S 9331 NY

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Bill No.: Summary Actions Committee&nbspVotes Floor&nbspVotes Memo Text LFIN Chamber&nbspVideo/Transcript S09331 Summary: BILL NO S09331 &nbsp SAME AS SAME AS A10413

&nbsp SPONSOR RAMOS &nbsp COSPNSR &nbsp MLTSPNSR &nbsp Amd §13, Work Comp L &nbsp Codifies certain regulations of the workers' compensation board relating to access to prescription medication and coordination with workers' compensation board regulations governing network pharmacy use; requires the workers' compensation board to file a report on out-of-network pharmacy use within 3 years of the effective date.

Go to top S09331 Text:

STATE OF NEW YORK ________________________________________________________________________

9331

IN SENATE

March 2, 2026 ___________

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 access to prescription medication and coordination with workers' compensation board regulations governing network pharmacy use

The People of the State of New York, represented in Senate and Assem- bly, do enact as follows:

1 Section 1. Legislative findings and intent. The legislature hereby 2 finds that timely access to medically necessary prescription medication 3 is essential to the health, safety, and recovery of injured workers, and 4 that delays in authorization or dispensing may cause unnecessary pain, 5 medical deterioration, and increased system costs. 6 The legislature further finds that the workers' compensation board has 7 adopted regulations governing out-of-network pharmacy access, effective 8 July 2025, which allow injured workers to obtain prescription medication 9 out of network when a contracted pharmacy fails to dispense such medica- 10 tion and which provide for payment surcharges when medication is subse- 11 quently determined to be compensable. These regulations represent impor- 12 tant protections that should be codified in statute to ensure 13 permanence, consistency, and enforceability, while preserving the 14 board's authority to adapt to evolving medical and pharmaceutical deliv- 15 ery systems. 16 It is the intent of this act to codify and harmonize existing regula- 17 tory protections in statute, establish clear, objective, and time-based 18 standards that minimize litigation and factual disputes, ensure prompt 19 access to prescription medication, preserve administrative efficiency, 20 and maintain the workers' compensation board's full regulatory flexibil- 21 ity to address emerging issues related to prescription medication 22 access. 23 § 2. Subdivision (i) of section 13 of the workers' compensation law is 24 amended by adding a new paragraph 6 to read as follows: 25 (6)(i) Notwithstanding paragraph five of this subdivision, a claimant 26 shall be permitted to obtain prescribed medication from a pharmacy of

EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD09234-02-6

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1 such claimant's choice outside of an employer or carrier contracted 2 pharmacy network when any of the following objective conditions occur: 3 (A) a prescription medication that has been authorized for dispensing 4 by the employer or insurance carrier has not been dispensed by a 5 contracted network pharmacy within the timeframes for dispensing estab- 6 lished by regulations of the workers' compensation board, as documented 7 in the workers' compensation board's electronic system of record or in 8 written authorization communications; 9 (B) the employer, insurance carrier, or contracted network pharmacy 10 has failed to issue a written authorization or reauthorization determi- 11 nation within the timeframes established by regulations of the workers' 12 compensation board following documented receipt of a request for such 13 determination, as reflected in the workers' compensation board's elec- 14 tronic data interchange system or, if submitted by mail, by the date 15 shown on the return receipt for certified mail; provided that, for 16 purposes of this subparagraph, a request for which the employer, insur- 17 ance carrier, or contracted network pharmacy seeks additional informa- 18 tion shall not toll or extend the applicable regulatory timeframe unless 19 and to the extent expressly authorized by the workers' compensation 20 board's regulations under specified circumstances; 21 (C) the claimant requires emergency prescription medication necessary 22 to prevent imminent harm to health or safety, as defined or recognized 23 under applicable medical treatment guidelines or regulations adopted by 24 the workers' compensation board, including but not limited to opioid 25 antagonists, insulin, cardiac medications, seizure medications, or anti- 26 biotics for acute infections; 27 (D) circumstances exist that permit out-of-network pharmacy access 28 pursuant to regulations adopted by the workers' compensation board under 29 its authority to ensure timely access to prescription medication, 30 including regulations providing for payment surcharges when medication 31 is subsequently determined to be compensable; or 32 (E) such other circumstances as the workers' compensation board may 33 identify by regulation to address delays in medication access that are 34 inconsistent with medical treatment guidelines or that impede the claim- 35 ant's recovery, provided that such regulations establish objective, 36 documentary, or time-based standards and do not require individualized 37 factual determinations by the board as a prerequisite to out-of-network 38 access. 39 (ii) Any pharmacy dispensing prescribed medication pursuant to subpar- 40 agraph (i) of this paragraph shall: 41 (A) adhere to the amounts prescribed by the workers' compensation 42 pharmacy fee schedule adopted pursuant to section thirteen-o of this 43 article; 44 (B) comply with the workers' compensation medical treatment guidelines 45 promulgated pursuant to subdivision five of section thirteen-a of this 46 article for the claimant's site of injury for which the medication is 47 prescribed; 48 (C) comply with the workers' compensation pharmacy formulary estab- 49 lished pursuant to section thirteen-p of this article; and 50 (D) assume financial responsibility for the cost of such medication in 51 accordance with the fee schedule prescribed under section thirteen-o of 52 this article if: 53 (I) the workers' compensation claim is denied or not established; or 54 (II) the prescribed medication is determined to be non-compensable by 55 the workers' compensation board or a court of competent jurisdiction.

