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New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
328 State Street  Schenectady, New York 12305
Governor David A. Paterson


Subject No. 046-245

New Pharmacy Fee Schedule and Durable Medical Equipment Fee Schedule Adopted

Date: July 18, 2008

The Chair of the Workers' Compensation Board adopted a new pharmacy fee schedule and a durable medical equipment fee schedule by emergency regulation effective July 7, 2008. The new schedules are codified as Parts 440 and 442 of Title 12 of the New York Codes, Rules and Regulations.

Pharmacy Fee Schedule

The new pharmacy fee schedule utilizes a reimbursement price of the average wholesale price (AWP) minus 12 percent for brand name drugs plus a $4.00 dispensing fee. The reimbursement price for generic drugs is AWP minus 20 percent plus a $5.00 dispensing fee. This new fee schedule is effective for all prescriptions drugs dispensed on or after July 7, 2008. In claims that are controverted, the reimbursement rate is 25 percent more than the maximum reimbursement rate for uncontroverted claims plus a dispensing fee of $7.50 for generics and $6.00 for brand name drugs.

Prescriptions filled from July 11, 2007, through July 6, 2008, should be paid in accordance with the previous fee schedule which is available at the Board's website under Pharmacy Fee Search. The pharmacy fee schedule does not apply to medical providers administering drugs through injection as part of medical treatment described in the New York Workers' Compensation Medical Fee Schedule.

A new provision was added to the pharmacy fee schedule that permits penalties to be imposed for violations of Workers' Compensation Law Section 13(i) and Section 13(o).

Durable Medical Equipment Fee Schedule

The durable medical equipment fee schedule adopted is still the Medicaid fee schedule. However, the regulation includes clarification on the application of the Medicaid fee schedule to workers' compensation claims. Specifically, the regulation provides that payments for bone growth stimulators are made in a single payment for the entire amount, that the reimbursement for orthopedic footwear is the lesser of the acquisition cost to the provider plus 50% or the usual and customary price charged to the public, and that hearing aids are not considered durable medical equipment for purposes of the fee schedule and the reimbursement amount is the provider's usual and customary price.

The Durable Medical Equipment Fee Schedule does not apply to medical providers supplying durable medical equipment to injured workers as part of medical treatment described in the New York Workers' Compensation Medical Fee Schedule. Billing and reimbursement follows the ground rules as described in the fee schedule.

Please visit the Board's website at:

http://www.wcb.ny.gov/content/main/hcpp/FeeSchedules.jsp

to review the pharmacy fee schedule and durable medical equipment fee schedule regulations and to access the previous pharmacy fee schedules for drugs dispensed prior to July 7, 2008.

Questions regarding any of these issues should be referred to the Office of General Counsel at (518) 486-9564.

 

Zachary S. Weiss
Chair