STATE OF NEW YORK
________________________________________________________________________
4926
2025-2026 Regular Sessions
IN SENATE
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:
1 Section 1. Subdivision (i) of section 13 of the workers' compensation
2 law is amended by adding a new paragraph 6 to read as follows:
3 (6) (i) Notwithstanding paragraph five of this subdivision, a claimant
4 shall not be required to obtain prescribed medicines through a pharmacy
5 with which the employer or carrier has a contract and may obtain
6 prescribed medicines from a pharmacy of such claimant's choice when:
7 (A) the employer or insurance carrier has refused to provide payment
8 for the claimant's prescribed medication and the claimant is unable to
9 obtain the prescribed medication from a pharmacy with which the employer
10 or carrier has a contract due to the failure to authorize such
11 prescribed medication within seventy-two hours of such request; or
12 (B) the prescribed medication is scheduled for reauthorization but the
13 employer or carrier has failed to reauthorize such prescribed medication
14 within seventy-two hours of the request for one or more of the following
15 reasons:
16 (I) the employer, carrier, or network pharmacy failed to respond to
17 the reauthorization request;
18 (II) medical reports have not yet been filed for reauthorization, or a
19 filed medical report contains a defect;
20 (III) the medication has been authorized previously; however the
21 employer or carrier denies reauthorization on the basis that the medical
22 treatment guidelines do not support reauthorization;
23 (IV) an independent medical examiner disagrees with reauthorization;
24 (V) reauthorization has been denied because maximum medical improve-
25 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
1 (VI) the case is in the process of being settled.
2 (ii) Any pharmacy that agrees to dispense prescribed medication to a
3 claimant pursuant to subparagraph (i) of this paragraph shall:
4 (A) adhere to the amounts prescribed by the fee schedule adopted under
5 the New York state workers' compensation pharmacy fee schedule
6 prescribed in section thirteen-o of this article;
7 (B) adhere to the New York state workers' compensation medical treat-
8 ment guidelines authorized under subdivision five of section thirteen-a
9 of this article for the claimant's site of injury for which the medica-
10 tion is prescribed;
11 (C) follow the New York state workers' compensation pharmacy formulary
12 prescribed under section thirteen-p of this article; and
13 (D) assume all liability for charges for such prescribed medication in
14 accordance with the fee schedule prescribed under section thirteen-o of
15 this article if a case is not established or if the prescribed medica-
16 tion is not later approved.
17 (iii) Upon approval of any prescribed medication dispensed by a phar-
18 macy pursuant to this subparagraph, such pharmacy shall be entitled to
19 submit a claim to the employer or its carrier for payment of such
20 prescribed medication or for reimbursement of the cost of such
21 prescribed medication. The employer or carrier shall pay the amount
22 prescribed by the fee schedule prescribed under section thirteen-o of
23 this article, or if the prescribed medication is not included on the
24 current fee schedule, the usual and customary charges for such
25 prescribed medication within forty-five business days of such approval.
26 Such pharmacy shall be permitted to continue to dispense such prescribed
27 medication to the claimant outside of the network after payment or
28 reimbursement of payment for the prescribed medication is established.
29 § 2. This act shall take effect on the thirtieth day after it shall
30 have become a law. Effective immediately, the addition, amendment and/or
31 repeal of any rule or regulation necessary for the implementation of
32 this act on its effective date are authorized to be made and completed
33 on or before such effective date.
