In May 2019, the New York State Workers’ Compensation Board released the much anticipated Drug Formulary, which was designed to provide high-quality and cost-effective medications. At that time, the New York Formulary compliance was limited to “new prescriptions.” Compliance in connection with refill and/or reoccurring prescriptions was set to apply on June 5, 2020.
Due to the COVID-19 pandemic, the Board moved the date for refill compliance with the Formulary to January 1, 2021. In November 2020, the Board suspended implementation of refill compliance to make system and process improvements, consider feedback of all stakeholders, and continue with outreach efforts.
As we move toward the second quarter of 2021, carriers and self-insured employers should be finalizing preparations for refill compliance under the Formulary. Any medication that the injured worker has been on in the past year is considered a refill. It should be noted that a change in dosage, upward or downward, is considered a new prescription and requires prior authorization if it is a non-formulary medication. Prior authorization is also required when: 1) The drug is not listed on the Formulary; 2) brand name drugs when generic drugs are available with the same active ingredient in different strength/dose; and 3) compound medications. Carriers/SIEs have the responsibility to notify every physician prescribing non-formulary medications and its objection to use non-formulary medications by December 1, 2019. If this step has not been taken, it should be done so immediately. Providers were given this waiting period to transition from a non-formulary medication to a formulary medication.
Notably, while the Formulary pre-authorizes use of certain medications on the list, all prescriptions remain subject to the New York Medical Treatment Guidelines and the 2014 Non-Acute Pain Management Guidelines. Continued review of overall compliance of medications will remain necessary.
Goldberg Segalla’s New York State Workers’ Compensation team continues to monitor information from the Board regarding the finalized date for implementation of the Formulary to refill medications. For more information on the New York State Workers’ Compensation Drug Formulary, please contact: