The New York Workers' Compensation Board (WCB) has proposed the adoption of Part 441 of 12 NYCRR and amendment of Section 440.2 of 12 NYCRR to establish a drug formulary that includes high-quality and cost-effective preauthorized medication.
The new drug formulary requirements are applicable to all workers' compensation injuries regardless of date of injury or date of disablement.
The new drug formulary requirements are applicable to all workers’ compensation injuries as follows:
- On or after July 1, 2018, every new prescription shall be dispensed consistent with the Pharmacy Formulary regardless of the date of accident or disablement unless prior authorization is received to dispense a non-preferred or unlisted drug.
- On or after December 31, 2018, every refill and renewal prescription shall be dispensed consistent with the Pharmacy Formulary regardless of the date of accident or disablement unless prior authorization is received to dispense a non-preferred or unlisted drug.
The Formulary is a list of drugs that are designated as either “Preferred” or “Non-Preferred”. Additionally, some drugs are listed as second or subsequent line therapy and should only be used when the preferred drug has been deemed ineffective. Drugs not listed in the Formulary are considered “Non-Preferred”.
- “Preferred drug” means a drug on the New York Pharmacy Formulary that does not require prior authorization.
- “Non-Preferred drug” means a drug on the New York Pharmacy Formulary that requires prior authorization by the insurance carrier or self-insured employer before dispensing.
In addition, the State of New York (NYS) has included in its proposed Pharmacy Formulary rules regarding subsequent prescriptions. The prescriber will need to review the categories listed under “Subsequent Prescriptions” to see if the prescribed drug is appropriate for the applicable body part and, where applicable, in conformance with the NYS Medical Treatment Guidelines (MTGs). If “Yes” is listed for the body part, then the prescription may be obtained without prior authorization. If “Yes” is not listed for the body part, prior authorization is required.
To review the Proposed Adoption of Part 441 of 12 NYCRR (Drug Formulary), please click on this text: http://www.wcb.ny.gov/drug-formulary-regulation/