New York Formulary Update March 2022

In early February, the New York Workers’ Compensation Board (WCB) announced an implementation program for their new OnBoard system. The innovative process will replace the WCB’s paper-based claims structures with a single, uniform web-based platform. OnBoard aims to improve accuracy and expand access to claim data in real-time, electronic self-service features to better interact with the WCB and reduce the amount of paper forms in order to respond to various stakeholder needs. 

To allow time to prepare and integrate systems, the WCB will rollout OnBoard in three phases commencing on March 7th and concluding to full capacity by May 2nd. The three phases will give guidance surrounding compliance measures and submissions. On Friday, March 4th, the drug formulary application within the medical portal will no longer be accessible. All prior authorization requests in progress will be suspended and converted to a medication prior authorization process (PAR) within Onboard. 

PHASE ONE starts March 7th – Drug Formulary Medication Prior Authorization

• Requires ALL prescription medication refills and renewals to comply with the state drug formulary. 
• Health care providers may request Board action on unpaid medical bills by submitting Form HP-1.0 via OnBoard. 
• Medical marijuana treatment for a workers’ compensation claim must be requested via OnBoard via a medication PAR. This change will replace the MG-2 variance request forms.

 PHASE TWO starts April 4th - Durable Medical Equipment Authorization

• Durable Medical Equipment, Orthotics, Prosthetics and Supplies (DME) fee schedule takes effect. Applies to the provision of medical supplies used to treat injury or illness that is work-related. Providers, vendors, and payers will utilize OnBoard to request, review, assign and respond to a PAR for a DME item.
• Delinks reimbursement for DME from Medicaid and binds it to the state-specific fee schedule. 
• Prior authorization will be required for items not listed in the DME fee schedule. 
• If a provider receives a partial approval or denial, they will have ten calendar days to file a request for an appeal.

PHASE THREE starts May 2nd – Treatment & Medical Treatment Guidelines (MTG) Variances

• Implementation of OnBoard will eliminate the use of these paper request forms and push prior authorization into the real-time electronic-based system.
• Part III includes the commencement of PAR requests for OnBoard regarding certain medical treatments and testing. As of now, providers and payers use various forms, including the C4-AUTH, HP-1, MG-1 and MG-2 to request authorization for medical treatment, testing, and variances from the MTG’s.
• Full use of OnBoard by providers for medical services and treatment variance requests will take effect.All requests and paper forms submitted prior to the implementation date will be permitted and would follow pre-OnBoard processes.

Providers, payers, and suppliers should be set up for the transition with the understanding that certain areas are subject to change as implementation progresses. For now, stakeholders should certify that registration is completed and best familiarize themselves with using the Onboard system. Providers should alert any workers’ compensation patients utilizing refill and renewal medications to prepare them for the drug formulary impact. Payers should discuss their drug formulary review procedures and reviewers to carry out PARs on medication refills and renewals. DME providers should be ready to handle orders/referrals from treating physicians to ensure that items requiring PAR are appropriately processed. They must also secure a NY Medicaid Provider ID within six months of April 4th and cite that information in their billing practices. 

Learn more about the New York Drug Formulary by watching our webinar.