The MyMatrixx Statehouse Watch is your home for the latest federal and state policy developments that impact workers’ compensation pharmacy and the services we provide. Here, our Regulatory Affairs team, which has over 40 years of combined experience in government relations and workers’ compensation, will provide updates and insight on the pending and adopted policy changes in this heavily regulated industry. You can also check policy developments by state using our interactive map.
Please contact MMXRegulatoryAffairs@mymatrixx.com if you have questions on any of this content.
Statehouse Watch: Latest News
Regulatory rundown in workers' comp pharmacy March 10, 2026
Florida Appellate Court Rules on Physician Dispensing and Provider Choice
States seek to regulate PBMs, impacting workers’ compensation
Regulatory rundown in workers' comp pharmacy February 13, 2026
Regulatory rundown in workers' comp pharmacy February 6, 2026
States kick off 2026 with proposed workers’ compensation legislation
Regulatory rundown in workers' comp pharmacy January 9, 2026
Regulatory rundown in workers' comp pharmacy for December 17, 2025
Pennsylvania Supreme Court hears oral arguments in lingering workers’ compensation pharmacy disputes
Regulatory rundown in workers' comp pharmacy for November 21, 2025
Archived Posts
Enforcement of new Arkansas PBM law halted by court
In late July, the U.S. District Court for the Eastern District of Arkansas (a federal court) granted a preliminary injunction to stop Arkansas Act 624 (HB 1150) from taking effect on January 1, 2026, stating in part that it “appears to overtly discriminate against plaintiffs as out of state companies.”
Act 624 would prohibit pharmacies affiliated with a pharmacy benefit manager (PBM) from dispensing medications within the state. The preliminary injunction means those pharmacies will continue to be able to provide medications and associated clinical care to Arkansas patients.
The Arkansas Attorney General plans to appeal the ruling, but unless the appellate court reverses or stays the order granting the preliminary injunction, Act 624 cannot go into effect while the litigation continues at the district court.
California workers’ comp UR rule changes disapproved
Further clarity and additionally needed notice were the reasons stated for why previously proposed utilization review (UR) rule changes were disapproved by California’s Office of Administrative Law (OAL) in late July.
That decision gives the California Division of Workers’ Compensation (DWC) 120 days to resubmit a revised regulation package to correct the identified deficiencies, which the DWC intends to do. Once any substantive regulation revisions are published, the DWC must make them available for public comment for at least 15 days. Following the comment period, the DWC plans to resubmit the rule changes to the OAL within sufficient time to meet the originally requested effective date of January 1, 2026.
From June 2024 through May 2, 2025, the DWC had taken their previously proposed revisions through three public comment periods prior to submitting to the OAL. Among other more substantive changes, the revisions included some changes to medication authorization procedures and requirements. MyMatrixx by Evernorth contributed to the public comments through our trade association.
Ohio proposed workers’ comp pharmacy rules changes
As part of a larger package of rules, the Ohio Bureau of Workers’ Compensation (BWC) has formally proposed amendments to their pharmacy fee schedules for both state fund and self-insuring employer claims. The BWC has proposed to:
- Rescind a rule providing standards and criteria governing BWC (state fund) opioid reimbursement.
- Add language incorporating the Ohio State Medical Board opioid prescribing rules into the state fund fee schedule in its place.
For MyMatrixx by Evernorth and our clients, the proposed self-insuring employer fee schedule rule amendments include the following notable changes:
- Decreasing the non-sterile compound reimbursement cap to $100 (from $400) to align with the $100 cap for state fund claims
- Amending compound medication dispensing fees to be based on the time necessary to compound the medication (five different time ranges and fees from $15 to $75)
- Accounting for instances in which a different dispensing fee may be required by law for medications dispensed outside of Ohio
- Proposing that bills submitted by a pharmacy are not required to include a prescriber’s DEA number (NPI is required)
- Changing language to clarify the conditions under which a self-insuring employer may approve reimbursement for a brand medication when a generic equivalent exists
MyMatrixx submitted comments in an earlier phase of this rule revision process, which the BWC agreed to and made a change in response, and we are now reviewing the latest version of these proposed changes. We will likely submit written comments in support. A public hearing is scheduled for September 3, 2025.
Texas bill limits use of AI in UR
Texas Senate Bill 815, a bill limiting the use of artificial intelligence (AI) in utilization review (UR), was passed and signed into law. The bill provides that a UR agent (including in workers’ comp) may not use an “automated decision system” to make an adverse determination (e.g., a prospective or retrospective UR denial). The bill also permits the Commissioner of Insurance to audit and inspect a UR agent's use of an automated decision system for UR at any time. The bill provides that this will not prohibit use of an algorithm, AI system, or automated decision system for administrative support or fraud-detection functions. SB 815 defines “automated decision system” as “an algorithm, including an algorithm incorporating an artificial intelligence system, that uses data-based analytics to make, suggest, or recommend certain determinations, decisions, judgments, or conclusions.” The new law takes effect September 1, 2025.
The use of AI in insurance, including workers’ comp, has been a topic of interest and discussion for some time. We have seen several states attempt to address the issue in legislation or regulation. In response, the Workers’ Compensation Research Institute (WCRI) recently published an overview of AI in workers’ comp, relying in part on interviews and informal discussions with leaders from various organizations (including MyMatrixx).
