Updates on recent legislative and regulatory activity impacting workers' compensation pharmacy
The MyMatrixx by Evernorth Regulatory Affairs team continually tracks and monitors legislation and regulations 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.
California proposed workers’ compensation treatment guideline updates
The California Division of Workers’ Compensation proposed additional changes to its Medical Treatment Utilization Schedule (MTUS) guidelines to incorporate the following updated guidelines from the American College of Occupational and Environmental Medicine (ACOEM):
- General Approaches - Initial Approaches to Treatment (ACOEM December 22, 2025)
- Eye Disorders Guideline (ACOEM December 22, 2025)
- Chronic Pain Guidelines (ACOEM December 22, 2025)
A virtual public hearing is scheduled for February 27, 2026, with written comments also due that day. Adopted MTUS guidelines are presumed correct on the issue of extent and scope of medical treatment in the state’s workers’ compensation system and are intended to guide treatment decisions in most cases.
Georgia workers’ comp bill would permit pharmacy direction of care and place conditions on prescribers
Georgia House Bill 1119, introduced in early February, would amend the workers’ compensation law to permit employers to use a “pharmacy management network” and require injured workers to use contracted network providers.
Additionally, the pharmacy management networks would:
- Reimburse third-party billers accepting assignment of bills from network providers at the agreed upon contractual amount
- Be required to register with the state’s Board of Workers’ Compensation and pay a fee.
- Need to meet certain standards for dispute resolution, prompt reimbursement, audit practices, and restrictions on fees charged to network providers, along with offering a mail-order option for obtaining medications.
Certain notices to employees and dispensing providers not part of the network would also be required to implement and enforce a network, and employees would not be required to use a network provider for controverted or disputed claims until compensability is established and notice of compensability is provided to the injured worker.
The bill outlines the following requirements for prescribing providers and dispensing providers for injured workers:
Prescribing providers would be required to:
- Document medical necessity of an off-label medication, obtain prior authorization, and be limited to prescribing a 30-day supply.
- Document the consideration of FDA-approved commercially available drugs and medical reasons for any compounded medication, obtain prior authorization, and be limited to prescribing a 90-day supply total to be provided in 30-day supply increments.
Dispensing providers, unless they are contracted with a pharmacy management network, would be limited to dispensing the following in the first seven days following the date of injury:
- A single five-day supply for Schedule II and III drugs
- A single 14-day supply for all other medications
Dispensing providers who are contracted with a pharmacy management network would not be subject to these limitations or reimbursement standards and may dispense medications to injured workers based on the provisions in the network contract.
This bill is similar in some of its pharmacy network provisions to separate legislation also introduced earlier this year in Arizona (HB 2813). MyMatrixx by Evernorth intends to voice support for both bills individually and/or through our trade association.
Proposed New Jersey bills would require cannabis coverage and allow barring providers from auto insurance system
New Jersey Assembly No. 1023 would require an employer or workers' compensation insurer, a private passenger automobile insurer, or health insurer to provide coverage for costs associated with the medical use of cannabis by insured individuals, unless there is intervention by the federal government to enforce the Controlled Substances Act. If payment by the insurer to the medical cannabis dispensary is not feasible, the insurer is to remit proof of payment to the dispensary directly to the insured for the costs for any benefits associated with the medical use of cannabis.
Meanwhile, New Jersey Senate No. 2314, would allow the state’s Department of Banking and Insurance (DOBI) to investigate and bar certain health care providers from receiving reimbursement under the state’s auto insurance system. The bill allows investigations into providers suspected of misconduct; incompetence; negligence; fraudulent reporting; improper solicitation; refusal to cooperate with regulators; or engaging in patterns of billing for services which were never rendered, are of no diagnostic value, or are medically unnecessary. After notice and an opportunity to be heard, DOBI may temporarily suspend or permanently bar a provider from receiving auto-related payments. DOBI would also be required to compile a list of providers who are barred from demanding, requesting, or collecting reimbursement. Barred providers would also be prohibited from treating auto claimants privately for remuneration.
Both bills were introduced in January and referred to their first committees. Similar bills on both topics have been introduced in past years, but they have not yet succeeded.
New York governor “State of the State” proposes to open up workers’ compensation to more providers and combat fraud
In her annual “State of the State” proposals for 2026, New York Governor Kathy Hochul included a proposal to allow any eligible licensed medical provider in good standing to treat workers’ compensation claimants. Existing law requires special authorization for providers treating workers’ compensation claimants, and the governor’s proposal stated that only about ten percent of eligible providers have gone through that authorization process. Hochul’s proposal argued, “Cutting this red tape will open the door to thousands more primary care providers and specialists who can help people heal and get back to work faster.” A similar proposal was included in Hochul’s 2025 “State of the State” but ultimately was not enacted in law through legislation.
This year’s “State of the State” proposals also included a plan to advance legislation that allows the Workers’ Compensation Board to offer resources that will allow district attorneys to establish dedicated workers’ compensation fraud units, to ensure they have they have the necessary resources to investigate and prosecute these crimes, “ultimately protecting honest workers and helping to reduce costs for businesses across New York State.” These proposals were subsequently included in budget bills introduced in January and currently pending in the legislature.
Ohio workers’ compensation pharmacy fee schedule updated
Ohio Bureau of Workers’ Compensation (BWC) amendments to rules governing the workers’ compensation pharmacy fee schedule were approved and filed with an effective date of February 16, 2026. Both state fund and self-insuring employer fee schedule rules were updated. For MyMatrixx and our clients, changes to the self-insuring employer rule included:
- Decreasing the non-sterile compound cap to $100 (from $400) to align with the state fund claims cap
- Amending compounding dispensing fees to be based on compounding time (multiple categories)
- Accounting for when a different dispensing fee may be required by another state’s law when the medication is dispensed outside of Ohio
- Adjusting some language addressing when an employer may override dispensing or refill limitation denials
- Amending some language for conditions under which an employer may approve brand name drug reimbursement when a generic equivalent exists
MyMatrixx submitted recommendations during the lengthy rule making process, which were agreed upon by the BWC and incorporated into the rule language.