The New York Workers’ Compensation Drug Formulary (Drug Formulary) is arranged by therapeutic category and then by the generic name of the medication. The applicable phase for which each medication is included is then indicated by an "x" under the respective phase(s) of the Drug Formulary; Phase A, Phase B or Perioperative Phase.

Unless otherwise limited, generally Phase A formulary drugs may be prescribed for up to a 30-day supply and Phase B formulary drugs may be prescribed for up to a 90-day supply.

When a provider submits a Medication PAR for a non-formulary medication, the request can be submitted and approved for up to a 365-day supply; however, the prescription can only be written for a maximum of a 90-day supply. If a Medication PAR for a 365-day supply is approved, the clinician can write the prescription for a 90-day supply with three refills.

Medication PARs for controlled substances (NYS CII – CV) can also be approved for up to a 365-day supply. Providers would need to follow NYS Controlled Substances laws (e.g., NYS CIII – CV; 30-day supply with up to five refills, CIIs and benzodiazepines 30-day supply with zero refills). The 365-day supply Medication PAR could be approved, but multiple prescriptions would need to be written to encompass the 365 days.

Medication PARs must include a duration of therapy; this can be up to 365 days. At the end of the approved time period, a new Medication PAR would need to be submitted and approved. If a different non-formulary medication is requested, or the same medication for a different dosage, a new Medication PAR must be submitted and approved prior to dispensing of the prescription.

The New York Workers’ Compensation Drug Formulary (Drug Formulary) is based on a medication’s effectiveness and appropriateness for the treatment of illnesses and injuries covered under the Workers’ Compensation Law. Formulary drugs do not require prior authorization.

Prior authorization from the insurer or self-insured employer is required for:

1. A drug not listed on the Drug Formulary,
2. A formulary brand name drug, when a generic is available,
3. Combination products, unless specifically listed on the Drug Formulary,
4. A brand name drug when a generic version containing the same active ingredient(s) is commercially available in a different strength/dosage, or
5. A compounded drug.

All non-formulary medications must be approved by a Medication PAR before they can be prescribed and dispensed. Special Consideration 4 has been added to address the use of medication in non-MTG body parts.

Specifically, Special Consideration 4 indicates "As clinically indicated for causally related injuries or conditions utilizing accepted standards of medical care". Meaning the item on the Drug Formulary can be prescribed and dispensed:

• When there is no adopted MTG for the established / accepted body part or condition, and/or
• For a condition directly associated with an established/accepted body part, but not specifically addressed in the MTG.

Any time the dosage or frequency of a medication is changed (either upwards or downwards) it is considered a new prescription. As such, if the medication is non- formulary, a Medication PAR would need to be submitted and approved before the medication could be dispensed.

The provider can submit Medication PAR at any point they feel it is appropriate.

Yes, Drug Formulary compliance is required within the NYS-allowed parameters for physician dispensing.

Medications provided by the provider and administered in the office do not need to comply with the Drug Formulary; however, a variance may be required for these procedures.

If the provider writes a prescription for the patient to pick up the medication at the pharmacy and bring back to their office to be administered, an approved Medication PAR is needed for a non-formulary medication.

If a conflict exists between the Board’s New York Workers' Compensation Medical Treatment Guidelines (MTGs) and the Drug Formulary, the provisions of the MTGs shall prevail, unless the drug was prescribed in accordance with Phase A or Phase B of the Formulary.

Clinical circumstances for when narcotics would not require prior authorization are very limited. Providers should consult the Drug Formulary and the appropriate MTG to determine when a Medication PAR is required. Documentation must support that the patient who requires long-term narcotics demonstrates objective gains/maintenance of function with improved pain control consistent with the Non-Acute Pain MTG recommendations.

Special Consideration 3 states that only the short-acting form of the medication is considered in Phase A of the Drug Formulary. Therefore, if a long-acting form is desired a Medication PAR must be submitted and approved before the medication can be dispensed. The only permissible long-acting formulation is the use of Fentanyl patches in Phase B.

