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 440.8 - Payment of bills

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Bills for
				  prescribed medicine shall be paid in accordance with the fee schedule
				  established by section
				  440.5  of
				  this Part and section
				  325-1.25 
				  of Part 325 of this Chapter. Objections to a bill for prescribed medicine shall
				  be filed in accordance with section thirteen-g  of the Workers' Compensation Law
				  and section
				  325-1.25 
				  of Part 325 of this Chapter.
(b)
				  Effective date. This regulation shall be effective on January 1,
				  2020.
(c) When a self-insured
				  employer or insurance carrier, receives a bill or reimbursement request from a
				  pharmacy, third party, pharmacy benefit manager or pharmacy processing agent
				  that has not been designated by the self-insured employer or insurance carrier
				  to dispense prescription medicines, it must notify such pharmacy and its
				  billing agent, if any, third party, or pharmacy benefit manager by the method
				  used to pay and receive bills and reimbursement requests, that the self-insured
				  employer or carrier requires the claimant to obtain his or her prescription
				  medicines from an independent pharmacy or pharmacy chain designated by, or
				  affiliated with a pharmacy benefit manager designated by, such employer or
				  carrier and the claimant was provided with the notification required by section
				  440.4  of
				  this Part. Notwithstanding any provisions to the contrary in this Part, the
				  self-insured employer or insurance carrier shall pay a bill or reimbursement
				  request submitted by a pharmacy or third party at the fee schedule rate where
				  the prescription was dispensed before the pharmacy and its billing agent, if
				  any, or the third party that submits the bill or reimbursement request received
				  notification that the self-insured employer or insurance carrier requires the
				  claimant to use a designated independent pharmacy, pharmacy chain or pharmacy
				  benefit manager. The pharmacy and its billing agent, if any, or the third party
				  that submits the bill or reimbursement request is deemed to have received the
				  notification required by this subdivision five business days after the date of
				  the notice. The self-insured employer or insurance carrier is not obligated to
				  pay any bill or reimbursement request for a prescription medicine dispensed
				  after the date the pharmacy and its billing agent, if any, or the third party
				  that submitted the bill or reimbursement request is deemed to have received the
				  notification required by this subdivision. In the event the prescription was
				  dispensed more than 90 days following such individual notification of the
				  claimant for controlled substances and 60 days following individual
				  notification of the claimant for non-controlled substances, the carrier or
				  self-insured employer shall not be liable.