Washington workers’ comp PTSD guidelines proposed
The Washington State Department of Labor & Industries (L&I) published a new post-traumatic stress disorder (PTSD) Clinical Guideline for public comment through September 12, 2025.
Designed as a best practice for the diagnosis and treatment of PTSD in workers’ compensation, the guideline was developed in partnership with
- L&I’s Industrial Insurance Medical Advisory Committee (IIMAC) and its PTSD Clinical Guideline Subcommittee
- The Office of the Medical Director
The guideline includes information on both psychotherapy and pharmacological treatment and considers psychotherapy as the first-line recommendation for treatment of PTSD. The guideline will be presented to the IIMAC in an public meeting in October, L&I’s response to all public comments will be available, and there will be time on the agenda for public testimony.
You’ve probably heard the idea, “Even the flutter of a butterfly’s wings can cause a hurricane on the other side of the world.” It’s called the butterfly effect, and it promotes the idea that everything matters and can have an impact. While not as delicate as butterfly wings, the same idea is true for the influx of proposed legislative changes and their potential impact on workers’ compensation and pharmacy care. 2025 has been another busy year for these state-by-state changes that may impact how claims are handled, what conditions and treatments are compensable, and how medical/pharmacy services are billed, reviewed, and reimbursed. Even provider contracting terms, network requirements, and pricing options between insurers, employers and their health care provider networks or PBMs can be impacted.
In a recent WorkCompWire Leaders Speak, Adam Fowler, MyMatrixx by Evernorth’s Director of Regulatory Affairs, breaks down some of the notable legislative actions in 2025 on topics including:
- Fee schedules and pricing
- Presumptive or special coverage
- Direction of care
- Reviewing medical treatment or medical bills
- Pharmacy benefit manager (PBM) legislation
Click to read more about which states are legislating these topics and the impact they will have on workers’ compensation claims.
Not always the right fit for workers’ compensation
In 2025, bills that target pharmacy benefit managers (PBMs) have popped up in nearly every state. Primarily, this state-level PBM legislation focuses on commercial health insurance where patients have cost share and there is less regulation in place. But, while some state PBM laws expressly exempt workers’ compensation from their language, workers’ comp can unintentionally also be impacted due to overbroad or vague legislative language. To counteract this, MyMatrixx by Evernorth works to educate policymakers on the differences in workers’ compensation and consequences these bills may have. Because of this, the following examples highlight several occasions where policymakers have made amendments to PBM requirements acknowledging that workers’ compensation may not fit into their broader health insurance policy goals.
Oklahoma Senate Bill 789 (enacted without governor signature):
· Prohibits PBM effective rate contracting with pharmacies
· Requires certain disclosures from PBMs that lease their networks to other PBMs
MyMatrixx worked with our trade association (AAPAN) and with the state’s Workers’ Compensation Commission chairman to emphasize the differences between workers’ comp and commercial health insurance. Together, we secured a workers’ compensation exemption from the bill’s pharmacy guaranteed profitability provision that would have required PBMs reimburse pharmacies no less than the National Average Drug Acquisition (NADAC) rate plus a higher dispensing fee. This conflicted with the state’s workers’ comp maximum fee schedule and would have tripled the required dispensing fee.
This same provision was later stricken from the bill entirely. SB 789, as amended, becomes effective November 1, 2025.
Kentucky House Bill 415 was signed and became effective June 27, 2025. This bill exempts several lines of insurance or benefit plans (including workers’ compensation) from an area of state insurance law that includes several health benefit plan mandates and pharmacy and PBM provisions.
One such provision required PBMs to reimburse certain pharmacies at NADAC plus a minimum dispensing fee that is more than double the workers’ comp fee schedule’s maximum dispensing fee.
MyMatrixx and others previously shared concerns with regulators on the conflict and confusion caused between this reimbursement and the workers’ compensation law and fee schedule. HB 415 states that, unless otherwise specifically indicated or provided, the sections in that area of law shall not apply to or affect coverage or benefits provided under the workers’ compensation law. This secured exemption should alleviate reimbursement conflict and concerns.
Montana House Bill 740 was signed into law also with workers’ compensation exemptions. The bill will:
· Prohibit effective rate contracting
· Prohibit PBMs from reimbursing a network pharmacy less than their contract price with the payer
· Prohibit certain fees from being charged to pharmacies
· Prohibit the steering of patients to PBM-owned or affiliated pharmacies
In collaboration with clients and industry partners, MyMatrixx secured a workers’ compensation exemption from a provision in this bill that will require certain PBMs and payers to reimburse independent pharmacies no less than NADAC plus a higher dispensing fee, subject to annual inflation increases. Without this exemption, the fee schedule would have conflicted with the Montana workers’ comp fee schedule and increased dispensing fees for workers’ comp PBMs and payers five times higher than the current workers’ comp maximum dispensing fee. HB 740, as amended, will apply to “conduct occurring on or after” October 1, 2025.
New York’s signed budget bill included additional reporting requirements for PBMs. Collaborating with AAPAN, we were able to previously secure several exemptions for workers’ compensation regarding PBM requirements on topics such as cost sharing and network requirements. The exemptions were adopted by the Department of Financial Services considering the differences between workers’ comp and commercial health insurance. These exemptions should cover the additional reporting requirements in the budget bill.
