Senate Bill S9331

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   9331
 
                             I N  S E N A T E
 
                               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:
 
   Section  1.    Legislative findings and intent. The legislature hereby
 finds that timely access to medically necessary prescription  medication
 is essential to the health, safety, and recovery of injured workers, and
 that  delays  in authorization or dispensing may cause unnecessary pain,
 medical deterioration, and increased system costs.
   The legislature further finds that the workers' compensation board has
 adopted regulations governing out-of-network pharmacy access,  effective
 July 2025, which allow injured workers to obtain prescription medication
 out of network when a contracted pharmacy fails to dispense such medica-
 tion  and which provide for payment surcharges when medication is subse-
 quently determined to be compensable. These regulations represent impor-
 tant  protections  that  should  be  codified  in  statute   to   ensure
 permanence,   consistency,  and  enforceability,  while  preserving  the
 board's authority to adapt to evolving medical and pharmaceutical deliv-
 ery systems.
   It is the intent of this act to codify and harmonize existing  regula-
 tory  protections in statute, establish clear, objective, and time-based
 standards that minimize litigation and factual disputes,  ensure  prompt
 access  to  prescription medication, preserve administrative efficiency,
 and maintain the workers' compensation board's full regulatory flexibil-
 ity to  address  emerging  issues  related  to  prescription  medication
 access.
   § 2. Subdivision (i) of section 13 of the workers' compensation law is
 amended by adding a new paragraph 6 to read as follows:
   (6)(I)  NOTWITHSTANDING PARAGRAPH FIVE OF THIS SUBDIVISION, A CLAIMANT
 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
              

