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.
Mississippi medical fee schedule updates adopted with multiple changes
The Mississippi Workers’ Compensation (WCC) adopted updates to its medical fee schedule (including pharmacy), effective June 1, 2026. Notable highlights included:
- Decreased base fee schedule rates for both brand and generic medications
- Set new limitations on coverage and reimbursement for physician dispensed medications
- Modified reimbursement caps and authorization requirements for certain compounds and topicals
- Added language addressing repricing agreements
- Added clarification on when an explanation of review is required
- Increased request timelines for reconsideration and dispute resolution
- Updated pain management rules
MyMatrixx by Evernorth submitted comments to the WCC during the proposed rulemaking that included recommendations to:
- Clarify the scope of the new physician dispensing limit
- Remove their originally proposed state-specific billing codes for topical compounds
Both recommendations were accepted and the WCC adjusted in response to them. MyMatrixx and others also inquired with the WCC about a removed pre-existing cap on manufactured topicals, which still needs to be clarified.
New York workers’ comp anti-pharmacy network bill progresses − again
New York Senate Bill S 9331 passed its first chamber on May 11. This is one of the re-introduced workers’ comp anti-pharmacy network bills, which would allow use of out-of-network pharmacies under additional conditions. The bill goes beyond recently amended Workers’ Compensation Board (WCB) rules to provide several other ‘outs’ from networks, including a potential long-term out-of-network option with the statement: “Such pharmacy shall be permitted to continue to dispense such prescribed medication to the claimant outside of the contracted network after payment or reimbursement for the prescribed medication is established.” A similar bill, A 10413, is also pending in the Assembly. MyMatrixx is working through our trade association to voice opposition again this year.
Both bills are similar – yet modified – from others that have passed over the last two years but were then vetoed by New York Governor Kathy Hochul. In a previous veto message, Hochul noted the bills would increase litigation, add bureaucratic steps for the WCB, and result in further delays in obtaining needed medication. In response, the WCB amended its regulations in 2025 to provide a process for out-of-network pharmacy use in situations where there is a non-established body part or condition. Hochul referenced those adopted regulation changes in her last veto message.
More Oklahoma PBM bills vetoed
Two bills targeting pharmacy benefit managers (PBMs) were vetoed by Oklahoma Governor Kevin Stitt in early May.
Senate Bill 2007 would have made amendments to reimbursement appeals procedures between PBMs and pharmacies.
Senate Bill 1500 would have added a required − and shorter − provider payment timeframe, which conflicts with the workers’ compensation law’s required provider timeframe for PBMs and all “payers” (broadly defined). This bill was another example of broader PBM legislation failing to account for the uniqueness of workers’ comp and thereby conflicting with the workers’ comp law. MyMatrixx voiced concerns with the bill through our trade association.
Unique West Virginia PBM bill enacted
West Virginia House Bill 5430, signed on April 1, 2026, amends the state’s PBM law. One of the bill’s most notable provisions prohibits PBMs from charging a private payer (regardless of contractual agreements) an amount greater than the national average drug acquisition cost (NADAC) for a drug, even if the pharmacy was reimbursed more than that amount (if under a contract). If, however, NADAC is not available, the PBM would not be able to charge an amount greater than the amount the PBM paid the pharmacy.
Complicating the new requirement is a provision under current law that requires a PBM to reimburse a West Virginia pharmacy for drugs at least NADAC (or Wholesale Acquisition Cost [WAC] if no NADAC) plus a $10.49 dispensing fee (a mandated reimbursement ‘floor’ regardless of agreed-to contracted rates, which tends to raise costs for health benefit plans).
HB 5430’s new restriction on what a PBM can charge will likely have unintended consequences on the overall pharmacy payments to comply with the amount charged to a payer by a PBM, including in workers’ comp claims. In addition, the bill carried with it an “in effect from passage” tag, which means its effective date is before the governor actually signed it, making it even more of a conundrum.
Given the unique quirks in this legislation and its retroactive effective date, additional guidance for stakeholders on how to comply with the new law, including regulation updates to account for it, will likely be needed from the West Virginia Offices of the Insurance Commissioner (the state agency charged with implementation and enforcement of the PBM law). MyMatrixx has been pursuing that agency guidance through our trade association. This new law impacts PBMs broadly, not just in the workers’ comp market.