We’re not out of the woods yet
While most state legislatures have adjourned for the year, there are many PBM bills still pending or eligible for carry-over to the next session. Most of these bills are not applicable to workers’ comp as currently written, but workers’ compensation and workers’ compensation PBMs will not go completely unscathed this year. We have seen a few states introduce last-minute bill amendments with significant provisions that sometimes alter the bill’s applicability and leave little time for public review or debate.
A comprehensive list of bills and details of their current status can be found on the Legislative and Regulatory Policy Tracker on our Statehouse Watch webpage. Select “PBM Regulation” as the topic; selecting “Workers’ Compensation” as the category will narrow down the list to the bills we believe could impact workers’ comp.
Questions on these bills or other public policy topics for our Regulatory Affairs team can be sent to MMXRegulatoryAffairs@MyMatrixx.com. For more information on policy developments in workers’ compensation impacting pharmacy across the country, please visit and bookmark Statehouse Watch at MyMatrixx.com. You can also join us for our next continuing education webinar on July 29th for a 2025 Legislative Wrap Up, where we will review PBM bills and several other legislative trends from this year.
Nevada Senate Bill 317, a large workers’ compensation bill, was recently signed into law. Among its multiple provisions, the bill includes the requirement for the state’s Division of Industrial Relations (DIR) to adopt the Official Disability Guidelines (ODG) Drug Formulary on or before July 1, 2027, as the formulary to be used by insurers for workers’ compensation claims. SB 317 also provides several basic requirements with respect to the related authorization and denial appeal process and sets forth other relevant implementation and transition dates.
Basic formulary requirements
As the official formulary for workers’ compensation claims, the bill requires DIR to:
- Adopt the ODG formulary on or before July 1, 2027
- Make the formulary available on a publicly accessible website as soon as practicable after adoption
- Update the website as necessary with current information relating to the formulary.
Workers’ comp insurers will be required to use the adopted formulary for any drug that is prescribed or dispensed to an injured worker for outpatient services but not for prescription drugs that are prescribed or dispensed for emergency medical services or inpatient services.
Except as otherwise provided in the law, the insurer is not to provide reimbursement for any drug listed but not approved, or omitted from, the formulary. However, insurers will be permitted to provide reimbursement for those categories of drugs if they have elected to approve the drug in their established procedures and in compliance with any applicable requirements that may be established by DIR.
If a physician believes a drug is medically necessary, but it is listed but not approved, or omitted from, the formulary and has not been approved by the insurer, they may submit an authorization request to the insurer. If the insurer denies the authorization request, the injured worker or their representative may appeal that denial to a hearings officer.
Other relevant dates
The bill provides several additional dates that will impact the scope of and application of the formulary, including a transition period.
Until January 1, 2028, an insurer may reimburse an impacted drug that is dispensed to an injured worker after July 1, 2027, if:
- The injured worker sustained the injury on or between January 1, 2027, and July 1, 2027; and
- The injured worker was originally prescribed the drug in connection with their claim on or between January 1, 2027, and July 1, 2027.
The amendments in SB 317 apply to any claim which is open, filed or reopened on or after the date of the bill’s passage and approval. The bill was approved by the governor on June 10, 2025.
Moving forward
While the bill outlines several requirements and dates, details on its implementation will be developed later through rulemaking by DIR. It may be important to also note that the Occupational Medicine Practice Guidelines developed by the American College of Occupational and Environmental Medicine (ACOEM) have already been adopted as medical treatment guidelines in the existing DIR rules. It is not yet known whether that will change. Nevada would not, however, be the first state to have adopted the ODG formulary but use treatment guidelines not from ODG.
The MyMatrixx by Evernorth Regulatory Affairs team will be monitoring and engaging in that rulemaking process, and our clinical teams will also be paying close attention. The basic requirements and prescribed dates in the bill should guide the rulemaking, so those should be reviewed in anticipation of eventual implementation and compliance by stakeholders.
Questions on this bill or other public policy topics for our Regulatory Affairs team can be sent to MMXRegulatoryAffairs@MyMatrixx.com. For the status of other recent legislation or regulations related to formularies or prior authorization across the country that we are tracking, refer to our Legislative and Regulatory Policy Tracker on our Statehouse Watch webpage (select “Formulary” or “Prior Authorization” as the topic and limit the category to “Workers’ Compensation” if only interested in those that may impact workers’ comp). For more information on policy developments in workers’ compensation impacting pharmacy across the country, please visit and bookmark Statehouse Watch at MyMatrixx.com.
The New York Workers’ Compensation Board (WCB) has adopted rule amendments, which provide a process for out-of-network pharmacy use for situations when there is a non-established condition or injury or another legal objection. These changes take effect July 11, 2025.
Current New York rules permit an employer or carrier to contract with pharmacies and require injured workers to obtain their medications from those designated pharmacies. Exceptions to using a designated pharmacy include:
- Emergencies when it is not reasonably possible to immediately obtain required prescribed medications
- A controverted claim
The Latest Adopted Rule Amendments
According to the new, adopted rule changes, a self-insured employer or carrier is required to provide written notice of a decision to not pay for a prescribed medication, which is pending resolution of a legal objection that contends:
- The medication treats a non-established body site; or
- The payer has not accepted liability for the body site or condition
Upon receipt of the written notice (assuming they were subject to a requirement to use a network pharmacy), the injured worker may use an out-of-network pharmacy while the legal objection is pending.