S. 9331 3

1 (iii) Upon a determination that the prescribed medication dispensed 2 pursuant to this paragraph is compensable, the dispensing pharmacy shall 3 be entitled to payment or reimbursement from the employer or carrier. 4 The employer or carrier shall pay the amount prescribed by the fee sche- 5 dule established under section thirteen-o of this article or, if the 6 prescribed medication is not included on the current fee schedule, the 7 usual and customary charges for such prescribed medication, within the 8 timeframes established by the workers' compensation board pursuant to 9 regulation. Such pharmacy shall be permitted to continue to dispense 10 such prescribed medication to the claimant outside of the contracted 11 network after payment or reimbursement for the prescribed medication is 12 established. 13 (iv) The objective conditions set forth in subparagraph (i) of this 14 paragraph are self-executing and shall not require a determination by 15 the workers' compensation board as a prerequisite to out-of-network 16 pharmacy access. The provisions of this paragraph shall be construed 17 consistently with regulations adopted by the board to ensure timely 18 access to prescription medication and shall not be construed to limit 19 the board's authority to adopt, amend, or implement rules and regu- 20 lations that facilitate medication access or minimize administrative 21 burden. 22 (v) The provisions of this paragraph shall be construed as complemen- 23 tary to regulations adopted by the workers' compensation board governing 24 pharmacy networks, medication authorization, and out-of-network access. 25 To the extent any such regulation provides greater access to out-of-net- 26 work pharmacy services or establishes more protective timeframes for 27 injured workers than those specified in this paragraph, such regulation 28 shall control. No regulation shall be construed to diminish the 29 protections established by this paragraph. 30 (vi) A claimant's exercise of the right to obtain medication from an 31 out-of-network pharmacy pursuant to this paragraph shall not constitute 32 evidence regarding the compensability of the underlying claim or the 33 medical necessity of the medication, and the fact that medication was 34 obtained out-of-network shall not be admissible for such purpose in any 35 proceeding before the workers' compensation board. 36 § 3. Reporting requirement. No later than three years after the effec- 37 tive date of this act, the workers' compensation board shall submit a 38 report to the governor, the temporary president of the senate, and the 39 speaker of the assembly analyzing the implementation of paragraph six of 40 subdivision (i) of section thirteen of the workers' compensation law as 41 added by section two of this act. Such report shall include: 42 (a) data on the frequency and circumstances of out-of-network pharmacy 43 utilization under this act; 44 (b) data on medication access delays before and after implementation 45 of this act; 46 (c) information regarding any increase or decrease in litigation or 47 administrative proceedings related to pharmacy access issues; 48 (d) analysis of costs and cost savings associated with improved medi- 49 cation access; 50 (e) stakeholder feedback from injured workers, employers, carriers, 51 pharmacies, and health care providers; and 52 (f) recommendations for statutory or regulatory modifications to 53 improve medication access, reduce administrative burden, or address 54 implementation challenges. 55 § 4. Severability. If any clause, sentence, paragraph, subdivision, 56 section, or part of this act shall be adjudged by any court of competent

S. 9331 4

1 jurisdiction to be invalid, such judgment shall not affect, impair, or 2 invalidate the remainder thereof, but shall be confined in its operation 3 to the clause, sentence, paragraph, subdivision, section, or part there- 4 of directly involved in the controversy in which such judgment shall 5 have been rendered. It is hereby declared to be the intent of the legis- 6 lature that this act would have been enacted even if such invalid 7 provisions had not been included herein. 8 § 5. This act shall take effect on the sixtieth day after it shall 9 have become a law. Effective immediately, the addition, amendment and/or 10 repeal of any rule or regulation necessary for the implementation of 11 this act on its effective date are authorized to be made and completed 12 on or before such effective date.

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