The Drug Formulary contains both prescription and non-prescription items (e.g., lidocaine 4% patches). If a formulary OTC is written on a prescription, the pharmacy should fill and process the prescription for the OTC item. Pain patches not specifically listed on the Drug Formulary would require prior authorization before they could be dispensed.

Long-term opioid prescriptions would need prior authorization, which can be for up to a 365-day supply.

Medical marijuana must be submitted as a Medication PAR through OnBoard.

Medications designated as "2nd" may be utilized after a "yes" for the associated MTG has been utilized.

Although there is no required duration of use for a "yes" drug, a "2nd" drug would be deemed appropriate if the "yes" drug has been tried by the injured worker and discontinued due to a provider documented:

• lack of efficacy or effectiveness, or
• diminished effectiveness, and/or
• an adverse event, or
• would be considered contraindicated because of the injured worker's comorbid condition(s).

To address this issue, Special Consideration 4 was added to the Drug Formulary - As clinically indicated for causally related injuries or conditions utilizing accepted standards of medical care. This means that the medication can be prescribed and dispensed:

• When there is no adopted MTG for the established / accepted body part of condition, and/or
• For a condition directly associated with an established / accepted body part, but not specifically addressed in the MTG.

Example: treatment of a post-operative infection following a knee replacement.

The Drug Formulary does not formally incorporate "Step Therapy". Although there is no required duration of use for a "yes" drug, a "2nd" drug would be deemed appropriate if the "yes" drug has been tried by the injured worker and discontinued due to a provider documented:

• lack of efficacy or effectiveness, or
• diminished effectiveness, and/or
• an adverse event, or
• would be considered contraindicated because of the injured worker's comorbid condition(s).

First line agents are identified in the adopted MTGs. Items within the identified therapeutic categories (i.e., NSAIDs) are delineated on the Drug Formulary.

If a request is denied, a substantially similar request should only be submitted with additional appropriate supporting clinical documentation and rationale.

Yes, that is correct. If a drug is not on the Drug Formulary, and the provider wishes to prescribe it, a Medication PAR should be submitted using OnBoard.

If for any reason, the provider does not agree with the Level 1 or Level 2 denial or partial approval of their request, and the provider submitted adequate justification for the request, they should request the next level review.

Occasionally, there is a bona fide, widespread, market unavailability of the generic version of a medication (and not merely a lack of the generic form at a particular pharmacy or pharmacy chain,) but the brand name version is readily available. The first priority is that the patient gets the medication they need. In such instances, the pharmacy may:

1. contact the prescriber to determine if there is a clinically equivalent, generic alternative in the Drug Formulary that is available; or
2. contact the insurer and/or PBM to determine whether the insurer/PBM would approve or partially approve the brand name form until such time that the generic form becomes available.

Alternatively, the insurer/PBM might issue a partial approval of the brand name form, for a duration long enough to cover Levels 1, 2 and 3 of the PAR review process, during which the prescriber can submit a PAR for the brand name form, which should include the following in the justification:

1. cite the widespread lack of market availability of the generic form;
2. explain why there are no available clinically equivalent, generic alternatives in the Drug Formulary; and
3. provide documentation that the patient and/or initial pharmacy unsuccessfully attempted to fill the original, generic prescription at alternate pharmacies.

If the insurer/PBM denies the PAR at the Level 2 Review, the insurer/PBM should provide documentation that either:

1. the originally requested, generic medication is available from a different pharmacy, and utilization of the alternate sourcing would not cause undue delay or hardship for the patient; or
2. that there is an available, clinically equivalent, alternative, generic medication in the Drug Formulary.

It should also be noted that a brand name drug may not be dispensed when a generic version of the same active ingredient is available in a different strength/dosage, that is yet another alternative.

If a prescription is received for a drug requiring prior authorization, and no Medication PAR has been submitted/approved, the patient should be referred to the physician.

