Recent legislative and regulatory activities impacting workers' compensation pharmacy in AZ, OH, and TX
The MyMatrixx by Evernorth Regulatory Affairs team tracks and monitors legislation and regulations impacting workers’ compensation pharmacy nationwide. You can follow what's happening state-by-state with our online tracker.
Arizona proposes fifth draft of topical language
The Arizona Industrial Commission (ICA) is now on its fifth round of edits to potential fee schedule changes related to prescription topical medications. The proposed draft was posted on the ICA website and was distributed to interested stakeholders in late July. The latest draft would:
- Initially cap reimbursement for prescription topicals at the lesser of the standard AWP-based fee schedule or $300 for a 30-day supply, pro-rated, plus a single $7 dispensing fee
- Require reimbursement at 120% of the pharmacy’s cost demonstrated by documentation plus a single $7 dispensing fee if a pharmacy dispenses a prescription topical with an acquisition cost that exceeds $300
- Provide that any further dispensing of the same medication following the initial 30-day supply be reimbursed at the lesser of the standard AWP-based fee schedule or $300 for a 30-day supply, pro-rated, plus a single $7 dispensing fee unless the dispensing pharmacy submits specific clinical rationale certified by the treating provider that:
- The specific medication is reasonably required for adequate treatment of the injured worker, and
- No other “less expensive” medication is an option for this patient (inclusive of rationale why or previous options tried)
- Clarify that the added language would not apply to compound topical medications (they are addressed elsewhere in the existing fee schedule)
- Add a new definition of “actual acquisition cost” that borrows from a federal Medicaid-related definition
MyMatrixx by Evernorth continues to provide input on the draft language and previously recommended including the clarifying language that the new provisions would not apply to topical compounds as noted above. We also continue to support the straightforward dollar cap without reliance on a manual documented cost methodology.
Ohio BWC formulary and first fill list updated
The Ohio Bureau of Workers’ Compensation (BWC) adopted updates to its drug formulary and first fill list, effective August 1, 2026. The formulary updates include the addition and removal of some medications and changes in coverage for others. Additions to the first fill list were also made.
The BWC uses its formulary and first fill list for state fund claims that it and its PBM administer; however, self-insuring employers (and their PBMs) are permitted (but not required) to use them. The formulary is a list of medications that can be used for treatment of approved conditions and includes information regarding medication restrictions or limitations. The first fill rule and list specify the circumstances under which the BWC will reimburse for the first fill for medical conditions prior to the date of an initial claim determination order.
Texas seeks input for topicals audit
The Texas Division of Workers’ Compensation (DWC) is soliciting input for its “Topical Analgesic Plan-Based Audit,” by August 6, 2026. The audit will evaluate:
- Prescribers of topical analgesics to ensure prescriptions are “medically necessary, reasonable, and appropriately documented”
- Compliance with the DWC’s adopted Official Disability Guidelines (ODG).
The audit was approved earlier this year as part of their 2026 Medical Quality Review Annual Audit Plan. The draft audit plan can be viewed here. More information can be viewed here.
MyMatrixx did submit feedback on this draft and has previously provided insight on how other jurisdictions have tackled the increased utilization and costs of topical medications in workers’ compensation. We, along with our trade association, also previously submitted comments supporting the selection of topical analgesics to be evaluated.
IAIABC to host PBM legislation webinar
The International Association of Industrial Accident Boards and Commissions (IAIABC) is hosting a webinar on August 20, 2026, titled," PBM Reform Ripple Effect," which will review the impact of broad Pharmacy Benefit Manager (PBM) legislation, which was designed for a fundamentally different system, and how it is making waves in the workers’ compensation system by creating conflicting rules.
The webinar will be presented by members of the American Association of Payers, Administrators, and Networks (AAPAN) PBM Council, including Adam Fowler, MyMatrixx Director of Regulatory Affairs. MyMatrixx by Evernorth is an AAPAN member. Registration is free for IAIABC members. More information can be viewed here