The rule changes also outline:
- Penalties for non-compliance
- The steps to re-notify the injured worker of the requirement to resume use of a network pharmacy after a legal objection is resolved.
- The amended process for controverted claims
In its rule adoption announcement, the WCB also provided a list of content requirements for the notice, most of which mirrors what is in the amended rules. Application of the WCB’s fee schedule(s) and formulary is also reiterated or clarified for these situations in the rules. One change from the WCB that differs from the proposal in late December, is to allow approximately 30 days from rule adoption until the regulation changes take effect for education, guidance, and programming.
Of note for employers and carriers, the amended rules provide that:
- The notice needs to be in writing and must go to the claimant, the WCB, and the independent pharmacy, pharmacy chain, or PBM designated by the carrier or employer.
- Failure of the designated pharmacy to dispense and/or failure of the self-insured employer or insurance carrier to pay for medications prior to providing the notice shall subject the employer or carrier, following a hearing, to penalties of at least $2,000, with increased penalties thereafter for any subsequent failures.
- When a claimant has been previously notified that they may use a non-designated pharmacy, following resolution of the legal objection, the employer/carrier must re-notify the claimant of the initial requirement to use a designated pharmacy in order to require a claimant to resume use of a designated pharmacy.
- In the event the claimant prevails, and the claim is established, or the legal objection is resolved in favor of the provider, the employer or carrier shall reimburse either the claimant, the pharmacy processing agent, other third party, or the unpaid pharmacy from which the claimant filled the medication in question. The reimbursement shall not exceed the maximum amount set by the fee schedule for controverted claims in existing rules (higher than the normal/standard fee schedule).
- The WCB’s formulary shall apply to prescriptions for body parts or conditions not yet accepted by the carrier or employer.
MyMatrixx by Evernorth submitted written comments to the WCB requesting clarifying language on certain aspects of the proposed rule text during the proposed rulemaking comment period. One of our requests for clarification was addressed in the response to comments and partially in the adopted text.
Moving Forward
It’s important to note there are additional anti-pharmacy network bills in New York (S 4926 and A 6887) still pending this year in the legislature. These bills are similar to S 1974, which was vetoed by Governor Kathy Hochul last year stating that the bill would have increased litigation, added bureaucratic steps for the WCB, and led to delays in obtaining needed medication.
The MyMatrixx Regulatory Affairs team continues to track legislative and regulatory actions related to pharmacy networks, as we know changes to direction of care may affect the ability of our clients and payers to leverage network pharmacies to:
- Control costs
- Ensure patient safety
- Provide access to the appropriate medications for accepted workplace injuries
For more details and the status of legislation related to networks or direction of care in New York or elsewhere in the country that we are tracking, refer to our Legislative and Regulatory Policy Tracker on our Statehouse Watch webpage (select “Networks or Direction of Care” as the topic).
Questions on this topic for the MyMatrixx Regulatory Affairs team can be sent to MMXRegulatoryAffairs@MyMatrixx.com. For more information on policy developments like this in workers’ compensation impacting pharmacy in states across the country, please visit and bookmark Statehouse Watch at MyMatrixx.com.
The multi-state trend to propose legislation focused on providing special workers’ compensation or occupational disease coverage for first responders for conditions such as mental stress, cancer, and cardiac conditions continues in 2025. Expansion of these laws can mean greater access to care for first responders, but it can also lead to increased claims and costs for employers. The following highlight several related bills introduced in 2025 that have been recently signed into law or made it just shy of that final step.
Connecticut
Connecticut Senate Bill 1426, signed into law and effective October 1, 2025, amends the state’s Firefighters Cancer Relief Program to expand coverage to skin cancer as an additionally covered type of cancer. The law allows firefighters to receive compensation and benefits in the same amount and manner that would be provided if caused by an occupational disease that arose out of and in the course of the firefighter's employment and was suffered in the line of duty.
Tennessee
Tennessee Senate Bill 288 amends an existing firefighter cancer presumption law to add prostate, breast and pancreatic cancers to the list of covered cancers. SB 288 was signed into law and takes effect July 1, 2025.
Tennessee House Bill 310, also signed into law and effective July 1, 2025, expands the existing state post-traumatic stress disorder (PTSD) presumption to include law enforcement officers and emergency medical responders. This adds to the existing presumption law, which states that PTSD is compensable for certain firefighters. HB 310 defines "emergency medical responders" as emergency medical technicians, technician-paramedics or paramedics, and "law enforcement officers" as individuals employed by the state or a local government as members of a law enforcement agency whose primary responsibility is the prevention and detection of crime and the apprehension of offenders.
West Virginia
West Virginia House Bill 2797, a workers’ compensation bill that expands the types of professionals who may diagnose PTSD, was signed into law and is scheduled to take effect July 11, 2025. Under current law, PTSD suffered by a first responder may be recognized as a compensable occupational disease under certain conditions and must be diagnosed by a licensed psychiatrist. HB 2797 adds certified mental health nurse practitioners and certified psychiatric physician assistants as those who may diagnose PTSD in first responders. While this change addresses the PTSD diagnosis, it should be noted that the same law allows several other provider types to treat PTSD.