If the provider does not request and receive a prior authorization for a non-formulary medication before writing the prescription, for a non-formulary medication the pharmacy may either:

1. refer the patient back to the provider or
2. reach out to the provider directly informing them that an approved Medication PAR is required before the prescription can be filled.

The Medical Portal can be accessed from the dropdown for “Online Services Log In”, found in the menu bar on the website, which will take the user to the NY.gov log in screen.

An overview of the Medical Portal, and specific information on getting an NY.gov ID and accessing the Medical Portal can be found on the Medical Portal page.

Each user of the Medical Portal is required to have their own credentials to access the Medical Portal. Providers will use the Medical Portal to request and renew Board authorization, to access the provider-specific dashboard in OnBoard and to submit Medication PARs and Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0).

Provider delegates will be able to access a delegate specific dashboard within OnBoard, draft PARs for the provider to submit, and submit Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0).

Yes, all Board-authorized physician assistants and out of state physician assistant’s will be able to access the Medical Portal. More information can be found under Who Can Do What on the Medical Portal Health Care Provider’s Overview page.

Yes, the Board encourages multiple users in each of these roles.

No specific qualifications are included in the regulation. However, the reviewer must be able to directly respond to the provider's submitted rationale for the request for the non-formulary medication.

Yes.

The Level 2 reviewer must be the "Carrier's Physician" as defined in Subchapter M of Chapter V of Title 12 of NYCCR Part 441.1(g).

Payers are responsible for designating their Level 1 and Level 2 reviewers. The Level 2 review must be conducted by the “carrier's physician”, there are no specific requirements for who may perform the Level 1 review. See Access and Administration: Payers for information regarding medical review organizations (MRO).

The OnBoard application is accessed from within the Medical Portal. Therefore, all users of OnBoard need to be registered to access the Medical Portal. MROs will need to request access, as a user of their organization, for anyone that will be performing a reviewer function on their behalf. This is the only way the MRO’s designated workload administrator can assign a PAR to an individual reviewer. Reviewers are expected to enter their own decisions.

OnBoard will only support one PBM and/or MRO per insurer/TPA, therefore, the insurer/TPA will need to identify one PBM and/or MRO for each insurer W number. If they require services from more than one, the insurer/TPA would need to add the users of the other unassigned PBMs or MROs as users under their own organization so PAR reviews can be assigned to those users.

PARs will be sent to both the payer and the designated PBM/MRO. The payer is encouraged to have at least one Workload Administrator with a reviewer role, or a Level 1 and Level 2 reviewer, so that if an issue arises the payer can respond to the request. The responsibility to respond within the designated timeframe always falls on the insurer, regardless of whether they have a PBM or MRO. However, if the request is sent to a PBM/MRO and the payer responds to the request, the PBM/MRO will lose the ability to review and respond to the PAR.

Yes, PBM’s must be registered for the Medical Portal so the payer may designate them as their Level 1 reviewer for Medication PARs.

Effective March 7, 2022, all medications (new, refills and renewals) must comply with the Drug Formulary. All medication prior authorization requests (PAR) must be submitted through OnBoard. The Board will take no action on requests for medication submitted on an MG-2 or C-4 AUTH.

The “PAR Status Date.” is the date the PAR entered its current status. “Due Date” is the date the insurer needs to respond to the PAR, or the date the provider must escalate by, if requesting next level review.

Yes, If the four-day turnaround for response (Level 1 or Level 2) has not been complied with and an Order of the Chair is issued, the provider, Pharmacy Benefits Manager and Insurer will receive a notification and the PAR Status on the OnBoard dashboard’s “Resolved” tab, will be “OOTC Issued – Granted”.

OnBoard does not currently have the capacity to verify whether a drug that is requested requires prior authorization. The drug not needing prior authorization should not be utilized as a reason to deny the Medication PAR.

