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Workers’ Compensation and your Prescription Drug Coverage Rights

Enacted in April 2017, New York State Workers’ Compensation Board established a drug formulary which is based on a medication’s effectiveness as well as the appropriateness for the treatment, illnesses and/or injuries under the Workers’ Compensation Law.

Within the New York State Pharmacy Formulary† (Formulary), a list of drugs are designated as either “Preferred” or “Non-Preferred” (Yes, or, No). In addition to these lists, some drugs are also noted as second or subsequent line therapy and should be used in times when the preferred drug has been declared ineffective for the injury and/or illness.

Can an Insurance Company Stop Paying for Your Pain Medication

While prescription drugs may be essential to your recovery process, their coverage could potentially be declined, even if you’ve used them previously and you’re seeking a refill.

According to the New York State Pharmacy Formulary, prescriptions are divided into categories called Initial Prescriptions and Subsequent Prescriptions. It is up to the medical provider to take the categories and prescription drugs into consideration not only for your recovery, but, also considering what could be denied.

Initial Prescriptions for Workers’ Compensation

Initial prescriptions are defined as prescriptions written for the first time while seeking medical attention for the work-related injury and/or illness. These initial prescriptions fall into three categories

:
  • First fill for a preferred drug.
  • “NYS Special Fill”: Drugs listed on the Formulary as a non-preferred drug but can be prescribed/dispense without pre-authorization if: (a) it is prescribed within seven days of the date of injury, and (b) doesn’t exceed the supply limit indicated on the Formulary.
  • “NYS Perioperative Fill”: Drugs listed on the Formulary as a non-preferred drug but can be prescribed/dispensed without pre-authorization if: (a) prescribed during the perioperative period (four days before, until four days after surgery), and (b) does not exceed the supply limit indicated on the Formulary.

Subsequent Prescriptions for Workers’ Compensation

These prescriptions are refills of the initial prescription or a new prescription that has been written following the first visit. They fall into two categories:

  • Preferred: With special attention to drugs listed as “preferred”, the prescriber is to review the categories listed under Subsequent Prescriptions to determine if it is appropriate for the body part and conforms with the NYS Medical Treatment Guidelines (MTGs). If it is not listed, prior authorization will be required.
  • Non-Preferred: If the prescription drug is not preferred, prior authorization is typically required. There are circumstances according to the Formulary and the MTGs for particular parts of the body and illnesses where the medication may be prescribed without prior authorization as long as it is not prescribed and/or dispensed as an initial prescription.
  • If additional medication is required, particularly if requirements are not met according to the Formulary and the MTGs it then becomes the insurance carrier’s responsibility to contact the medical prescriber. During which time they will need to discuss changing the prescription to a preferred drug or submitting prior authorization for the medication. They will also need to discuss continued authorized payment for the medication until the prescriber has either changed the preferred drug for the injury/illness or received the denial of the prior authorization request.

For additional information on handling your workers’ compensation and prescription drug coverage, contact our attorneys today. We are dedicated to each of our clients and determined to achieve the best outcome – the return of your health and mobility to the injured area.

References:

†: New York State Pharmacy Formulary