 S. 9331                             2
 
 SUCH  CLAIMANT'S  CHOICE  OUTSIDE  OF  AN EMPLOYER OR CARRIER CONTRACTED
 PHARMACY NETWORK WHEN ANY OF THE FOLLOWING OBJECTIVE CONDITIONS OCCUR:
   (A)  A PRESCRIPTION MEDICATION THAT HAS BEEN AUTHORIZED FOR DISPENSING
 BY THE EMPLOYER OR  INSURANCE  CARRIER  HAS  NOT  BEEN  DISPENSED  BY  A
 CONTRACTED  NETWORK PHARMACY WITHIN THE TIMEFRAMES FOR DISPENSING ESTAB-
 LISHED BY REGULATIONS OF THE WORKERS' COMPENSATION BOARD, AS  DOCUMENTED
 IN  THE  WORKERS' COMPENSATION BOARD'S ELECTRONIC SYSTEM OF RECORD OR IN
 WRITTEN AUTHORIZATION COMMUNICATIONS;
   (B) THE EMPLOYER, INSURANCE CARRIER, OR  CONTRACTED  NETWORK  PHARMACY
 HAS  FAILED TO ISSUE A WRITTEN AUTHORIZATION OR REAUTHORIZATION DETERMI-
 NATION WITHIN THE TIMEFRAMES ESTABLISHED BY REGULATIONS OF THE  WORKERS'
 COMPENSATION  BOARD  FOLLOWING  DOCUMENTED RECEIPT OF A REQUEST FOR SUCH
 DETERMINATION, AS REFLECTED IN THE WORKERS' COMPENSATION  BOARD'S  ELEC-
 TRONIC  DATA  INTERCHANGE  SYSTEM  OR, IF SUBMITTED BY MAIL, BY THE DATE
 SHOWN ON THE RETURN RECEIPT  FOR  CERTIFIED  MAIL;  PROVIDED  THAT,  FOR
 PURPOSES  OF THIS SUBPARAGRAPH, A REQUEST FOR WHICH THE EMPLOYER, INSUR-
 ANCE CARRIER, OR CONTRACTED NETWORK PHARMACY SEEKS  ADDITIONAL  INFORMA-
 TION SHALL NOT TOLL OR EXTEND THE APPLICABLE REGULATORY TIMEFRAME UNLESS
 AND  TO  THE  EXTENT  EXPRESSLY  AUTHORIZED BY THE WORKERS' COMPENSATION
 BOARD'S REGULATIONS UNDER SPECIFIED CIRCUMSTANCES;
   (C) THE CLAIMANT REQUIRES EMERGENCY PRESCRIPTION MEDICATION  NECESSARY
 TO  PREVENT  IMMINENT HARM TO HEALTH OR SAFETY, AS DEFINED OR RECOGNIZED
 UNDER APPLICABLE MEDICAL TREATMENT GUIDELINES OR REGULATIONS ADOPTED  BY
 THE  WORKERS'  COMPENSATION  BOARD,  INCLUDING BUT NOT LIMITED TO OPIOID
 ANTAGONISTS, INSULIN, CARDIAC MEDICATIONS, SEIZURE MEDICATIONS, OR ANTI-
 BIOTICS FOR ACUTE INFECTIONS;
   (D) CIRCUMSTANCES EXIST THAT  PERMIT  OUT-OF-NETWORK  PHARMACY  ACCESS
 PURSUANT TO REGULATIONS ADOPTED BY THE WORKERS' COMPENSATION BOARD UNDER
 ITS  AUTHORITY  TO  ENSURE  TIMELY  ACCESS  TO  PRESCRIPTION MEDICATION,
 INCLUDING REGULATIONS PROVIDING FOR PAYMENT SURCHARGES  WHEN  MEDICATION
 IS SUBSEQUENTLY DETERMINED TO BE COMPENSABLE; OR
   (E)  SUCH  OTHER  CIRCUMSTANCES AS THE WORKERS' COMPENSATION BOARD MAY
 IDENTIFY BY REGULATION TO ADDRESS DELAYS IN MEDICATION ACCESS  THAT  ARE
 INCONSISTENT WITH MEDICAL TREATMENT GUIDELINES OR THAT IMPEDE THE CLAIM-
 ANT'S  RECOVERY,  PROVIDED  THAT  SUCH  REGULATIONS ESTABLISH OBJECTIVE,
 DOCUMENTARY, OR TIME-BASED STANDARDS AND DO NOT  REQUIRE  INDIVIDUALIZED
 FACTUAL  DETERMINATIONS BY THE BOARD AS A PREREQUISITE TO OUT-OF-NETWORK
 ACCESS.
   (II) ANY PHARMACY DISPENSING PRESCRIBED MEDICATION PURSUANT TO SUBPAR-
 AGRAPH (I) OF THIS PARAGRAPH SHALL:
   (A) ADHERE TO THE AMOUNTS  PRESCRIBED  BY  THE  WORKERS'  COMPENSATION
 PHARMACY  FEE  SCHEDULE  ADOPTED  PURSUANT TO SECTION THIRTEEN-O OF THIS
 ARTICLE;
   (B) COMPLY WITH THE WORKERS' COMPENSATION MEDICAL TREATMENT GUIDELINES
 PROMULGATED PURSUANT TO SUBDIVISION FIVE OF SECTION THIRTEEN-A  OF  THIS
 ARTICLE  FOR  THE  CLAIMANT'S SITE OF INJURY FOR WHICH THE MEDICATION IS
 PRESCRIBED;
   (C) COMPLY WITH THE WORKERS' COMPENSATION  PHARMACY  FORMULARY  ESTAB-
 LISHED PURSUANT TO SECTION THIRTEEN-P OF THIS ARTICLE; AND
   (D) ASSUME FINANCIAL RESPONSIBILITY FOR THE COST OF SUCH MEDICATION IN
 ACCORDANCE  WITH THE FEE SCHEDULE PRESCRIBED UNDER SECTION THIRTEEN-O OF
 THIS ARTICLE IF:
   (I) THE WORKERS' COMPENSATION CLAIM IS DENIED OR NOT ESTABLISHED; OR
   (II) THE PRESCRIBED MEDICATION IS DETERMINED TO BE NON-COMPENSABLE  BY
 THE WORKERS' COMPENSATION BOARD OR A COURT OF COMPETENT JURISDICTION.
 S. 9331                             3
 
