Relates to contracted network pharmacy use, the official text

S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   4926
 
                        2025-2026 Regular Sessions
 
                             I N  S E N A T E
 
                             February 14, 2025
                                ___________
 
 Introduced  by  Sen.  RAMOS  -- read twice and ordered printed, and when
   printed to be committed to the Committee on Labor
 
 AN ACT to amend the workers' compensation law, in relation to contracted
   network pharmacy use
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:

   Section  1. Subdivision (i) of section 13 of the workers' compensation
 law is amended by adding a new paragraph 6 to read as follows:
   (6) (I) NOTWITHSTANDING PARAGRAPH FIVE OF THIS SUBDIVISION, A CLAIMANT
 SHALL NOT BE REQUIRED TO OBTAIN PRESCRIBED MEDICINES THROUGH A  PHARMACY
 WITH  WHICH  THE  EMPLOYER  OR  CARRIER  HAS  A  CONTRACT AND MAY OBTAIN
 PRESCRIBED MEDICINES FROM A PHARMACY OF SUCH CLAIMANT'S CHOICE WHEN:
   (A) THE EMPLOYER OR INSURANCE CARRIER HAS REFUSED TO  PROVIDE  PAYMENT
 FOR  THE  CLAIMANT'S PRESCRIBED MEDICATION AND THE CLAIMANT IS UNABLE TO
 OBTAIN THE PRESCRIBED MEDICATION FROM A PHARMACY WITH WHICH THE EMPLOYER
 OR CARRIER  HAS  A  CONTRACT  DUE  TO  THE  FAILURE  TO  AUTHORIZE  SUCH
 PRESCRIBED MEDICATION WITHIN SEVENTY-TWO HOURS OF SUCH REQUEST; OR
   (B) THE PRESCRIBED MEDICATION IS SCHEDULED FOR REAUTHORIZATION BUT THE
 EMPLOYER OR CARRIER HAS FAILED TO REAUTHORIZE SUCH PRESCRIBED MEDICATION
 WITHIN SEVENTY-TWO HOURS OF THE REQUEST FOR ONE OR MORE OF THE FOLLOWING
 REASONS:
   (I)  THE  EMPLOYER,  CARRIER, OR NETWORK PHARMACY FAILED TO RESPOND TO
 THE REAUTHORIZATION REQUEST;
   (II) MEDICAL REPORTS HAVE NOT YET BEEN FILED FOR REAUTHORIZATION, OR A
 FILED MEDICAL REPORT CONTAINS A DEFECT;
   (III) THE MEDICATION  HAS  BEEN  AUTHORIZED  PREVIOUSLY;  HOWEVER  THE
 EMPLOYER OR CARRIER DENIES REAUTHORIZATION ON THE BASIS THAT THE MEDICAL
 TREATMENT GUIDELINES DO NOT SUPPORT REAUTHORIZATION;
   (IV) AN INDEPENDENT MEDICAL EXAMINER DISAGREES WITH REAUTHORIZATION;
   (V)  REAUTHORIZATION  HAS BEEN DENIED BECAUSE MAXIMUM MEDICAL IMPROVE-
 MENT HAS BEEN REACHED; OR
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD09234-01-5
 S. 4926                             2
 
   (VI) THE CASE IS IN THE PROCESS OF BEING SETTLED.
   (II)  ANY  PHARMACY THAT AGREES TO DISPENSE PRESCRIBED MEDICATION TO A
 CLAIMANT PURSUANT TO SUBPARAGRAPH (I) OF THIS PARAGRAPH SHALL:
   (A) ADHERE TO THE AMOUNTS PRESCRIBED BY THE FEE SCHEDULE ADOPTED UNDER
 THE  NEW  YORK  STATE  WORKERS'  COMPENSATION  PHARMACY   FEE   SCHEDULE
 PRESCRIBED IN SECTION THIRTEEN-O OF THIS ARTICLE;
   (B)  ADHERE TO THE NEW YORK STATE WORKERS' COMPENSATION MEDICAL TREAT-
 MENT GUIDELINES AUTHORIZED UNDER SUBDIVISION FIVE OF SECTION  THIRTEEN-A
 OF  THIS ARTICLE FOR THE CLAIMANT'S SITE OF INJURY FOR WHICH THE MEDICA-
 TION IS PRESCRIBED;
   (C) FOLLOW THE NEW YORK STATE WORKERS' COMPENSATION PHARMACY FORMULARY
 PRESCRIBED UNDER SECTION THIRTEEN-P OF THIS ARTICLE; AND
   (D) ASSUME ALL LIABILITY FOR CHARGES FOR SUCH PRESCRIBED MEDICATION IN
 ACCORDANCE WITH THE FEE SCHEDULE PRESCRIBED UNDER SECTION THIRTEEN-O  OF
 THIS  ARTICLE  IF A CASE IS NOT ESTABLISHED OR IF THE PRESCRIBED MEDICA-
 TION IS NOT LATER APPROVED.
   (III) UPON APPROVAL OF ANY PRESCRIBED MEDICATION DISPENSED BY A  PHAR-
 MACY  PURSUANT  TO THIS SUBPARAGRAPH, SUCH PHARMACY SHALL BE ENTITLED TO
 SUBMIT A CLAIM TO THE EMPLOYER  OR  ITS  CARRIER  FOR  PAYMENT  OF  SUCH
 PRESCRIBED   MEDICATION  OR  FOR  REIMBURSEMENT  OF  THE  COST  OF  SUCH
 PRESCRIBED MEDICATION. THE EMPLOYER OR  CARRIER  SHALL  PAY  THE  AMOUNT
 PRESCRIBED  BY  THE  FEE SCHEDULE PRESCRIBED UNDER SECTION THIRTEEN-O OF
 THIS ARTICLE, OR IF THE PRESCRIBED MEDICATION IS  NOT  INCLUDED  ON  THE
 CURRENT   FEE  SCHEDULE,  THE  USUAL  AND  CUSTOMARY  CHARGES  FOR  SUCH
 PRESCRIBED MEDICATION WITHIN FORTY-FIVE BUSINESS DAYS OF SUCH  APPROVAL.
 SUCH PHARMACY SHALL BE PERMITTED TO CONTINUE TO DISPENSE SUCH PRESCRIBED
 MEDICATION  TO  THE  CLAIMANT  OUTSIDE  OF  THE NETWORK AFTER PAYMENT OR
 REIMBURSEMENT OF PAYMENT FOR THE PRESCRIBED MEDICATION IS ESTABLISHED.
   § 2. This act shall take effect on the thirtieth day  after  it  shall
 have become a law. Effective immediately, the addition, amendment and/or
 repeal  of  any  rule  or regulation necessary for the implementation of
 this act on its effective date are authorized to be made  and  completed
 on or before such effective date.