Breaking Down New York’s Workers’ Compensation Drug Formulary

FORMULARY UPDATE: OnBoard Rollout March-May 2022

After a series of delays, the NY WCB announced in February some new policies and rules that will coincide with the release of OnBoard. The OnBoard system converts the WCB’s paper-based system to an innovated web portal to modernize and serve injured workers more efficiently. To ensure a smooth transition, the WCB will rollout OnBoard in three phases commencing March 7 and concluding May 2.

Phase One on March 7 will focus on the prior authorization process known as PAR. It is expected that PAR will transfer with ease from the current Medical Portal process to the OnBoard system. Providers, payers, and other stakeholders should note that their current processes will be transferred to the onboard system at this time. Other changes effective on March 7 include

• All prescription refills and renewals be compliant with the state drug formulary.
• Medical cannabis treatment for a workers’ compensation claim must be requested on OnBoard via a medication PAR.
• Health care providers may request Board action on unpaid medical bills by submitting Form HP-1.0 on OnBoard.

Phase Two on April 4 will bring the durable medical equipment, orthotics, prosthetics, and supplies (DME) fee schedule into effect. This change applies to the provision of all medical supplies utilized to treat a work-related injury or illness. Similar to medications, providers, vendors, and payers will operate OnBoard to request, review, assign and respond to a PAR for a DME item. Payers will have four days to approve, partially approve or deny a request. A provider will be given ten days to file an appeal if necessary. DME providers must obtain a NY Medicaid Provider ID within six months from April 4, 2022.

Phase Three completes the OnBoard rollout. This step will include the introduction of PAR requests via OnBoard for specific medical treatments and testing. All requests and paper-based submissions sent before the implementation date will be accepted and follow pre-OnBoard procedures. Stakeholders should ensure they are registered and become familiar with the new web-based system.

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Original Article published March 13, 2020.

Starting December 2019, New York implemented a workers’ compensation drug formulary, which has had a widespread effect on the overall process required for injured workers to receive timely and efficient care post-injury. Health care providers are now spending already precious time making sense of the complex formulary, while also trying to diligently understand and access the state’s Medical Portal for prior authorization requests.

The Medical Portal is a web-based application that enables users to submit medical information, mainly prior authorization requests, and to view Workers’ Compensation Board information electronically in real-time. The Medical Portal is intended to create more efficient processes, to enable higher levels of self-service and tracking, and ultimately to improve the performance of the NYS workers’ compensation system overall.

Since the first formulary implementation date for new prescriptions, providers noticed that many of the medications historically linked to treating work-related injuries, such as muscle relaxers and opioids, now require prior authorization. These rules can delay a patient from receiving care. 

Although the new process can seem daunting, here at Injured Workers Pharmacy, we serve as a resource for both the patient and their health care providers during this somewhat tricky transition. New York’s final implementation of the drug formulary has been delayed and a new date for the final implementation has not yet been set. However, IWP will be ready for the final implementation date. For all refills and renewals, the information listed below will better assist you and your office staff in navigating the New York Workers’ Compensation Board prior authorization process. 

ACCESSING THE MEDICAL PORTAL FOR HEALTH CARE PROFESSIONALS

Step 1: Visit the New York State WCB website by clicking here

Step 2: On the top page navigation, select “Providers.”

Step 3: On left-hand side of the page, Select “Medical Portal Overview.”

Step 4: Scroll down until you reach the “Sign Up For The Medical Portal” link – click the link.

Step 5: Follow the helpful guidance before proceeding.

GENERAL INFORMATION ABOUT THE MEDICAL PORTAL

Q: What information will a health care provider need when setting up an account?

• A NY.gov ID and temporary password will be generated for new providers as part of the signing up process; this ID will be separate from any other NY.gov ID a user may already have, such as for DMV, Clinical Service Applications, etc.
• Providers will be prompted to provide their Department of Health – Health Commerce System (HCS) user ID if the health care provider is registered with the Department of Health

Q: What will a health care provider gain from accessing the portal?

• Submit patient medical information and view WCB information electronically with status updates
• Apply to become a board authorized provider
• Renew provider workers’ compensation board authorization and/or update their information
• Access the NY WCB Drug Formulary, Medical Treatment Guidelines (MTGs), and other resources

Q: Who has access to the Medical Portal?

The information listed in the medical portal is available to a variety of Board stakeholders such as:

• Medical providers
• Payers, such as insurance carriers, Pharmacy Benefit Managers (PBM), and third-party administrators (TPAs)
• Self-Insured Employers

It is also important for health care providers to understand that pharmacies are not provided access to this portal and cannot retrieve updates based on claims submitted. 

Q: What are some of the common issues that have arisen in the first three months since implementation?

• Approval Process for Portal: Once a physician has signed up to create an account, this can take up to 5 business days for approval. Based on this time frame, it is advised that any health care provider who may be treating an injured worker register as soon as possible to avoid any interruptions in care.
• 7-Day Supply Consideration: A situation may arise that requires a patient to start therapy that will require prior authorization, such as a muscle relaxer or an opioid therapy. In those cases, a physician can authorize a 7-day supply of the medication while the prior authorization is received and reviewed by the WCB to limit any delays inpatient care. The special considerations for this would include that it would only be a maximum of a one-time 7-day supply, be prescribed within the proper course of therapy, and be a short-acting only product.
• Naloxone Treatment: Oftentimes, a physician may find it appropriate to consider prescribing Naloxone or “Narcan” for a patient while they receive opioid therapy. Based on the WCB guidelines, they do support the use of Naloxone therapy; however, at this time, it would still require a prior authorization request.

SUBMITTING YOUR PRIOR AUTHORIZATION TO IWP

Once approval is granted, please submit a copy of the approval to IWP via your preferred method:

Fax: 800-497-4276

Email: priorauth@IWPharmacy.com 

We will begin processing the medication when both the prior authorization and prescription are in-house. 

Our knowledgeable Pharmacy team is always available to assist with questions you may have related to the New York workers’ compensation drug formulary or suitable alternatives for your patient. Please do not hesitate to contact our team at 888-321-7945 or use our Contact Us page to speak with a Pharmacist directly. 

*This blog has been updated to reflect changes in the final implementation of New York's workers' compensation drug formulary.