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Medical Fee Schedules Pharmacy Fee Schedule

Medical Fee Schedules

Pharmacy Fee Schedule

As set forth in New York Codes, Rules and Regulations (NYCRR), Title 12, Section 440.5:

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.

See: Part 440.5 Pharmacy Fee Schedule

Related: New York Workers' Compensation Drug Formulary (Drug Formulary) webpage

Frequently asked questions

  1. When was the Pharmacy Fee Schedule established?

    The permanent regulations to establish the fee schedules for pharmacy and the rules for the use of the fee schedules and pharmacy networks was adopted by the Chair of WCB on November 6, 2012. The emergency regulations began on July 11, 2007.

  2. What is the maximum reimbursement for prescription drugs?

    The maximum reimbursement or payment for prescription drugs or medicines is the lesser of the calculated cost, the contract price (for designated pharmacies), or the usual and customary price for the prescription drug or medication (includes medications listed on the Board's Drug Formulary and/or medications wherein a prior authorization request was approved).

    The usual and customary price is based on the Average Wholesale Price (AWP), which can be found in the most current prescription Red Book or Medi-Span database.

  3. What is section 441.4?

    12 NYCRR Section 441.4 references application of the Drug Formulary. The Board's Drug Formulary identifies drugs using the generic or chemical name. The Formulary organizes these drugs into three lists (Phase A, Phase B & Perioperative Formulary Drugs) and includes both prescription and over-the-counter drugs. See the Drug Formulary page for complete details.

  4. How should over-the-counter Formulary drugs be billed?

    Over-the-counter Formulary drugs should be billed directly to the carrier or its pharmacy benefits manager.