7 Things to Know About the NYS Formulary Launch

The New York State formulary begins to go into effect for new prescriptions on December 5th. Here are the seven most important things you need to know to get up to speed ASAP.

1. The formulary was created to decrease opioid abuse and addiction in New York.
   According to the Department of Health, the number of opioid-related overdose deaths rose from 1,074 in 2010 to 3,009 in 2016—nearly a 180% increase. The soon-to-launch formulary will create restrictions around the medications that can be used to treat the injured worker’s diagnosis as a way to decrease the number of people who are introduced to opioids and become addicted.

2. The NYS formulary operates a little differently than other formularies.
   Traditionally, drug formularies simply outline a list of approved medications that can be used to treat any condition. New York’s formulary takes it a step further.

   The New York formulary outlines the drugs and supply times that are approved to treat specific conditions, within specific timeframes and contingent upon providing specific documentation. For example, if an employee breaks her ankle on the job, New York’s formulary now outlines specific medications and dosages that can be used to treat her sprained ankle within the first 30 days, after those first 30 days and before and/or after surgery.

3. The formulary includes three drug phases.
   The three phases are Phase A, Phase B and Perioperative. Each phase outlines the medications, supply time and amount of time before or after an injury occurred that medication can be prescribed as approved by the Board.

4. The new prior authorization process can involve up to three levels of review.
   The first level review is the initial request for prior authorization which can be done by either a payer or representative of the payer. This person should be a medical expert with extensive experience and knowledge on prescription drugs and their usage. (Our medical professionals act as Level One reviewers through their training in our Nurse Prescription Case Management NRxCM® program).  

   The second level review occurs when the prescription has been denied or partially approved and a provider requests it be looked at again. This time, it’s reviewed by the Carrier’s Physician.

   The third and final level review takes place when the prescription has been denied or partially approved once again and a provider has asked that it be looked at once more—this time by the Board’s Medical Director’s Office. Their decision is then considered final. 

5. The formulary will be managed through a portal.
   You will no longer be submitting forms for prior authorization requests. Instead, the Workers’ Compensation Board (WCB) is rolling out a portal over the next month which will be used to request, track and manage all prior authorization requests.

6. There are two critical dates to know: December 5th, 2019 and June 5th, 2020.
   On December 5th, the formulary will begin to go into effect for new prescriptions. This is also when first and second level review contacts need to be submitted and when carriers and self-insured employers need to 1) identify all claimants with prescriptions for drugs not listed on the formulary and 2) provide written notification to both the claimant and the prescribing medical provider.

   On June 5, 2020, refills and renewal prescriptions will need to be prescribed and dispensed in accordance with the formulary rules.

7. The formulary is not going anywhere.
   Which means it’s critical that you and your organization put a plan in place ASAP to navigate this new process.

Have any additional questions about the formulary? We go into more detail on the drug phases, prior authorization process and more in our formulary overview video below. Also feel free to shoot us a note—we’d be happy to connect you with one of our formulary experts.