New York Formulary Flash

Drug News from Preferred Medical …

The New York Workers’ Compensation Board announced on November 18 it is “temporarily suspending the January 1, 2021, date for refill compliance, and a new date (likely spring, 2021), will be announced soon.” The original May 2019 regulations set the date for refill and renewal prescription compliance with the drug formulary as June 5, 2020. Due to the impacts of COVID-19, the date was then moved to January 1, 2021. Now the date is to-be-determined.

Per the Board, the rationale for this latest deferral is that “it is taking some additional time to ensure that the Formulary and prior authorization process work for all stakeholders” as they address provider and payer feedback. The Board is also “aligning with the initial release of the Board’s new business information system, OnBoard” which will consolidate the prior authorization process of all treatments (including prescription medications). This means the most recent delay is strategic rather than pandemic-related.

In communication with stakeholders, the Board has confirmed this deferral affects both refills and renewal prescriptions. However, any change in medication (must be the same name) or dosage would constitute a “new” prescription rather than a refill or renewal and therefore be subject to the formulary.

To summarize:

  • “Refill” = An additional fill ordered by the prescriber at the same time that the initial fill was ordered; the number of refills must be explicitly included in the prescription.
  • “Renewal” = Additional fill(s) for a medication that the injured worker has been taking where there are no available refills and so the prescriber writes a new prescription.

This means the only fills subject to the New York work comp drug formulary until further notice are fills for “new” (initial) prescriptions.

As mentioned, the Board is transitioning to a new claims administration platform called OnBoard. During OnBoard’s limited release – anticipated in spring of 2021 – the Board will eliminate all paper processes for requesting authorization of treatment and require those requests to be submitted via OnBoard. This is also when the Board intends to implement prior authorization requirements for certain durable medical equipment (DME).

If the Board’s projected dates are accurate, this likely means refill and renewal prescriptions will become subject to the formulary around the same time that the Board implements the new DME prior authorization requirements and transitions all prior authorization requests to the new OnBoard platform.

Fortunately, many prescribers are already submitting formulary requests electronically through the Board’s “Medical Portal.” The Board assured stakeholders on a November 19 webinar that those providers who currently have access to the Medical Portal will automatically have access to OnBoard when it is released so the transition should be somewhat easier.

OnBoard will ask providers to answer a series of questions to help direct them to the appropriate request type so requests do not get run through the wrong process. This is important because different request types require different information, and every request type other than formulary/medication requests will be automatically assigned to a “second level” clinician review if the request is not approved. If it is a medication request, second level review is not automatic – the burden is on the prescriber to appeal the denial for a second level review.

The outlier in all of this is marijuana. Currently, cannabis treatment is subject to a variance request (MG-2) since the Board’s Medical Treatment Guidelines do not support it. The Board has suggested that, upon OnBoard’s limited release, a marijuana treatment request will instead be submitted as a medication request, meaning that it could be denied through the “first level” review process that is often delegated to PBMs. But that is a different story for a different time.

Stay tuned as we continue to follow the intricacies of New York.