Medication PARs which have not received a final determination, will remain on the provider’s “Active” tab and the payer’s “MyPARs” tab. Once the PAR has received a final decision, it will appear on the “Resolved” tab. At this time PARs will remain on the “Resolved” tab indefinitely.

All insurers and self-insured employers are required to use OnBoard to process Medication PARs for non-formulary medications.

The regulation does not specify a specific time frame. The Medical Director’s office (MDO) strives to respond to all requests expeditiously in the order that requests are received.

The most recent decision stands unless the provider requests a higher-level review.

All new Medication PARs, whether for a medication previously submitted or a new medication never before submitted, would be a Level 1 review.

The dashboard defaults to show PARs based on Due Date but can be sorted by any column on the dashboard. If the status of a PAR has changed since the last time you logged in, the row will be displayed in bold.

If an Order of the Chair is issued, the provider, Pharmacy Benefits Manager and Insurer will receive a notification and the PAR Status on the OnBoard dashboard’s “Resolved” tab, will be “OOTC Issued – Granted”.

OnBoard automatically tracks the time frames associated with the process. The due date and status of a submitted PAR can be found on the Dashboard.

When submitting a Medication PAR or requesting next level review of a denied or partially approved Level 1 or Level 2 request, the provider must directly respond to the reviewer's rationale for the denial or partial approval. This can be done by either entering free text onto the Medication PAR and/or attaching supporting documentation.

More information can be found on the Provider’s OnBoard training page for Medication PARs.

All providers submitting Medication PARs will do so using OnBoard. See a list of provider types that can submit Medication PARs.

The provider must provide relevant clinical information to support the request which may include narrative, progress notes and other supporting documentation (e.g., symptoms, justification for initial or ongoing treatment, diagnostic testing, equipment, etc.), any contraindications or adverse effects experienced, and if applicable, evaluation of efficacy of previous treatment or medication. This can be either entered as free text and/or as an attachment to the Medication PAR.

Although the form does not limit the number of medications that can be added, each medication requested will be submitted as a separate Medication PAR.

More information can be found on the Provider’s OnBoard training page for Medication PARs.

When a provider requests multiple non-formulary medications for a single patient, a separate Medication PAR is submitted for each medication. Each non-formulary Medication PAR must contain supporting documentation to justify the request for the non-formulary medication.

More information can be found on the Provider’s OnBoard training page for Medication PARs.

Requests for non-formulary medications should be submitted by the provider before the prescription is written.

No, any provider who practices within NYS and is eligible for Board-authorization, must be authorized to submit a Medication PAR. See Expanded Provider Law and Who Can Submit Medication PARs.

The workload administrator is responsible for assigning (or reassigning) reviews. The Board recommends that an entity identify multiple workload administrators and multiple reviewers.

More information can be found on the OnBoard training page for Workload Administrator: Assigning PARs.

The Workload administrator will assign the PAR to a reviewer. If there is a need, the Workload Administrator can reassign the PAR to another reviewer.

More information can be found on the OnBoard training page for Workload Administrator: Assigning PARs.

All transactions associated with a Medication PAR (i.e., submission and review) are done on using OnBoard.

Only the workload administrator can assign/reassign reviews. However, an individual can be both a workload administrator and a reviewer.

More information can be found on the OnBoard training page for Workload Administrator: Assigning PARs.

Yes. More information can be found on the OnBoard training page for Workload Administrator: Assigning PARs.

The review can opt in to receive email or text message notifications when a new item has been added to their dashboard. See OnBoard training Notifications for Updates to Dashboard.

All responses, whether approved, partially approved or denied, should be submitted through OnBoard.

The medication should be approved (since it’s on the Drug Formulary), but the provider should be informed that prior authorization is not required since the medication is considered a formulary drug.

Providers often use the brand name as shorthand for entering the name of a medication. Whatever is indicated as “Type of Drug” should be used for the response to the Medication PAR.

Order of the Chair notifications get emailed to the address provided by the Online Administrator in the Order of the Chair Notifications section.