Montana
While Montana Senate Bill 394 passed both legislative chambers, it was ultimately not signed into law by the governor. The bill would have amended state law to specify PTSD as a new type of injury eligible for workers’ compensation benefits for certain first responders. Under the bill, a first responder must have been diagnosed with PTSD, according to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, and the diagnosis must have found that the injury or occupational disease arose out of the course and scope of employment. The bill defined “first responder” to include a firefighter, law enforcement officer, or an emergency care provider.
MyMatrixx by Evernorth continues to track it all
MyMatrixx has tracked around 90 bills related to special or presumptive coverage for first responders in more than half of the states so far this year. The status of the bills is fluid, and by the time of this publication, others may have progressed. A comprehensive list of bills and details of their current status can be found on the Legislative and Regulatory Policy Tracker on our Statehouse Watch webpage (select “Presumptions” as the topic).
Questions on these bills or other public policy topics for our Regulatory Affairs team can be sent to MMXRegulatoryAffairs@MyMatrixx.com. For more information on policy developments in workers’ compensation impacting pharmacy across the country, please visit and bookmark Statehouse Watch at MyMatrixx.com.
So far in 2025, there have been several proposed pieces of legislation in states related to pharmacy and other health care provider networks in workers’ compensation. MyMatrixx by Evernorth is tracking several of these bills related to pharmacy and physician choice, which could impact the ability of our clients to direct pharmacy and medical care.
Pharmacy Choice
There are four pharmacy choice bills pending in New York: Senate No. 4926, Assembly No. 6887, Assembly No. 3859, and Senate No. 306. All these bills would steer the law in favor of injured worker choice versus employer/insurer choice.
Senate No. 4926 and Assembly No. 6887 would allow injured workers to go out of a designated pharmacy network when an employer or insurer refuses to provide payment and the injured worker is unable to obtain the medication from a network pharmacy due to:
- Failure of the employer or insurer to authorize within 72 hours
- Failure of the employer or insurer to reauthorize within 72 hours for one or more of several listed reasons.
S 4926 was introduced in February and passed the Senate Labor Committee, while A 6887 was introduced in March and is awaiting action in the Assembly Labor Committee.
Both bills are similar to a bill that passed out of chamber last year but was vetoed by the governor stating the bill would:
- Increase litigation
- Add bureaucratic steps for the New York State Workers’ Compensation Board (WCB)
- Lead to delays in obtaining needed medication
The governor also referenced proposed regulation changes from the WCB that would provide a process for out-of-network pharmacy use in situations when a condition or injury has not been established or there is another legal objection. The governor said those proposed regulation changes seek to accomplish the intent of the bill and more efficiently address concerns without causing delay. The MyMatrixx by Evernorth Regulatory Affairs team submitted written comments on those proposed changes, which are still pending in the rulemaking process.
Assembly No. 3859 would change the current law provision that allows an employer or carrier to “require” use of a pharmacy network changing it to simply “encourage” use. The bill also states that injured workers may use non-network pharmacies if the pharmacy is registered as a resident, in-state pharmacy and the medications are casually related to the claimant's work-related injuries (non-resident, out-of-state pharmacies and compound medications would be excluded).
Senate No. 306. would entitle an out-of-network pharmacy providing causally related medications to an injured worker to be reimbursed at the same rate negotiated between the workers’ compensation carrier and the carrier’s established pharmacy network if that network provides mail-order service or is located within a reasonable distance from the injured worker.
Both A 3859 and S 306 were introduced in January and are still in their original chambers’ Labor committees awaiting action.
One bill that has failed to progress through the legislative process this session was Arizona House Bill 2429. This bill took the opposite approach of New York by permitting an employer to establish a “pharmacy management network” and require their injured workers to obtain medications through that network. The bill would have also required:
- An employer to notify employees of the network and to register the network with the Industrial Commission.
- Third-party billers to be reimbursed only at the contractual amount agreed by that network pharmacy.
The bill was introduced in mid-January and referred to two committees, with no subsequent action.
Physician Choice
Physician choice is also a topic of several pieces of legislation this year. We have been tracking bills in Arkansas, California, Colorado, Indiana, Iowa, Kansas, Montana, and Nevada that could have an impact on the ability of our clients to direct medical care, including the choice of treating physicians who prescribe medications to injured workers. For more on those and their current status, many which favor injured worker choice, we encourage review of our Legislative & Regulatory Tracker (select “Workers’ Compensation” as the category and “Direction of Care” as the topic).
More
The MyMatrixx by Evernorth Regulatory Affairs team tracks and monitors newly introduced and pending legislation and regulations across the country. You can visit our Statehouse Watch webpage for updates on other topics. Questions for our Regulatory Affairs team can also be sent to MMXRegulatoryAffairs@MyMatrixx.com.
After several previous attempts to establish a workers’ compensation pharmaceutical fee schedule in Maryland, the latest effort, Senate Bill 306, is seeing forward legislative momentum after being voted favorably out of the state’s Senate with amendments.
From fee disputes to reasonable costs
Under current Maryland regulations, the workers’ comp. insurer determines the pharmaceutical reimbursement value based on "nationally recognized and published relative value studies, or on the values assigned for services involving similar work and resources." This reimbursement value is subject to review by the Commission and has led to many disputes between parties.
