June 11, 2025
The Chair has adopted the amendments to Sections 440.3, 440.4, and 441.3 of 12 NYCRR to provide a path for claimants to obtain medically necessary medication either through use of a network pharmacy or by notice of their ability to use an out-of-network pharmacy.
The Notice of Proposed Rule Making was published in the December 31, 2024, edition of the State Register. The Notice of Adoption will be published in the June 11, 2025, edition of the State Register. The amendments will take effect July 11, 2025.
Pursuant to Section 13(i)(5) of the Workers' Compensation Law, a payer may designate a network pharmacy and require claimants to obtain all prescribed medicines from that network pharmacy. When a payer has designated a network pharmacy but is controverting the claim, or if the claim has been established or accepted by the payer but the payer will not pay for medication for an additional body part or condition that has not been established and for which the payer has not accepted liability, Section 440.3(d) of Title 12 NYCRR requires that the payer provide written notice to the claimant, the Board, and the network pharmacy, which shall include the following information:
- If the claim is controverted, that the payer will not pay for the prescription medication until the controversy is resolved and the claim is established.
- If the claim has been established or accepted by the payer, that the payer will not pay for the prescription medication for any additional body part or condition that has not been established and for which the payer has not accepted liability until liability for the additional body part or condition is established.
- That following the establishment of the claim or the amendment of the claim to include the additional body part or condition, the payer must re-serve the claimant with the notice required in Section 440.4(b) of Title 12 NYCRR to require a claimant to use a designated network pharmacy.
- That during the pendency of any dispute concerning the payer's liability for the claim or for an additional body part or condition, and until the claimant is re-served with the notice required in Section440.4(b) of Title 12 of the NYCRR, the claimant may go outside the network pharmacy to obtain medication.
- A contact phone number for the claimant to call with questions. Additional contact information, such as an email address, is optional.