Recent legislative and regulatory activities impacting workers' compensation pharmacy in CA, ID, and PA
MyMatrixx by Evernorth Regulatory Affairs team tracks and monitors legislation and regulations impacting workers’ compensation pharmacy nationwide.
California proposed MPN regulation changes
The California Division of Workers’ Compensation (DWC) has officially proposed revisions to its Medical Provider Network (MPN) regulations following stakeholder feedback from last year during a “forum” period.
Among other changes, the proposed updates would:
- Allow MPN applicants to submit certain materials electronically
- Simplify resubmissions for previously approved and unchanged MPN plans
- Establish a process for terminating MPNs that are no longer in use
- Require MPNs to post provider directories on their websites without a password
- Require providing participating providers with the MPN’s name, identification number, and other required notices before listing them in the network
For MPNs that include “ancillary services” providers (includes pharmacies), the proposed changes would:
- Require additional provider information, including filing applicable licensing information and maintaining an online roster of ancillary providers
- Establish requirements for ancillary providers offering “remote” services, including pharmaceutical services.
- Implement additional penalties, including for MPN applicant failure to provide required notices to each participating provider.
A virtual public hearing on the proposed changes has been scheduled for December 11, 2026, with written comments also due by that date. MyMatrixx by Evernorth encourages clients with MPNs to review the proposed changes, particularly for impact to incorporation of pharmacies within their MPNs.
Idaho workers’ comp subcommittee on physician dispensed medications
The Idaho Industrial Commission’s Advisory Committee on Workers’ Compensation has established a subcommittee to examine and research physician dispensed medications and then provide recommendations.
In the first meeting on October 19, 2026, the subcommittee discussed cost concerns associated with certain physician dispensed medications as compared to the costs of medications dispensed through retail pharmacies and/or pharmacy benefit manager (PBM) networks. While much of the focus was on topical medications, the cost issue also extended to oral medications. ‘NDC shopping’ (selecting national drug codes with higher reimbursement values) was also discussed. The MyMatrixx Regulatory Affairs team took part in the meeting and offered to provide information on what other states have done to address these concerns.
Of note is that Industrial Commission regulation changes from 2025 established a reimbursement limitation on any physician dispensed medication (including topicals) not to exceed the lesser of the average wholesale price (AWP) of the drug or 130% of the AWP for the lowest-cost therapeutic equivalent drug. The fee schedule also states that physicians are not to receive a dispensing or compounding fee. While this fee schedule change targeted one-for-one equivalent medications and capping their costs, the subcommittee did discuss whether some providers are bypassing this cap by using similar medications with no one-for-one equivalent.
Pennsylvania workers’ comp pharmacy bill dead
With the Pennsylvania legislative session winding down, the prospects for passing Senate Bill 1215, which addresses “excessive costs” for topical and compounded medications in the state’s workers’ comp system, are gone. The bill, which stalled after passing out of the Senate Labor & Industry Committee in June, would have:
- Required compound billing and reimbursement based on the ingredients
- Added caps on compounds and topicals based on certain dollar amounts
- Incorporated the Federal Upper Limit (FUL) as part of a “lesser of” reimbursement methodology in capping non-compounded topicals
Of note, SB 1215 would not have removed the existing fee schedule’s reference to average wholesale price, which has been the source of notable litigation still pending with the Pennsylvania Supreme Court. While the outcome of the ruling is uncertain, industry groups forecast that the eventual resolution may prompt attempts to change the law in 2027.
The MyMatrixx Regulatory Affairs team joined other stakeholders in providing input on this bill.
SAWCA conference this month
The Southern Association of Workers’ Compensation Administrators (SAWCA) will hold its 2026 All Committee Conference November 16 – 20 in White Sulphur Springs, West Virginia.
SAWCA is an organization made up of 22 workers’ compensation jurisdictions (state agencies) and many other industry organizations from across the country. MyMatrixx by Evernorth is a SAWCA associate member and the sponsor of this year’s conference Regulator Roundtable. The conference provides opportunities for regulators and industry participants, like MyMatrixx, to share perspectives and best practices to improve workers’ compensation systems in multiple states.