In contrast, most other states’ workers’ compensation systems establish fee schedules for dispensed pharmaceuticals, thereby reducing disputes and adding certainty to providers and payers.
Contracting with a pharmacy network through a pharmacy benefit manager, like MyMatrixx by Evernorth, is one of the most effective and most common ways of controlling medication costs. However, not all providers accept contracted rates, and this is when a state fee schedule can assist by placing a reasonable ceiling on pharmaceutical costs for the non-contracted “out of network” transactions.
SB 306 and its amendments
As first introduced, SB 306 would direct the Workers’ Compensation Commission to adopt a fee schedule limiting reimbursement to "an index or indexes based on acquisition cost" and may include "reasonable" dispensing fees. The Senate Finance Committee subsequently approved the following amendments:
- The fee schedule should be in place by September 1, 2026.
- The fee schedule would be limited to medications provided by licensed pharmacies (would exclude dispensing physicians).
- The Commission may include in the fee schedule any percentage increase or decrease to the index(es) it determines.
- The bill would not prohibit insurers/employers from agreeing with PBMs or providers to rates other than fee schedule or from agreeing to use other pricing indexes.
- The state’s Prescription Drug Affordability Board would be required to conduct a study of workers’ compensation prescription drug affordability challenges and make recommendations, if applicable, for policies to address identified affordability challenges, with findings and recommendations due March 1, 2026 (six months prior to the deadline for the fee schedule to be in place).
MyMatrixx perspective
In support of the bill, MyMatrixx submitted written testimony to the Senate Finance Committee while also encouraging legislators and the Commission to ensure all dispensed medications are covered under the fee schedule. By this, we meant all national drug codes (NDCs) for both prescription and over-the-counter medications and all providers that may dispense.
Though subject to future determination, based on acquisition cost, there are two “indexes” that are likely available to adopt by the Commission:
- National Average Drug Acquisition Cost (NADAC): NADAC is the result of a survey process the federal Centers for Medicare and Medicaid Services (CMS) uses to estimate pharmacy pricing for drugs acquired by retail pharmacies that state Medicaid programs can utilize to set reimbursement rates to pharmacies. Given the voluntary nature of this index and its connection with Medicaid, it does not cover all medications dispensed within the workers’ compensation system. The medications that fall into this gap in coverage represent an even higher percentage of total medication costs (some more expensive drugs dispensed in the workers’ compensation system may not have a NADAC).
- Wholesale Acquisition Cost (WAC): WAC is generally a more comprehensive published index that could be used to account for many of the NADAC gaps. However, though rarer, there are some medications which also lack a WAC.
Given these gaps, we support the ability of the Commission to adopt ‘backup’ published reimbursement indexes to avoid potential loopholes. Practically, that may require the inclusion of other published and regularly updated industry indexes that are not necessarily tied to “acquisition cost.” Granting the Commission authority to do adopt such backup sources will ensure all medications have a fee schedule rate and avoid the current subjective system of disputes and uncertainty. In lieu of that, the Commission should still be granted authority to cap reimbursement for these gap medications, even if not tied to an acquisition cost index.
Additionally, we support applying this fee schedule to all providers, including dispensing physicians. Physician dispensing has been a concern in many states for workers’ compensation for several years. A 2024 Workers’ Compensation Research Institute report showed that physician-dispensed medications accounted for over half of total medication payments in the Maryland worker’s compensation system. MyMatrixx believes the practice of physician dispensing bypasses the benefits of a PBM and ignores critical patient safety alerts that are typically identified and communicated to retail pharmacies before medications are dispensed. We believe it important to hold dispensing physicians to the same standards as dispensing pharmacists, including reimbursement. Prior to the amendments, SB 306 would have included dispensing physicians, and we believe that any finally enacted legislation should include dispensing physicians and not create a loophole for those providers to inflate medication costs for the state’s employers.
Looking Forward
SB 306 now needs to be considered by the House. MyMatrixx is closely following activity with this bill, and we remain committed to collaborating with legislators, the Commission, and our Maryland clients to ensure any changes enable the processing of required medications at the appropriate costs without negative impacts to workers’ compensation payers and the injured workers we serve. We encourage clients to follow the progress of this legislation and reach out to legislators to share any comments or concerns.
The MyMatrixx Regulatory Affairs team tracks and monitors newly introduced and pending legislation across the country. You can visit the Legislative and Regulatory Policy Tracker on our Statehouse Watch webpage to sort current bills by topic and state for a broader snapshot−or the details−of the legislation. Questions for our Regulatory Affairs team can be sent to MMXRegulatoryAffairs@MyMatrixx.com.
The California Division of Workers’ Compensation (DWC) has proposed amendments related to the treatment guidelines for Chronic Pain and the use of Cannabis for the treatment of pain. The CA DWC has scheduled a public hearing on March 14, 2025, 10:00 A.M. PT to discuss the proposed amendments as listed below. Any written comments to the DWC on these amendments are due by that date.
• Amendment to Section 9792.24.2. Chronic Pain Guidelines. (ACOEM December 19, 2024)
• Adoption of Section 9792.24.8 Cannabis Guideline (ACOEM January 28, 2025)
The proposed amendments reference the latest evidence-based updates and adoption of the Medical Treatment Utilization Schedule (MTUS) as outlined by the American College of Occupational and Environmental Medicine (ACOEM).