Level 3 determinations will appear on the reviewer’s Resolved tab within OnBoard. They may also receive an email or text notification based upon their preferences selected on their My Profile within OnBoard. See OnBoard training Notifications for Updates to Dashboard.

All reviews need to directly respond to the rationale submitted by the provider for the request.

Medication PARs and requests that were completed in the former Drug Formulary application, can be found within the claimant’s case folder in eCase.

All time frames are calendar days, which include weekends and holidays.

If the Level 1 or Level 2 review does not occur in the designated time frame, an Order of the Chair would generally be issued within one business day.

A Medication PAR may be submitted at any time.

The provider does not select the reviewer. The request is automatically routed based on claim information received from insurer. The clock starts when the provider submits the request.

Onboard: Limited Release is being released in three phases.

Phase 1 effective March 7, 2022: Medication Prior Authorization Requests and Requests for Decision on Unpaid Medication Bill(s) (HP-1.0)

Phase 2 effective April 4, 2022: Durable Medical Equipment PARs

Phase 3 effective May 2, 2022: Treatment/Testing PARs, replacing the MG-1, MG-2 and C-4 Auth forms.

Upon completion of each step in the process (e.g., submission of the request, decision of the Level 1 reviewer, provider's request for review of Level 1 denial, etc.), the Medication PAR is filed in the injured worker's case folder. The injured worker's case folder is available to all parties of interest who have eCase access.

No, Attorneys will not have access to OnBoard: Limited Release, however, all transactions associated Medication PARs are filed in the claimant’s case folder. See more OnBoard Information for Attorneys.

The primary insurer will be responsible for responding and for obtaining reimbursement from the secondary insurer.

Each medication considered formulary for the medical treatment body part is indicated with a "yes" on the Drug Formulary.

If the case has been established by the Board, all accepted body parts are returned in the case search. If the case has not been established, information from the claim administrators First Report of Injury (FROI) is provided. If the Board or claim administrator updates the information, the updated information is returned the next time a case search is performed.

The provider selects the applicable body part when completing the PAR.

The provider will do a case search and associate the request for the non-formulary medication with the selected case. A Medication PAR submitted on a wrong claim may be denied by the insurer.

The provider is responsible for communicating medication status to the patient.

It should be expected that if the Level 1 or Level 2 requests are not responded to in the allocated time frame, that an Order of the Chair will be issued.

All providers treating NYS workers' compensation patients are required to comply with the Drug Formulary and established prior authorization process. If an injured worker presents at the pharmacy with a prescription for a non-formulary medication for which a Medication PAR has not been submitted and approved, the injured worker should be referred to their provider.

Out-of-state patients will continue to get their prescriptions as they currently do. These prescriptions will need to comply with the Drug Formulary and utilize the Medication PAR process for non-formulary medications.

Yes, out-of-state providers need to comply with the Drug Formulary and are required to use OnBoard to submit Medication PARs for non-formulary medications.

Yes. See what dentists can do in OnBoard.

Unfortunately, there is no simple answer since each patient’s clinical situation is different. The prior authorization process (which should be reviewed based on documentation of medical necessity and consistency with the MTGs as applicable), should not be utilized as a mechanism for abruptly discontinuing medications as a means of enforcing weaning directives.

Any time a patient has been on long-term opioids, review of a Medication PAR should be based on the information that the provider submits as part of the Medication PAR and the medical facts of the case.

When there is a weaning directive in place which has not been implemented, the insurer should work directly with the provider to ensure that a specific weaning approach is developed and implemented. There should be ongoing dialog and mutual agreement/understanding between the provider and insurer about how a tapering/discontinuation plan will be implemented. Again, the prior authorization process should not be utilized as a mechanism for abruptly discontinuing medications as a means of enforcing weaning directives.

When responding to a Medication PAR where a weaning directive has been issued, a copy of that directive must be attached in the response back to the provider.