Why Am I Having Problems with Getting My Brand Name Medication?

At MCV Law, we are often asked, “Why is the medication I have been taking for years now being denied?” An example is LYRICA.

Although Lyrica has been approved multiple times in the past, the rules changed on December 5th, 2019 when the New York Workers’ Compensation Board implemented a Drug Formulary and Medical Portal. The formulary and the state and federal mandates regulating medications that were designed for acute pain but have also been prescribed for chronic pain conditions have resulted in different standards and rules.

The medical provider is now required to follow the formulary process. To obtain approval for a Brand Name medical, the medical provider must set forth the exact reason the Brand Name medical has been prescribed. The reason needs to be more than “because it works better for the injured worker or the injured worker has better relief." Rather, the new rules require generic medications unless the provider can show a medical necessity for a brand name medication or evidence of adverse effects from the generic version.

The people reviewing the request for variations from the formulary are requiring an actual medical explanation of why one particular brand name drug works better for the injured worker and/or why the generic is counter-productive or has adverse effects. The fact is the process requires more than the medical providers usually offer.

The bottom line is that, while the new formulary defaults to generic medications, it is not impossible to get your brand name drug. To do so, however, the medical provider must be exact and thorough in setting forth the exact reasons the brand name drug is a medical necessity.

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