Adopted MTUS medical treatment guidelines are presumed to be correct on the issue of extent and scope of medical treatment, and they are intended to guide treatment and authorization of it in the state’s workers’ compensation system.
Chronic Pain Guideline Updates
The ACOEM Chronic Pain guidelines include interventions regardless of FDA approval and are not an endorsement of their use. Many of the medications listed within the amendments are utilized off-label. Updates address regarding:
- Outdated language and definitions of pain
- Exercise for pain treatment
- Medications for regional pain, fibromyalgia treatment, and weight reduction
- Lidocaine patches and opioids
- Neuropathic pain medications
- Including, but not limited to, antidepressants, antipsychotic, antiviral, clonidine, dextromethorphan, muscle relaxants, magnesium, topical NSAIDS, Ketamine, topical capsaicin, lidocaine patches, memantine, vitamin B, and homeopathic treatments
- Medication complications
- Comorbidities
- Follow up care
A MyMatrixx clinical pharmacist reviewed the proposed updates to the Chronic Pain Guidelines and noted the inclusion of Topical Non-Steroidal Anti-inflammatories (NSAIDs) as a recommended treatment of Complex Regional Pain Syndrome (CRPS). Topical NSAIDs are also indicated as a second- or third-line adjunct to strengthening, conditioning, and aerobic exercises for treatment of CRPS that is severe enough to require medications. These updates will provide clinicians with an additional tool to expedite a successful recovery for those with complex medical conditions.
Cannabis Guideline Updates
The ACOEM Cannabis Guideline is focused on the treatment of pain resulting from disorders that are likely to be work-related (e.g., spine pain, chronic radicular pain, osteoarthrosis). Other conditions are out of scope. Within these pain disorders, the guidelines do not recommend cannabinoids for the treatment of chronic pain, acute pain, subacute pain, or postoperative pain. Additionally, acute, or chronic cannabinoid use is not recommended for individuals who perform safety-critical jobs.
Comments
The DWC is accepting written comments on these proposed updates until 11:59 P.M. on March 14, 2025. Written comments should be submitted to:
Maureen Gray
Regulations Coordinator
Department of Industrial Relations
Division of Workers’ Compensation
1515 Clay Street, 18th Floor
Oakland, CA 94612
Written comments may also be submitted by FAX, addressed to the above-named contact at (510) 286-0687, and via email to dwcrules@dir.ca.gov.
More details can be viewed on the DWC website here.
For more policy developments impacting workers’ compensation pharmacy across the country, please visit and bookmark Statehouse Watch at MyMatrixx.com.
Over the last several years, many states have attempted, and some have passed, legislation focused on providing workers’ compensation coverage and protections for first responders (firefighters, emergency medical technicians, police officers, paramedics, etc.) for conditions such as cancer, cardiac health and stress. In 2025, this trend continues including several new “presumptive” coverage bills.
Benefit-of-the-doubt presumptive coverage
Several state bills this year address presumptions, which shift the burden of proof of an illness from the claimant/first responder to the employer when determining if a claim is compensable. Presumptive coverage legislation is based on the fact that, due to their occupations, first responders are statistically more likely to be at risk for certain illnesses/conditions even though it can be difficult to conclusively prove the illness/condition resulted from the workplace and not factors outside of the job.
Expansion of these laws means greater access to care for first responders. Due to the types of conditions/illnesses they cover, it also means increased claims and higher costs for employers.
- Claims for mental health issues such as post-traumatic stress disorder (PTSD) often require different and longer-duration treatments than physical injury claims.
- Cancer treatment medications can be costly and are often prescribed with additional medications to manage treatment side effects. (You can find more information on this in our article, “Helping Heroes Fight Cancer.”)
A busy year for special coverage
MyMatrixx has been tracking over 70 bills since January 1 that either expand, clarify, or amend special or presumptive coverage.
A 2025 New York bill, S 755, actually reverses S 6635, a bill passed in late 2024. S 6635 expanded the coverage for stress-related claims from just first responders to all workers, stating that the Workers’ Compensation Board may not disallow a claim based on that worker’s stress was not greater than the stress occurring in a normal work environment.
In early February 2025, S 755 was passed and signed into law and now limits those coverage provisions to only certain first responders in relation to a work-related emergency (not all workers). It also adds that first responders must demonstrate the disorder arose out of extraordinary work-related stress attributable to a distinct work-related event or events directly related to the employment and occurring during the performance of job duties.
Over a dozen related bills have already failed in three states this year: Mississippi, North Dakota, and Virginia. These included bills which would have expanded mental stress, heart, lung, and/or cancer coverage in first responders and, in at least one case, correctional officers.
A majority of the special or presumptive coverage bills are still pending in about half of the states but will evolve over the next few months. A list of these bills and details of their current status can be found on our Legislative and Regulatory Policy Tracker on our Statehouse Watch webpage. On the page, you can sort bills by topic and state, and if you select the “Presumption” topic from the tracker menu you can view most of these bills.
MyMatrixx tracks it all
MyMatrixx continues to track and monitor the growing list of legislation for impacts both legislatively and clinically. We will stay ahead of presumption legislative activities and help manage the resulting medications for the benefit of both the injured worker and the payer.
