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 proposes updates to workers’ compensation mental health guidelines
The California Division of Workers’ Compensation proposed updates to two of its Medical Treatment Utilization Schedule (MTUS) guidelines: the Workplace Mental Health Guideline and the Posttraumatic Stress Disorder Guideline. Both are updates from the American College of Occupational and Environmental Medicine (ACOEM) dated October 1, 2025. A virtual public hearing is scheduled for December 19, 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.
Illinois PBM bill passes with exclusion for workers’ compensation
Illinois House Bill 767 was passed in late October and is awaiting governor action (we expect it to be signed). The bill was intended to amend and clarify (sometimes referred to as a “trailer bill”) the new requirements imposed on pharmacy benefit managers (PBMs) hastily passed earlier this year in a larger bill. Among other changes, HB 767 clarifies an express exclusion for workers’ compensation plans. The net result is that the PBM law, as amended, will clearly not apply to workers’ compensation.
There has been a trend of policymakers seeking to add requirements and limitations on PBMs without acknowledging that workers’ compensation may not fit into those broader health insurance policy goals. MyMatrixx by Evernorth works individually and through our trade associations to educate policymakers on the differences in workers’ compensation and the consequences these broader bills may have. We discussed this issue and provided examples in a prior blog post.
Michigan bill aims to shorten workers’ compensation employer direction of care timeframe
Michigan House Bill 5182, introduced in late October, would shorten the timeframe in which an employer may chose an injured worker’s physician from 28 days after inception of medical care to 10 days after notice of injury. The bill has been referred to the House Committee on Economic Competitiveness and includes the following provisions:
- A presumption that treatment provided or recommended by a provider of the employee's own choice is “reasonable”
- A requirement for care to be “timely”
- Allowing an injured worker or provider to request preauthorization for payment of medical benefits, with a stipulation that if the employer, insurer or third-party administrator (TPA) does not authorize a request within 10 days, the injured worker may file an application for mediation or hearing to obtain the medical care
- Allowing the imposition of penalties on the employer, insurer, or TPA to pay the “reasonable costs” of litigation and attorney fees at the rate of 30% of the amount of the unpaid charges, reimbursed expenses, or costs of proposed treatment or medication ordered
- A requirement for providers to submit bills within 60 days using a state-agency prescribed form, with a loss of the right to collect payment if not submitted within 180 days.
Nevada posts new workers’ compensation formulary FAQ
With the pending implementation of the ODG Drug Formulary in Nevada scheduled for 2027, thanks to legislation (SB 317) signed earlier this year, the Nevada Division of Industrial Relations (DIR), Workers’ Compensation Section (WCS) posted a new frequently asked questions (FAQ) document on that legislation.
Included in the FAQ are formulary topics such as formulary access, formulary updates, implementation dates, and authorization process requirements.
Per the law, implementation of the formulary is not until July 1, 2027, with an outlined transition period for a certain subset of claims based on date of injury and prescription history until January 1, 2028. As part of the state’s educational efforts, ODG also hosted a webinar, “The ODG Drug Formulary: A Comprehensive Guide for the State of Nevada,” on November 5.
MyMatrixx provided an overview of SB 317’s formulary provisions in a Statehouse Watch blog post in June and an update on the DIR’s notice of formulary adoption in September. Our Regulatory Affairs team attended the state’s annual conference in September, where information on the formulary was presented, and offered our assistance to DIR leadership as they plan for training and implementation, followed up by an individual meeting with DIR in October. We were also provided an earlier draft of the FAQ and were able to recommend content for it that was incorporated.