12 CRR-NY 440.5NY-CRR
12 CRR-NY 440.5
12 CRR-NY 440.5
440.5 Fee schedule.
(a)
(1)
(i) Prior to October 1, 2019, the maximum reimbursement or payment for prescription drugs or medicines in uncontroverted cases, including all brand name and generic prescription drugs or medicines, shall be the average wholesale price for the national drug code for the prescription drug or medicine on the day it was dispensed minus 12 percent of the average wholesale price plus a dispensing fee of $4 for brand name drugs or medicines, minus 20 percent of the average wholesale price plus a dispensing fee of $5 for generic drugs or medicines.
(ii) On or after October 1, 2019, the maximum reimbursement or payment for New York Workers’ Compensation formulary drugs or when applicable, drugs that received prior authorization in accordance with section 441.4 of this Title, including all brand name and generic prescription drugs or medicines, shall be the lesser of the calculated cost, the contract price (for designated pharmacies), or the usual and customary price for the prescription drug or medication.
(2) The maximum reimbursement for prescription drugs or medicines dispensed in controverted cases during the period the case is controverted, including all brand name and generic prescription drugs or medicines, shall be 25 percent more than the calculated cost at the time the prescription drugs or medicines are provided if the case was uncontroverted, plus a dispensing fee of $7.50 for generic prescription drugs or medicines and $6 for brand-name prescription drugs or medicines. Prior to the filing of a prescribed notice denying the claim for workers’ compensation, 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 paragraph [1] of this subdivision) of medications from, as applicable, phase A, B or the perioperative section of the pharmacy formulary.
(3) Nothing in this section shall bar a self-insured employer or insurance carrier from providing a lower reimbursement rate or dispensing fee pursuant to a written agreement with any independent pharmacy, pharmacy chain, or pharmacy benefit manager.
(4) The maximum reimbursements or payments for prescription drugs or medicines set forth in this subdivision shall be the maximum payment any individual or entity may receive from any claimant, individual, entity, self-insured employer, insurance carrier, or third party in connection with a claim for workers’ compensation benefits.
(b) Fees for pharmacy benefit management shall be established by agreement between the self-insured employer or insurance carrier and the independent pharmacy, pharmacy chain, or pharmacy benefit manager. Fees to a pharmacy processing agent shall be established by agreement between the independent pharmacy, pharmacy chain, or pharmacy benefit manager and the pharmacy processing agent. The chair may audit agreements from time to time for the purpose of ensuring compliance with this Part.
(c) Notwithstanding any other provision of this Part, if a prescription drug or medicine has been repackaged, the average wholesale price used to determine the maximum reimbursement shall be the average wholesale price of the underlying drug product, as identified by its national drug code (or NDC), of the underlying drug product used in the drug packaging. If the NDC is not supplied with the bill for the prescription drug or medicine, the self-insured employer or insurance carrier may identify the NDC of the underlying drug product to calculate reimbursement. While a pharmacy may engage in repackaging by removing a finished drug product from the container in which it was distributed by the original manufacturer and placing it into a different (often smaller container), the maximum reimbursement must be calculated using the AWP for the container in which the finished drug product was distributed by the original manufacturer prior to any repackaging.
(d) Compound drug, as defined in section 441.1(a) of this Title, shall be reimbursed at the ingredient level, with each ingredient identified using the applicable NDC of the drug product, and the corresponding quantity. Ingredients with no NDC are not separately reimbursable. When a compound drug is prescribed and dispensed in accordance with section 441.1(a) of this Title or pursuant to section 441.1(m) of this Title (prior authorization), payment shall be based upon a sum of the allowable fee for each NDC ingredient(s) as set forth in this section, plus a single dispensing fee of $6 per compound drug. Compound drugs with any non-formulary drug ingredient and/or for formulary drugs being prescribed for other than an FDA approved route of administration are not reimbursable.
(e) The fee schedule created by this section shall not apply to prescription drugs or medicines provided as part of treatment governed by the medical and hospital fee schedule issued pursuant to Workers’ Compensation Law section 13.
12 CRR-NY 440.5
Current through August 31, 2021
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