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.