New York proposes revised rules for pharmacy fee schedule

Optum Workers' Comp
| Dec 14, 2018

The New York State Workers’ Compensation Board (WCB) recently proposed revised rules to update pricing methodology for prescription drugs, as of Part 440 of Title 12 NYCRR.  The proposed rule would establish a “lesser of” standard, among the current means to calculate price, and addresses rebate transparency as a way of injecting potential savings to the workers’ compensation system.

Specifically, the proposed regulations state:

  • Prescription drugs shall be reimbursed in accordance with the fee schedule in effect on date the Rx was dispensed.
  • Formulary will include medications available in Phase A, B, and C; and also includes a perioperative medication list.
  • Compound drug payment shall be based upon a sum of allowable fee(s) for each NDC ingredient, plus a single dispensing fee per compound drug.
  • Maximum reimbursement for repackaged drug(s) must be calculated using AWP for the container in which the finished drug product was distributed by original manufacturer.

    As mentioned above, the WCB proposed a new section, subsection (g), regarding rebates.  The proposed language states:

  • Any rebates or third-party revenue related to drugs dispensed through a contract for pharmacy benefit management and delivered to the designated pharmacy shall be passed through in full to the insurance carrier or self-insured employer. Carriers shall offset bills to insured employers by the amount of any passed-through rebate and third-party revenue. Such rebates and third-party revenue shall be reported at least annually to the carrier or self-insured employer and reported to the WCB Chair upon request.

The OWCA Government Affairs Team will review the proposed fee schedule language to identify impact on the processes of providing pharmacy care as well as any impact to pharmacy reimbursement.  Like any public policy development, the proposed language is undergoing a formal rule-making process and is subject to change.  We urge all stakeholders to review the proposed language and provide comments to the WCB by the public comment deadline, February 3, 2019.


Full text of the proposed rule – I.D. No. WCB-49-18-00010-P can be found at:


Should you have any questions on this or any other public policy development topics, please contact the OWCA Government Affairs team at

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