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 440.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
(a) "Average
				  Wholesale Price" or "AWP" means the average wholesale price of a prescription
				  drug as provided in the most current release of the Red Book published by
				  Thomson Reuters or Medi-Span Master Drug Database by Wolters Kluwar Health or
				  any successor publisher, on the day a prescription drug is dispensed or other
				  nationally recognized drug pricing index adopted by the Chair or Chair's
				  designee.
(b) "Brand name drug"
				  means a drug for which an application is approved under the Federal Food, Drug,
				  and Cosmetic Act Section 505(c).
(c) "Calculated cost" means the Average
				  Wholesale Price for the national drug code of the prescription drug or medicine
				  on the day it was dispensed plus a dispensing fee. For brand name drugs the
				  Calculated cost shall be AWP minus twelve percent of the Average Wholesale
				  price plus a dispensing fee of four dollars. For generic drugs the Calculated
				  cost shall be AWP minus twenty percent plus a dispensing fee of five
				  dollars.
(d) "Contract price" means
				  the maximum amount that a designated pharmacy (as set forth in section
				  440.3  of
				  this Part) will pay a pharmacy for generic drugs and brand name drugs that have
				  generic versions available (multi-source brands).
(e) "Controlled substance" has the meaning
				  provided in Public Health Law Section
				  3306.
(f) "Formulary" means the New York Workers'
				  Compensation Formulary which is a list of drugs for work-related injuries that
				  is incorporated by reference in section 441.2  of this Part and that must be
				  used to prescribe medication for all Disability events. The Formulary includes
				  medications available in Phase A and B; and, also includes a list of
				  medications available for Perioperative periods that may be prescribed without
				  Prior Authorization during the applicable Phase or Perioperative
				  period.
(g) "Generic drug" means an
				  FDA-approved drug that is therapeutically equivalent to a brand name drug, as
				  determined by the FDA's designation of the drug with the Therapeutic
				  Equivalence Evaluation Code designation as an "A" product in the "Approved Drug
				  Products with Therapeutic Equivalence Evaluations" (commonly referred to as the
				  Orange Book), irrespective of dosage for the route of administration (oral,
				  topical or systemic) prescribed. A brand name drug may not be dispensed when a
				  generic version of the same active ingredient is commercially available in a
				  different strength/ dosage.
(h)
				  "Independent pharmacy" means a pharmacy (including a remote pharmacy) that is
				  not part of a pharmacy chain.
(i)
				  "Insurance carrier" means the State Insurance Fund, stock corporations, mutual
				  corporations or reciprocal insurers with which employers have insured, and any
				  special fund maintained by the Board that is responsible for paying for medical
				  treatment and care of injured workers, including but not limited to, the
				  Special Fund for Reopened Cases created and governed by Workers' Compensation
				  Law Section 25-a and the Uninsured Employers' Fund created and governed by
				  Workers' Compensation Law Section 26-a.
(j) "Pharmacy benefit management" means the
				  services provided to a self-insured employer or insurance carrier, directly or
				  through another entity, including:
(1) the
				  negotiation of the amount to be paid for prescription medicine or drugs by the
				  self-insured employer or insurance carrier and the amount paid to an
				  independent pharmacy, pharmacy chain, or remote pharmacy dispensing
				  prescription medicine or drugs;
(2)
				  procurement of prescription medicines or drugs to be dispensed to injured
				  employees; or
(3) the
				  administration or management of prescription medicine or drug benefits,
				  including, but not limited to, any of the following:
(i) mail service pharmacy;
(ii) claims processing, New York Pharmacy
				  Formulary administration and prior authorization review, retail network
				  contracting and management, or payment of claims to pharmacies for dispensing
				  prescription medicines or drugs;
(iii) patient compliance, therapeutic
				  intervention, or generic substitution programs;
(iv) disease management; and
(v) retrospective review.