N.Y. Comp. Codes R. & Regs. tit. 12, Appendices, app A
(cf. Part 440)
NOTIFICATION CONCERNING PAYMENT FOR MEDICATION
Dear [Name]
[Carrier or self-insured employer] has filed papers with the workers' compensation board contesting your claim for workers' compensation benefits. Under state law, an insurance company is not required to reimburse a worker for medications while it is contesting the claim, and we have chosen not to do so.
However, the Worker's Compensation Board requires that we notify you of the following. While we are contesting the claim, the following rules apply:
[*] You may obtain your medications from any pharmacy. You are not required to use a pharmacy designated by [carrier or self-insured employer].
[*] If you prevail on your claim, [carrier or self-insured employer] must reimburse you or the pharmacy directly (if it extends you credit). The specific amount of the reimbursement may differ from the amount you paid, and is set by the Workers' Compensation Board based on the kind of medication you purchase. If you have any questions about this, please contact the Board at 1-877-632- 4996.
[*] If you do not prevail on your claim, [carrier or self-insured employer] is not required to reimburse you or the pharmacy.
If you have any questions or problems, you may call us at [toll free number], or find further information at [website]. In addition, you may contact the Workers' Compensation Board at 1-877-632-4996 or the Advocate for Injured Workers at 800-580-6665, or you can find further information on the web at www.wcb.state.ny.us
N.Y. Comp. Codes R. & Regs. tit. 12, Appendices, app A