N.Y. Comp. Codes R. & Regs. tit. 12 § 441.4

Current through Register Vol. 46, No. 25, June 18, 2024

Section 441.4 - Application of Formulary

The Formulary identifies drugs using the generic or chemical name. The Formulary organizes these drugs into three lists identified below and includes both prescription and over-the-counter drugs. Over-the-counter Formulary drugs should be billed directly to the carrier or its pharmacy benefits manager.

(a) Phase A: The drugs on this list may be prescribed and dispensed without obtaining Prior Authorization during the thirty days following an accident or injury or until the carrier accepts the claim or the Board establishes the claim, whichever is less, for up to a thirty days supply, subject to the following:

1. Controlled substances and muscle relaxants may not exceed a single seven-day supply of a Formulary drug. These medications are indicated on Phase A of the Formulary as "1" in the "Special Considerations" column.

2. Anti-infectives, including antibiotics and post-exposure medications, may be prescribed and dispensed in accordance with the prescribed course of treatment. These medications are indicated on Phase A of the Formulary as "2" in the "Special Considerations" column.

(b) Prior Authorization is required for any Phase A drug that is not prescribed in accordance with this subdivision.

(c) Phase B: The drugs on this list may be prescribed and dispensed, up to a 90- day supply, without obtaining Prior Authorization after 30 days following an accident or injury or when the carrier has accepted the claim or the Board has established the claim. When a body part or illness has been accepted (with or without liability) or established, drugs must also be prescribed in accordance with, as applicable, the adopted Medical Treatment Guidelines. Phase B drugs designated as "2^nd" Drugs may be prescribed and dispensed without Prior Authorization, following a trial of a first line drug prescribed in accordance with Phase B and, as applicable, the adopted Medical Treatment Guidelines.

1. Anti-infectives, including antibiotics and post-exposure medications, may be prescribed and dispensed in accordance with the prescribed course of treatment. These medications are indicated on Phase B of the Formulary as "2" in the "Special Considerations" column.

2. Prior Authorization is required for any Phase B drug that is not prescribed in accordance with this subdivision.

(d) Perioperative Formulary Drugs. Drugs listed as Perioperative Formulary drugs may be prescribed without Prior Authorization when prescribed during the perioperative period. The Perioperative period refers to the four days before and four days after the patient goes into the hospital, clinic, or doctor's office for surgery; with the day of surgery being day zero. Perioperative Formulary drugs may not be prescribed or dispensed outside of such perioperative period without Prior Authorization unless such drug is identified for the applicable Phase. Carriers should advise their pharmacy networks, including pharmacy benefit managers, when surgery has been authorized or scheduled.

1. Controlled substances and muscle relaxants may not exceed a single seven-day supply of a Formulary drug. These medications are indicated on the Perioperative Formulary as "1" in the "Special Considerations" column.

2. Anti-infectives, including antibiotics and post-exposure medications, may be prescribed and dispensed in accordance with the prescribed course of treatment. These medications are indicated on the Perioperative Formulary as "2" in the "Special Considerations" column.

N.Y. Comp. Codes R. & Regs. Tit. 12 § 441.4

Adopted New York State Register June 5, 2019/Volume XLI, Issue 22, eff. 6/5/2019