   (III)  UPON  A  DETERMINATION THAT THE PRESCRIBED MEDICATION DISPENSED
 PURSUANT TO THIS PARAGRAPH IS COMPENSABLE, THE DISPENSING PHARMACY SHALL
 BE ENTITLED TO PAYMENT OR REIMBURSEMENT FROM THE  EMPLOYER  OR  CARRIER.
 THE EMPLOYER OR CARRIER SHALL PAY THE AMOUNT PRESCRIBED BY THE FEE SCHE-
 DULE  ESTABLISHED  UNDER  SECTION  THIRTEEN-O OF THIS ARTICLE OR, IF THE
 PRESCRIBED MEDICATION IS NOT INCLUDED ON THE CURRENT FEE  SCHEDULE,  THE
 USUAL  AND  CUSTOMARY CHARGES FOR SUCH PRESCRIBED MEDICATION, WITHIN THE
 TIMEFRAMES ESTABLISHED BY THE WORKERS' COMPENSATION  BOARD  PURSUANT  TO
 REGULATION.  SUCH  PHARMACY  SHALL  BE PERMITTED TO CONTINUE TO DISPENSE
 SUCH PRESCRIBED MEDICATION TO THE CLAIMANT  OUTSIDE  OF  THE  CONTRACTED
 NETWORK  AFTER PAYMENT OR REIMBURSEMENT FOR THE PRESCRIBED MEDICATION IS
 ESTABLISHED.
   (IV) THE OBJECTIVE CONDITIONS SET FORTH IN SUBPARAGRAPH  (I)  OF  THIS
 PARAGRAPH  ARE  SELF-EXECUTING  AND SHALL NOT REQUIRE A DETERMINATION BY
 THE WORKERS' COMPENSATION BOARD  AS  A  PREREQUISITE  TO  OUT-OF-NETWORK
 PHARMACY  ACCESS.  THE  PROVISIONS  OF THIS PARAGRAPH SHALL BE CONSTRUED
 CONSISTENTLY WITH REGULATIONS ADOPTED BY  THE  BOARD  TO  ENSURE  TIMELY
 ACCESS  TO  PRESCRIPTION  MEDICATION AND SHALL NOT BE CONSTRUED TO LIMIT
 THE BOARD'S AUTHORITY TO ADOPT, AMEND,  OR  IMPLEMENT  RULES  AND  REGU-
 LATIONS  THAT  FACILITATE  MEDICATION  ACCESS OR MINIMIZE ADMINISTRATIVE
 BURDEN.
   (V) THE PROVISIONS OF THIS PARAGRAPH SHALL BE CONSTRUED AS  COMPLEMEN-
 TARY TO REGULATIONS ADOPTED BY THE WORKERS' COMPENSATION BOARD GOVERNING
 PHARMACY  NETWORKS, MEDICATION AUTHORIZATION, AND OUT-OF-NETWORK ACCESS.
 TO THE EXTENT ANY SUCH REGULATION PROVIDES GREATER ACCESS TO OUT-OF-NET-
 WORK PHARMACY SERVICES OR ESTABLISHES  MORE  PROTECTIVE  TIMEFRAMES  FOR
 INJURED  WORKERS THAN THOSE SPECIFIED IN THIS PARAGRAPH, SUCH REGULATION
 SHALL  CONTROL.  NO  REGULATION  SHALL  BE  CONSTRUED  TO  DIMINISH  THE
 PROTECTIONS ESTABLISHED BY THIS PARAGRAPH.
   (VI)  A  CLAIMANT'S EXERCISE OF THE RIGHT TO OBTAIN MEDICATION FROM AN
 OUT-OF-NETWORK PHARMACY PURSUANT TO THIS PARAGRAPH SHALL NOT  CONSTITUTE
 EVIDENCE  REGARDING  THE  COMPENSABILITY  OF THE UNDERLYING CLAIM OR THE
 MEDICAL NECESSITY OF THE MEDICATION, AND THE FACT  THAT  MEDICATION  WAS
 OBTAINED  OUT-OF-NETWORK SHALL NOT BE ADMISSIBLE FOR SUCH PURPOSE IN ANY
 PROCEEDING BEFORE THE WORKERS' COMPENSATION BOARD.
   § 3. Reporting requirement. No later than three years after the effec-
 tive date of this act, the workers' compensation board  shall  submit  a
 report  to  the governor, the temporary president of the senate, and the
 speaker of the assembly analyzing the implementation of paragraph six of
 subdivision (i) of section thirteen of the workers' compensation law  as
 added by section two of this act. Such report shall include:
   (a) data on the frequency and circumstances of out-of-network pharmacy
 utilization under this act;
   (b)  data  on medication access delays before and after implementation
 of this act;
   (c) information regarding any increase or decrease  in  litigation  or
 administrative proceedings related to pharmacy access issues;
   (d)  analysis of costs and cost savings associated with improved medi-
 cation access;
   (e) stakeholder feedback from injured  workers,  employers,  carriers,
 pharmacies, and health care providers; and
   (f)  recommendations  for  statutory  or  regulatory  modifications to
 improve medication access,  reduce  administrative  burden,  or  address
 implementation challenges.
   §  4.  Severability.  If any clause, sentence, paragraph, subdivision,
 section, or part of this act shall be adjudged by any court of competent
 S. 9331                             4
 
 jurisdiction to be invalid, such judgment shall not affect,  impair,  or
 invalidate the remainder thereof, but shall be confined in its operation
 to the clause, sentence, paragraph, subdivision, section, or part there-
 of  directly  involved  in  the controversy in which such judgment shall
 have been rendered. It is hereby declared to be the intent of the legis-
 lature that this act would  have  been  enacted  even  if  such  invalid
 provisions had not been included herein.
   §  5.  This  act  shall take effect on the sixtieth day after it shall
 have become a law. Effective immediately, the addition, amendment and/or
 repeal of any rule or regulation necessary  for  the  implementation  of
 this  act  on its effective date are authorized to be made and completed
 on or before such effective date.