Effective July 11, 2025, the New York Workers’ Compensation Board (WCB) amended its Pharmacy Network Rules to clarify when injured workers may use out-of-network pharmacies.

Under the updated rule, if a claim is controverted, or if an accepted claim includes a denied body part or condition, payers must notify the injured worker, the Board, and the network pharmacy that medications related to the disputed condition will not be reimbursed.

However, before the injured worker is served such notice, pharmacies must dispense medications, and the payer is responsible for covering the cost of formulary medications at the following reimbursement rates:

• Brand-name drugs | AWP - 12% + $4.00
• Generic drugs | AWP - 20% + $5.00

If the injured worker prevails and claim is established, or the legal objection is resolved in favor of the provider, the payer must reimburse whoever paid for the medication, according to the following fee schedule for controverted claims:

• Brand-name drugs: (AWP - 12%) x 1.25 + $6.00
• Generic drugs: (AWP - 20%) x 1.25 + $7.50

Once the dispute is resolved and the claim is fully accepted, the payer must reimburse whoever covered the medication costs and issue a second notice reminding the injured worker to return to using an in-network pharmacy. All payer notices must include a contact number where a claimant may call with any questions.

The WCB is expected to provide access to education, guidance, and to allow programming efforts associated with the notice before this update takes effect.

This rule change provides clearer guardrails for out of network pharmacy use during claim disputes, reducing uncertainty for injured workers and stakeholders. For other stakeholders, it reinforces the importance of timely and accurate notifications and coordination to ensure compliance, manage reimbursement, and maintain a seamless experience for injured workers.