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New York Workers’ Comp. Board Proposes Pharmacy Formulary

by User Not Found | Jan 04, 2018

The New York State Workers’ Compensation Board has officially proposed rules to establish a prescription drug formulary in response to legislation passed earlier this year. That legislation required the Board to “establish” the formulary on or before December 31, 2017; however, the rules propose effective dates of July 1, 2018 for new prescriptions and December 31, 2018 for refill and renewal prescriptions, regardless of date of injury. Those dates may be adjusted further as a result of the rule-making process.

The proposed formulary and related rules classify drugs as “preferred” (does not require prior authorization) or “non-preferred” (requires prior authorization), while also providing certain exemptions for “special fill” and “perioperative fill” medications (similar to California). In addition – brand name drugs with a generic available, compounds and drugs not listed on the formulary will all require prior authorization.

Unique to New York, under the proposed language initial prescriptions (prescriptions written when first seeking medical attention for a work related injury or illness) may be handled differently than subsequent prescriptions (refills of initial prescriptions or new prescriptions written subsequent to the first visit). The draft formulary table contains separate column sections for initial v. subsequent prescriptions. Additionally, the column section for subsequent prescriptions is further broken down by the applicable body part/section of the Board’s medical treatment guidelines.

For refills and renewal prescriptions of drugs prescribed prior to the initial July 1, 2018 proposed effective date, the rules will require the insurance carrier or self-insured employer to provide written notice to the injured employee and treating medical provider no later than October 1, 2018. The content is to include notice of the impending date and applicability of the formulary as well as a process for determining an equivalent preferred drug and the process to request prior authorization for a non-preferred or unlisted drug.

These are high-level observations, as our Government Affairs, Regulatory and Clinical teams are in the process of reviewing the proposed rules and formulary in detail. The rules are open for public comment until February 26, and we encourage our clients to also review the rules and submit comments to the Board. Copies of all of the relevant documents and information on how to submit comments can be viewed on the Board’s website here: http://www.wcb.ny.gov/drug-formulary-regulation/.  

For questions on this or other recent regulatory developments, please contact our Government Affairs team at AskGovtAffairs@optum.com


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