Current through Register Vol. 45, No. 52, December 27, 2023
(a) Universal
notice requirements when the self-insured employer or insurance carrier
designates an independent pharmacy, pharmacy chain, or pharmacy benefit
manager. The self-insured employer or insurance carrier shall provide notice to
potential claimants of its designated independent pharmacy, pharmacy chain, or
pharmacy benefit manager, in writing and in plain language, as follows:
(1) All insurance carriers that have
designated an independent pharmacy or pharmacies, pharmacy chain or chains, or
pharmacy benefit manager under this Part shall provide to all employers whose
employees will be required to use such pharmacy or pharmacies, a notice not
materially different than the form prescribed by the chair for such purpose.
All self-insured employers who have designated an independent pharmacy or
pharmacies, pharmacy chain or chains, or pharmacy benefit manager under this
Part, which their employees are required to use, shall prepare a notice
materially the same as the form prescribed by the chair as described in this
paragraph. Such notice shall include:
(i)
either the identity of all independent pharmacies and pharmacy chains
designated by the carrier, or where the carrier designates a pharmacy benefits
manager or other party, the identity and contact information for the pharmacy
benefits manager or other party, who shall provide a list of all pharmacies in
the employee's state to the employee in writing or electronically upon and in
accordance with an employee's request; and
(ii) a toll-free number and website where the
employee may access information regarding the procedures the employee must
follow to fill and refill prescriptions through a remote pharmacy or other
means, and may obtain a list of such pharmacies including their name, address
and phone number, searchable by geographic location and fully updated as of the
date at issue, in that employee's state.
(2) Each employer within seven days following
receipt of such notice, and each self-insured employer upon the designation of
an independent pharmacy or pharmacies, chain pharmacy or pharmacies, pharmacy
benefit manager, or other party under this section, must either:
(i) post the notice required in paragraph (1)
of this subdivision in the same location where the notice of workers'
compensation coverage required by section 51 of the Workers' Compensation Law
is posted; or
(ii) distribute a
copy of the notice to all employees in New York State by providing the notice
in paper format or sending it electronically; or
(iii) posting the notice on its employee
accessible intranet or internet website.
(3) If the designated independent pharmacies,
pharmacy chains, or pharmacy benefit manager change, the carrier or
self-insured employer, or its designee, must revise the notification required
by paragraphs (1) and (2) of this subdivision to reflect such changes. The
carrier or its designee shall provide such revised notification to all
employers whose employees are required to use such pharmacy or pharmacies or
pharmacy benefit manager. Such revised notification shall be posted or
distributed by each employer in accordance with paragraph (2) of this
subdivision. The designation of any new independent pharmacy, pharmacy chain,
or pharmacy benefit manager previously listed in the notice provided under
paragraph (1) of this subdivision, or the removal of any such pharmacy chain,
independent pharmacy, or pharmacy benefit manager, shall not be valid until
seven business days after such posting and distribution of the revised
notice.
(b) Individual
notice requirements for self-insured employers and insurance carriers. All
self-insured employers and insurance carriers shall provide the claimant upon
being informed that a work related accident, injury, or illness has occurred,
with a document, such as a pharmacy benefit card:
(1) identifying the self-insured employer or
insurance carrier; and
(2) listing
telephone and other contact information by which a claimant or pharmacy may
make inquiries concerning the workers' compensation coverage for the claimant.
If the self-insured employer or insurance carrier has designated an independent
pharmacy or pharmacies, chain pharmacy or pharmacies, or pharmacy benefit
manager, and requires the claimant to obtain prescription medicine from such
pharmacy or pharmacies or from a pharmacy affiliated with the pharmacy benefit
manager, the document shall include such information as necessary to notify the
claimant or pharmacies when the claimant attempts to fill a prescription, that
the self-insured employer or insurance carrier has made such designation,
including the website address and toll-free telephone number required by
paragraph (a)(1) of this section and any identifying code that the claimant may
be required to use when making purchases through a remote pharmacy. The
document may contain such accurate and relevant information in regard to the
workers' compensation coverage for the claimant as the self-insured employer or
insurance carrier deems appropriate, and shall be accompanied by such
explanatory information in easily understood plain language as is necessary to
explain how to use the document to purchase medication. In addition, upon
receiving notification of the claim, the self-insured employer or insurance
carrier shall provide the claimant a toll-free number and website where any
information about the designated independent pharmacies, pharmacy chains, or
pharmacy benefit manager can be obtained; and
(3) a list of designated independent
pharmacies or chain pharmacies that shall include pharmacies located within 15
miles of the claimant's place of residence or employment if the claimant
resides in a rural area or within five miles if the claimant resides in a
municipality which is an incorporated city or village having a population of
2,500 or more; and
(4) contact
information for any designated remote pharmacy.
(c) The requirement to use a designated
independent pharmacy, chain pharmacy, or pharmacy benefit manager, shall not be
effective until all notification requirements set forth in subdivisions (a) and
(b) of this section have been met.
(d) A self-insured employer's, insurance
carrier's, or employer's failure to comply with the notification requirements
of this Part may be subject to sanction by the chair in accordance with section
440.10 of
this Part. Such sanction may include a direction that reimbursement to any
pharmacy, pharmacy processing agent or other third party that paid for the
medication harmed by such failure to be at a rate greater than that provided to
designated pharmacies, although in no case more than the fee schedule, and the
costs to the harmed party resulting from the failure plus statutory interest.
In cases of persistent and significant non-compliance, such sanction may
include suspension or prohibition of the self-insured employer's or insurance
carrier's designation of pharmacies under this Part.
