N.Y. Comp. Codes R. & Regs. tit. 12 § 440.8

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

Section 440.8 - Payment of bills

(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.

N.Y. Comp. Codes R. & Regs. Tit. 12 § 440.8

Amended New York State Register April 17, 2019/Volume XLI, Issue 16, eff. 4/17/2019

Amended New York State Register April 17, 2019/Vol. XLI, Issue 16, eff. 10/1/2019

Amended New York State Register January 29, 2020/Volume XLII, Issue 04, eff. 1/29/2020

Amended New York State Register November 23, 2022/Volume XLIV, Issue 47, eff. 11/23/2022