New York Codes, Rules and Regulations
Title 12 - DEPARTMENT OF LABOR
Chapter V - Workers' Compensation
Subchapter M - Pharmacy And Durable Medical Goods Fee Schedules And Appendices
Part 440 - Pharmacy Fee Schedule
Section 440.3 - Designated pharmacies
Current through Register Vol. 45, No. 52, December 27, 2023
(a) A self-insured employer or insurance carrier, or its agent, may designate one or more independent pharmacy, pharmacy chain, or pharmacy benefit manager that injured employees must use to obtain outpatient prescription medications, provided that the self-insured employer or insurance carrier:
(b) Each independent pharmacy or pharmacy chain designated under this Part must maintain a sufficient inventory such that it may service claimants without undue delay. Each designated pharmacy must either:
(c) A claimant shall not be required to obtain medications from a designated pharmacy:
(d) In any claim controverted by the self-insured employer or insurance carrier pursuant to Workers' Compensation Law Section 25(2), where the self-insured employer or insurance carrier will not reimburse the designated independent pharmacy, pharmacy chain, or pharmacy benefits manager for prescription medicines dispensed to the claimant until the controversy is resolved and the claim established, even under the provisions of Workers' Compensation Law Section 21-a, the self-insured employer or insurance carrier shall provide notice of this decision to the claimant with the notice that the right to compensation is controverted. Such notice shall be in the form prescribed by the Chair, and shall state that the self-insured employer or insurance carrier does not intend to reimburse the independent pharmacy, pharmacy chain, or pharmacy benefit manager it has designated while the claim is controverted and until it is established, and the claimant may elect to use a pharmacy not designated pursuant to this Part during the period that the claim is controverted. Prior to the filing of such prescribed notice, the claimant may be prescribed and dispensed and the insurance carrier or self-insured employer will be responsible for the cost (as set forth in section 440.5 of this Part) of medications from, as applicable, Phase A, B or the Perioperative section of the Pharmacy Formulary. In the event the claimant prevails on his or her claim, the self-insured employer or insurance carrier shall reimburse either:
(e) For purposes of this part, no remote pharmacy may offer purchases solely by email or online, but must provide an option to make purchases by telephone and mail order.
(f) Where a claim is apportioned between more than one self-insured employer or insurance carrier, the claimant may select among pharmacies designated under this Part by all such self-insured employers or insurance carriers liable for apportionment. If any such self-insured employers or insurance carriers have not designated any independent pharmacies, pharmacy chains, or pharmacy benefit manager under this Part, the claimant is not bound by any designation made under this Part.
(g) Any rebates or third-party revenue related to drugs dispensed through a contract for pharmacy benefit management and delivered to the designated pharmacy shall be passed through in full to the insurance carrier or self-insured employer in accordance with contract terms that document the methodology for such transactions. Carriers shall offset bills to insured employers by the amount of any passed-through rebate and third-party revenue. Such rebates and third-party revenue shall be reported at least annually to the carrier or self-insured employer and reported by the carrier or self-insured employer to the Chair upon request.
Amended New York State Register April 17, 2019/Volume XLI, Issue 16, eff. 4/17/2019
Amended New York State Register April 17, 2019/Vol. XLI, Issue 16, eff. 10/1/2019