Updates on recent legislative and regulatory activity impacting workers' compensation pharmacy
The MyMatrixx by Evernorth Regulatory Affairs team continually tracks and monitors legislation and regulation impacting workers’ compensation pharmacy. Below are some updates on more recent developments. You can follow many of these measures and more with our online tracker.
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.