approve or deny a Medication PAR within four calendar days of submission by the provider:
- A partial approval authorizes the requested drug, but limits the length of time, quantity prescribed or number of refills from that requested by the provider.
- A prior authorization request that is not responded to within four calendar days (by an approval, denial or partial approval) may be deemed approved as prescribed, not to exceed a 365-day supply, upon issuance of an Order of the Chair.
- A partial approval or denial of a Medication PAR must:
- Provide a specific reason for the denial or partial approval with reference to the specific prior authorization request made by the provider.
Level 2 Review
Within 10 calendar days of a denial or partial approval of a Level 1 review, the provider may request review of such denial or partial approval by the insurer’s physician.
The Level 2 review has these requirements and time frames:
- The Medication PAR shall include:
- Additional information from the provider further justifying the need for the requested non-formulary medication addressing the reason(s) stated in the Level 1 denial or partial approval.
- The insurer’s physician shall approve, partially approve or deny a prior authorization request within four calendar days of submission by the provider.
- A request for Level 2 review that is not responded to within four calendar days (by an approval, denial or partial approval) may be deemed approved as prescribed, not to exceed a 365-day supply, upon issuance of an Order of the Chair.
Level 3 Review – Review by the Board of a Medication PAR Denial or Partial Approval
Within 10 calendar days of a denial or a partial approval by the insurer’s physician of a Level 2 review, the provider may seek review by the Board’s Medical Director’s Office.
The Level 3 review has these requirements and time frames:
- The provider shall submit the Medication PAR to the Medical Director’s Office within ten calendar days of the Level 2 review partial approval or denial date.
- The request must include a response to the reason(s) stated in the Level 2 partial approval or denial.
- To ensure the timely review of requests, the Chair or Medical Director may designate private entities to evaluate such requests for review of partial approvals or denials of a Level 2 review, provided the entity has:
- The appropriate URAC accreditation or such accreditation/certification as designated by the Chair,
- Other demonstrated expertise and criteria established by the Board, and
- No conflict of interest related to the review and resolution of the request.
The decision by the Medical Director’s Office is final and binding on the provider, the insurer, self-insured employer and pharmacy network.
In the event a Level 3 Review is denied, the provider may not submit a Medication PAR for the same medication unless they submit evidence that there has been a change in the patient’s medical condition that renders the denial of the prior authorization request no longer applicable to the patient’s current medical condition.
- Drug Formulary (Effective 03/07/2022)
- Quick Guide to the Drug Formulary
- See all versions of Drug Formulary
- Drug Formulary Frequently Asked Questions (04/07/22)