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New York Formulary in the Works

by
Optum Workers' Comp
| Apr 11, 2017

The New York legislature passed a late night budget agreement on Sunday, April 9, 2017, following several days of off-again on-again negotiations. Included in the adopted budget language was a provision directing the New York Workers’ Compensation Board to establish a comprehensive prescription drug formulary on or before December 31, 2017. The legislation directs the Board to include the following provisions in the formulary:

  • A tiered list of high-quality, cost effective medications that are pre-approved to be prescribed and dispensed
  • A list of non-preferred drugs that can be prescribed and dispensed with prior approval
  • A pharmacy reimbursement strategy
  • Administration of a prescription drug rebate program
  • Processes for pre-approval and drug utilization review
  • Limitations on the prescribing of compounded medications and compounded topical preparations
  • A process to permit an interested party to submit a request to the Board to alter or amend the status of a prescription drug from non-preferred to preferred

Most of these provisions mirror suggestions included in the Board’s formulary concept document released last year. The document received significant stakeholder feedback, however, the feedback was not made public. We, along with other stakeholders did express concern over blanket pre-approval of medications without establishing relatedness and appropriateness for the injury. Additionally we and others expressed concern about creating a reimbursement strategy involving regulating rebate regulations currently handled by private contracts between private parties, especially when the state has no direct financial interest or is a party to the transaction involving the medication. Finally, we are concerned allowing an “interested party” to submit a request to the Board to change the status of a medication from non-preferred to preferred runs a significant risk of politicizing a process which should be based on prevailing medical evidence. 

That being said, our experience has been that the Board is open to hearing from stakeholders and has, in most cases, adopted reasonable approaches to their pharmacy policies. We look forward to working with the Board as the rule development process takes shape. 

For questions or additional information, please contact Brian Allen at Brian.Allen@optum.com or at 801-661-2922.





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