The New York Workers’ Compensation Drug Formulary (“Formulary”) is scheduled to take effect for all prescriptions in 2021. The effective date has been delayed with no set time in place currently.
So, what does this mean for your Workers’ Compensation claim? Drugs prescribed in accordance with the Formulary do not require prior authorization. However, your doctor must seek prior authorization for all medications that fall outside of the Formulary. This includes brand name drugs and compounded drugs. Your doctor also must seek prior authorization for any refills or renewals of any current medications that fall outside of the Formulary, even if you were taking these medications prior to the Formulary taking effect. This prior authorization must be submitted through the Medical Portal.
Once your doctor submits a prior authorization, the insurance carrier must approve, partially approve or deny the authorization request within four calendar days. If your prescription is denied or partially approved, you should call your doctor immediately and ask them to thoroughly respond to the reasons the medication was denied or partially approved. Your doctor is the only one who can address the issues raised by the carrier by submitting documentation through the Portal.
The denial or partial approval, along with your doctor’s response, then goes to the Second Level Review where the carrier’s doctor will review the request. The carrier again has four calendar days to respond. If the carrier partially approves or denies the prior authorization again, the provider may request a review of the partial approval or denial within ten calendar days.
The Third Level Review is performed by the Board’s Medical Director’s Office. The decision by the Medical Director’s Office is final and binding. Your doctor may not submit a new prior authorization for a medication that has been denied by the Medical Director’s Office unless there has been a change in your condition that renders the prior decision inapplicable.
With these changes, there can be some time between when you are prescribed a medication that falls outside the Formulary and when it is available at your pharmacy. If you are running out of a medication, speak with your doctor. Do not wait until you have run out. Remember, the carrier has four days to approve or deny a medication. If your doctor does not submit your medication through the Portal and you pay for the medication out of pocket, it is unlikely that the carrier will reimburse you.
Call your attorney’s office at the point of sale when you are having issues with filling your medication. This is when the attorney’s office can speak with the carrier to determine the issue. Your attorney’s office cannot aid in this process before the prescriptions are prescribed.
More information on the Formulary can be found here.
If you have questions about your Workers’ Compensation claim, call Lewis and Lewis at (716) 854-2100 today!
Key Takeaways:
- Anticipated in 2021, all prescriptions must go through the Medical Portal, even refills of medications you have been taking for years.
- The carrier has four business days to respond to a prior authorization for a prescription. Do not wait until you are out of your medication to see your doctor, as there may be a period you are without your medication.
- Your doctor is the only one who can address denials. When you receive a denial, call your doctor immediately and ask that they address the denial.
- If your doctor does not submit your prescription through the Portal and you pay out of pocket, it is unlikely you will be reimbursed.
