N.Y. Comp. Codes R. & Regs. tit. 12 § 440.4

Current through Register Vol. 46, No. 45, November 2, 2024

Section 440.4 - Notification

(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.

N.Y. Comp. Codes R. & Regs. Tit. 12 § 440.4