New York is Changing How Medications are Managed

The change goes into effect in two weeks. Here is what you need to know:

Since 2020, the New York Workers’ Compensation Board has been promising to implement an entirely new, online process for requesting and approving authorization for tests in treatments in worker’s compensation claims.

After more than a year of delay due to the global pandemic, the Board has finally provided a timeline.

The new system, OnBoard Limited Release (OBLR) will be implemented in three phases, starting with Phase 1 on March 7, 2022.

Here’s what you need to know about what will happen on March 7.

  1. There will be a new formulary.
    The new formulary table contains several updates, including new diagnoses, new recommendations, and a new step therapy indicator (“3rd” – indicating that the medication requires prior auth until both a “Yes” medication and a “2nd” medication have been used).

    In theory, PBMs should already be aware of this, but it may come as a shock to some prescribers, as the current version of the formulary has been in place since April of 2020.

  2. The new Medical Treatment Guidelines (MTGs) will not go into effect yet.
    Over the past several months, the Board has adopted multiple MTG updates. The Board has delayed implementation of the new MTGs until Phase 3 of OBLR, which is planned for May 2, 2022.
  3. The formulary will apply to all fills – not just new fills.
    When the formulary was initially introduced in December of 2019, it only applied to new fills; it explicitly excluded refills and renewal fills of medications that patients had been taking prior to the start of the formulary.

    The Board intended for the formulary to apply to all fills as of June of 2020, but that date was pushed back multiple times.

    During that time, the Board also required payers/PBMs to mail out notices to prescribers and injured workers at multiple points to let them know that the formulary would (eventually) apply to refills and renewals.

    This month, the Board announced that March 7, 2022 would be the date that the formulary would apply to refills and renewal fills.

    Many prescribers have already made adjustments to bring medication regimens in line with the formulary.  Those that haven’t done so will need to prepare to begin submitting prior authorization requests (PARs) for those medications as of March 7.

  4. Marijuana will now go through the formulary prior auth process.
    In the past, providers could request prior authorization for medical marijuana by submitting a Form MG-2 to request a variance from the treatment guidelines.

    That made sense, as marijuana is not recommended by New York’s current treatment guidelines.

    As of March 7, marijuana requests will need to be submitted electronically via OnBoard. From there, the request will be processed as a “Medication PAR” under the equivalent of the existing formulary prior authorization process.

    This means that marijuana requests will be reviewed by an entity designated for level 1 medication PARs – typically a PBM.

    Note that marijuana currently is not on the New York formulary or recommended by the New York Medical Treatment Guidelines, so the odds of a marijuana PAR being granted are, by default, pretty low.

    For payers that wish for marijuana PARs to be approved, the most cost-efficient step may be to communicate that to their PBM or the personnel that handle their Level 1 medication reviews.

  5. Providers wishing to file a Form HP-1 dispute will now need to do so electronically.
    The paper form HP-1 will become obsolete as of March 7. As of that date, the Board will only accept electronic submission of the Form HP-1.0 via OnBoard.

    Providers will need to set up accounts on OnBoard (if they have not already done so) in order to file the Form HP-1.0 electronically.

Action Points to Consider:

  • Confirm that your PBM is ready to apply the new formulary on March 7. If there are any claim-specific exceptions that you’d like to have in place, make sure that those are communicated.
  • Make sure that your PBM partner has sent out the required notices to prescribers and injured workers re: the formulary’s application to refills and renewal fills. (If they haven’t, this may limit the ability to apply the formulary to refills and renewals in those claims.)
  • Have a plan for how to handle medical marijuana PARs. Are there situations/claims where you would prefer the PAR to be approved?  If so, make sure that this is communicated to the persons responsible for handling your Level 1 medication reviews.