It has been a busy year for state legislatures with many bills introduced that would impact the workers’ comp industry and pharmacy benefit managers (PBMs). Bills around PBM licensure, pricing, therapeutic psilocybin, and direction of care were a major focus for MyMatrixx as those topics directly impact our services and our clients.
All but 11 states have concluded their activity for 2024. The following summarizes the 2024 legislative session with the status the bills that have either failed, been vetoed, are still pending, or have been enacted.
You can also always track the status of the latest bills on our online Policy Tracking Map.
PBM Licensure Bills
Of the 48 PBM Licensure bills introduced in 2024, the following have greatest impact on the workers’ compensation marketplace.
Louisiana bill, LA HB 603 was enacted and went into effect August 1, 2024. This bill changes pharmacy auditing regulations for claims and records of pharmacies and pharmacists and includes standards for audits, claims and quality assurance reviews.
Oklahoma bill, SB 1670 was enacted and went into effect May 22, 2024. Focused on the Pharmacy Audit Integrity Act and pharmacy reimbursement, this bill provides for audits and reviews of pharmacy records and removes the potential requirement for a pharmacy to submit prescription copies for a review of a claim.
These remaining bills were not enacted in their respective states but may be reintroduced in future legislative sessions.
| State | Bill # | Status | Language |
| Minnesota | MN HB 5470 | Failed | Mandates reimbursement at NADAC or higher; prohibits spread pricing |
| Missouri | MO HB 1627 | Failed | Required pass through pricing |
| Missouri | MO SB 1105 | Failed | Prohibits spread pricing |
| Missouri | MO SB 1213 | Failed | Required PBM reporting |
| Oklahoma | OK SB 1390 | Vetoed by Governor | Providing certain fines and fees; creating Attorney General's Pharmacy Benefits Manager Enforcement |
Direction of Care
The use of network pharmacies is a valuable tool to maintain transparent prescription management programs in place. This helps ensure medication safety for the injured worker and cost control for the employer. In 2024, several bills were introduced with the potential to negatively impact pharmacy networks.
While most of these bills were not enacted, New York bill, NY SB 1974 remains in review with the Governor. This bill would restrict an employer from directing an injured worker to use a network pharmacy under these conditions:
- The employer or insurance carrier refused payment of a medication through a network pharmacy as it wasn’t authorized within 72 hours of such request; or
- The employer or carrier failed to reauthorize a medication within 72 hours of the request for any of these reasons:
- Lack of response to the reauthorization request
- Medical reports not filed for reauthorization or contain a defect
- Medical treatment guidelines do not support reauthorization
- Independent medical examiner disagrees with reauthorization
- Maximum medical improvement has been reached
- The case is in the process of being settled
The non-network, chosen pharmacy that agrees to dispense the prescribed medication shall adhere to:
- Reimbursement amounts per state fee schedule;
- NY medical treatment guidelines for which the medication is prescribed;
- Follow NY pharmacy formulary; and
- Assume all liability for charges for such prescribed medication if a case is not established or if the prescribed medication is not later approved.
| State | Bill # | Status | Language |
| California | CA AB 1278 | Failed | Added regulation to Medical Provider Network creating more administration to operationalize Direction of Care in the state. |
| New York | NY AB 1219 | Failed | Imposes regulations on Direction of care |
| New York | NY AB 334 | Failed | Directing care would become optional for employees |
| Oklahoma | SB 1390 | Vetoed by Governor | Patients Right to Pharmacy Choice Act. |
| Wyoming | WY HB 173 | Failed | A person’s choice of in network provider shall include a retail pharmacy. |
Pricing
Legislation on dispensing fees, pricing methodologies, and price adjustments are always of interest for employers, insurers, and the workers’ compensation industry. The following bills:
Pending Illinois bill, IL HB 4548 would prohibit spread pricing with PBM contracting. The bill includes medication reimbursement not lower than National Average Drug Acquisition Cost (NADAC) plus a professional dispensing fee of $10.49. Also includes rebate audit access at least once per plan year.
Louisiana bill, LA SB 640 was enacted and went into effect August 1, 2024. The bill states that No PBM shall reimburse a pharmacy or pharmacist in this state an amount less than the acquisition cost for the covered drug.