Questions on these bills or other public policy topics for our Regulatory Affairs team can be sent to MMXRegulatoryAffairs@MyMatrixx.com. For more information on policy developments in workers’ compensation impacting pharmacy across the country, please visit and bookmark Statehouse Watch at MyMatrixx.com.
We are just one month into 2025, and already several states are off and running by introducing bills to add new laws or amend existing ones. Below, we’ve outlined some of these bills that, if passed and enacted, would have notable impact on pharmacy reimbursement and medical services coverage in workers’ compensation claims.
Workers’ comp pharmacy reimbursement bills
Several states have introduced bills regarding the provision and reimbursement of pharmaceuticals in workers’ compensation to address who can be reimbursed and for how much.
- New York S 306 is a unique bill that would entitle an out-of-network pharmacy providing causally related medications to an injured worker to be reimbursed at the same rate negotiated between the workers’ comp. carrier and the carrier’s established pharmacy network IF that network provides mail-order service or is located within a reasonable distance from the injured worker. For context, current New York law allows carriers to establish pharmacy networks and require injured workers to obtain medications from network pharmacies.
- Illinois HB 1256 is another attempt to allow custom compound medications to only be prescribed in a one-time, 7-day supply, but beyond that require preauthorization by the employer. With this, the preauthorization could only be approved if the compound meets specific standards outlined in the bill. The bill also states:
- Provider bills would need to include the original manufacturer's NDC for each compound ingredient and the ingredient reimbursement would be based on the average wholesale price (AWP) of that NDC (ingredients without an NDC are not to be charged).
- A single dispensing fee, determined by the Workers’ Compensation Commission, would be paid for the compound, with a state-specific dispensing fee billing code outlined.
- Arizona HB 2429 would permit an employer to establish a “pharmacy management network” to provide necessary medications to injured workers and require those injured workers to obtain medications through that network. The bill would require an employer to notify employees of the network and to register the network with the Industrial Commission. Also, third-party billers would be reimbursed only at the contractual amount agreed by that network pharmacy.
- Maryland SB 306 would require adoption of a pharmacy fee schedule, where none exists today. Under current workers’ compensation regulations, pharmaceutical reimbursement is determined by the carrier based on "nationally recognized and published relative value studies, or on the values assigned for services involving similar work and resources." This bill would direct the Workers’ Compensation Commission to adopt a fee schedule limiting reimbursement to "an index or indexes based on acquisition cost" and may include "reasonable" dispensing fees.
- Hawaii HB 205 would provide that workers’ compensation payments for non-prescription, over-the-counter, or non-legend drugs be at cost plus 40%. For comparison, under current law, prescription medications are reimbursed at AWP plus 40%. The bill also states:
- Payment shall not be authorized unless the drug has been clinically established as necessary by the provider to treat the injured employee for a work injury
- Providers may seek reimbursement for any applicable Hawaii general excise tax.
Other legislation
Several other newly introduced bills would impact the provision of medical services in workers’ compensation, including bills related to:
- Presumptive coverage for first responders for conditions such as cancer and PTSD
- Physician networks
- Medical fee schedules
In addition, there are bills seeking to further regulate pharmacy benefits managers (PBMs) as a whole, some of which would apply to workers’ compensation.
MyMatrixx is tracking it all
The MyMatrixx Regulatory Affairs team continually tracks and monitors the growing list of newly introduced and pending legislation throughout the year. Statistically, most bills introduced each year do not make it through the legislative process to become law, and accurately predicting their chances of becoming law early on is not always possible. However, several bills we will track this year will pass. Our team will engage with policymakers and clients where appropriate and advantageous to ensure good public policy for our industry.
For a broader snapshot−or the details−of the legislation we are tracking across the country, visit the Legislative and Regulatory Policy Tracker on our Statehouse Watch webpage where you can sort bills by topic and state.
Questions for our Regulatory Affairs team can be sent to MMXRegulatoryAffairs@MyMatrixx.com. For more information on policy developments in workers’ compensation impacting pharmacy across the country, please visit and bookmark Statehouse Watch at MyMatrixx.com.
In 2024, the New Mexico Workers’ Compensation Administration (WCA) proposed rule changes to several areas of their regulations, including 11.4.7.9 (D)(6), which would impact the provider dispensed days’ supply limit and prior authorization for renewal prescriptions. Recently, these proposed rule changes were withdrawn by the state. As explained in our October 2024 post, the changes would have increased the days’ supply requirements from 10 days to 14 days and would have disallowed reimbursement for “renewal or refill” prescriptions if pre-authorization was not obtained.
The WCA withdrawal was a result of multiple negative public comments submitted. MyMatrixx submitted comments to support more control of physician dispensing, and we suggested some clarifying language. For now, this section of the rule in Part 7 will remain unchanged. Other proposed changes to Part 7 were also withdrawn. The state has concluded these topics may be addressed in future rule making.
However, the WCA did adopt other proposed changes regarding payment of claims, claims resolution and proof of coverage. See this link for further detail.
Moving Forward
In light of the public comments received, the WCA noted it will resume work on Part 7 in future rulemakings. MyMatrixx will track any related developments.
Questions on this topic for our Regulatory Affairs team can be sent to MMXRegulatoryAffairs@MyMatrixx.com. For more information on policy developments like this in workers’ compensation impacting pharmacy in states across the country, please visit and bookmark Statehouse Watch at MyMatrixx.com.