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New York Workers’ Compensation Board provides overview of Drug Formulary Prior Authorization System

by
The Policy Matters team
| Sep 04, 2019

As the procedures to implement the New York Workers’ Comp Drug Formulary continue to evolve, the New York Workers’ Compensation Board (WCB) has issued updated guidance and clarified requirements for all stakeholders. The WCB just released registration requirements and the roles various individuals and entities will play not only now, but once the formulary goes into effect in December 2019.

To support the formulary, a prior-authorization process for requesting non-formulary drugs is required. It will be at the organization level and will be handled through the dashboard of the portal. 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 regulation 441.1 (g) for the definition of the carrier’s physician.
  • Level 3 Review - is performed by the WCB’s Medical Director’s Office.

Multiple roles are designated within the formulary administration application, which include but are not limited to the following:

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 role(s)
Work Load Administrator
  • Responsible for assigning prior authorization requests for review
PBM User Administrator
(if utilized)
  • 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)



How do you gain access?
The Drug Formulary Prior Authorization system will be accessed via the medical portal. Users will need a NY.Gov ID, which will be provided to the user as part of the registration process.

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

After application has been submitted
It typically takes three to five business days for the WCB 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.

Until the Formulary Prior Authorization system becomes fully available (November 2019), entering and updating contacts and users, by the user administrator (Payer or PBM) in the Formulary Administration application, will be the only functionality available.

Moving forward
Optum supports the WCB in their efforts to provide information regarding the various formulary procedures and offer updated communications to help drive compliance among stakeholders. We suggest clients review this latest WCB release and register to receive future updates at http://www.wcb.ny.gov/content/ebiz/drugformulary/ .

As the drug formulary processes develop, the Optum Workers’ Comp and Auto No-fault Government Affairs team will continue to monitor the latest developments on behalf of our clients.

Should you have any questions regarding this or any other public policy development, please contact the OWCA Government Affairs Team at AskGovtAffairs@optum.com.


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