Kentucky bill, SB 188 was enacted and will go into effect January 1, 2025. This bill changes the definition of Health Plan and imposes reimbursement dispense fee at no lower than NADAC and not less than Medicaid, currently $10.64.
| State | Bill # | Status | Language |
| Iowa | HSB 640 | Failed | Mandated passthrough pricing and prohibited spread pricing. |
Therapeutic Psilocybin
Over the last few years, therapeutic psilocybin has been debated in the state houses as a treatment for mental health conditions such as end of life psychological distress, alcohol use disorder, depression, and anxiety. While Oregon and Colorado have already legalized psilocybin-assisted therapy and decriminalized the personal possession of drugs, it is still illegal on the federal level. It is under review by the Federal Drug Administration (FDA), and if approved, it will have an impact on some injured workers treatments. Until then, states grapple with how to legitimize this alternative treatment for patients.
Pending Alaska bill, AK HB 228 would establish a task force for the regulation of psychedelic medicines approved by the FDA. The task force would prepare for the potential medicalization of psychedelic medicines and make policy recommendations to the Alaska State Legislature concerning insurance and licensure.
Indiana bill, IN HB 1259 was enacted and will be in effect July 1, 2024 − July 1, 2025. The bill states that a research institution may apply for state financial assistance to conduct a clinical study to evaluate the efficacy of psilocybin as an alternative treatment for mental health and other conditions, including:
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Group Health PBM Bills
MyMatrixx is dedicated to monitoring the legislative and regulatory activities that impact the workers’ comp industry and our clients. While the following PBM legislations are targeted for group health and currently do not impact workers compensation, we often find that what begins with group health PBMs, often makes its way to the workers’ compensation industry. It’s important for us to track these bills as well so we can inform clients of potential changes and advise on how to move forward as appropriate.
| State | Bill # | Status | Language |
| Alabama | AL HB 238 | Failed | Prohibits a PBM to reimburse an in-network pharmacy an amount that is less than or more than the acquisition cost plus a professional dispensing fee equal to the fee paid by the state. |
| Arizona | AZ SB 1164 | Failed | An insurer, PBM or Utilization Review Agent, must uphold or reverse a determination to deny a coverage within 72 hours of receipt and appeal of denial. |
| California | CA HB 913 | Failed | No PBM shall reimburse a pharmacy or pharmacist an amount less than the acquisition cost for the covered drug. |
| California | CA SB 966 | Pending | Imposes duties on PBMs and requirements for PBM services and PBM contracts, including requiring the use of a passthrough pricing model. Creates the PBM Fines and Penalties Account into which civil fines and administrative penalties would be deposited. |
| Georgia | GA SB 289 | Failed | Required PBM reporting |
| Iowa | IA HB 2401 | Failed | Required pass through pricing |
| Indiana | IN HB 1332 | Enacted | Regarding registration of insurers and rebates.
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| North Carolina | NC HB 246 | Pending | Limits the use of spread pricing, fees, and rebates |
| New Hampshire | NH SB 555 | Pending | Adds new reporting requirements for PBMs |
| Oregon | OR HB 4149 | Enacted | Provides a licensure requirement for PBMs. Mandates reimbursement for dispensing fee must be no lower than $10 per prescription and prohibits adjudication fees for a pharmacy. |
| Pennsylvania | HB 1993 | Enacted | Implements PBM licensure requirements, Transparency reporting, analysis of spread pricing, NADAC & $10. 49 Dispensing fee. Penalties for violation not more than $1000,000 - aggregate penalty of $1,000,000PA. Effective 90 days from July 17, 2024 |
| Pennsylvania | PA SB 1000 | Pending | Prohibits spread pricing, Direction of Care and requires development of NADAC guidelines |
| Rhode Island | RI SB 106 | Pending | Requires PBM reporting, prohibits spread pricing and mandates pass through pricing. |
| Rhode Island | RI SB 2385 | Pending | Prohibits spread pricing and restricts PA and fines of up to $10,000 fine per violation. |
| Rhode Island | RI SB 2395 | Pending | Imposes pricing mandate - requiring a NADAC floor + Medicaid rate for dispensing fees. |
| Virginia | VA HB 1041 | Pending | Requires transparency and PBM income must be derived from a PBM fee. |
| Washington | HB 5213 | Enacted | Imposes regulations for pharmacy auditing and mandates pass through pricing. |
| Wisconsin | WI AB 773 | Failed | Mandated reimbursement at a NADAC Floor with Medicaid Dispensing fee. |
MyMatrixx Actions
MyMatrixx monitors the progress of all bills that impact the workers’ comp industry, and we will continue to advocate on behalf of our clients. If you have questions on any of the above bills, please contact your MyMatrixx Account Management team.
This communication is for informational purposes only and does not constitute legal advice. It should not be relied upon as legal advice.