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.
Differences between commercial and workers’ comp PBMs reviewed at recent hearing
The Oklahoma House of Representatives Appropriations and Budget Health Subcommittee held a hearing entitled “PBMs: Evaluating the breakdown of drug costs in Oklahoma” on November 3. Representatives of different trade groups, interests groups and state officials testified in the meeting and were questioned by legislators. Much of the testimony and questioning was anti-PBM and covered pharmacy claims of not being adequately reimbursed along with concerns with health insurance member access to community pharmacies.
On behalf of workers’ compensation industry, the American Association of Payers, Administrators and Networks (AAPAN), a trade association MyMatrixx by Evernorth is a member of, also testified. AAPAN’s testimony highlighted the many differences between workers’ compensation and commercial health insurance PBM policies.
In his testimony, Scott Biggs, an Oklahoma Workers’ Compensation Commission Commissioner, highlighted how existing pharmaceutical regulations in workers’ compensation may indirectly impact PBM activities including:
- Fee schedules
- Adopted drug formulary
- Dispute handling (exclusive jurisdiction in workers’ comp claims)
In its closing remarks, the Pharmaceutical Care Management Association (PCMA), which represents commercial health PBMs, emphasized the need to understand the different plan types in the system and how they should or should not be regulated.
As discussed in a prior blog post, MyMatrixx works through our trade associations to educate policymakers on the differences in workers’ compensation and the consequences these broader health insurance PBM bills may have. For example, the workers’ compensation industry often focuses on payers wanting to control high medication costs; in contrast, discussions targeting PBMs more broadly often focus on a desire to increase reimbursement to pharmacies for medications.
Earlier this year, MyMatrixx worked with AAPAN and the Oklahoma Workers’ Compensation Commission chairman to secure a workers’ compensation exemption from an Oklahoma PBM bill’s pharmacy guaranteed profitability provision. The provision would have required a minimum reimbursement to pharmacies, which was in conflict with the state’s workers’ comp maximum fee schedule and also tripled the required dispensing fee. This provision was later stricken from the bill entirely.
Oregon schedules stakeholder meeting on workers’ compensation medical rules
The Oregon Workers’ Compensation Division scheduled a rulemaking advisory committee meeting to review potential changes to various medical rules (including fee schedules). The meeting is scheduled for November 18, 2025. The Division will post an agenda here. To RSVP for the meeting, which may be attended in-person or virtually, or for more information, reach out to Marie Rogers, the Division’s Policy Analyst/Rules Coordinator at marie.a.rogers@dcbs.oregon.gov. MyMatrixx plans to attend the meeting.
Pennsylvania workers’ comp bill would expand employer direction of care
Pennsylvania House Bill 1998, formally introduced in late October, would extend the ability of employers to direct care to a panel of providers. Current state law permits employers to require use of designated providers for the first 90 days of treatment. This bill would remove references to that 90-day limit, thereby extending the employer’s direction of care ability throughout the claim lifecycle. Similar to existing law during the first 90 days, the bill would still require the provider panel to be a list of at least six designated health care providers, no more than four of whom may be a coordinated care organization and at least three of whom must be physicians.
The bill’s author argued in his earlier co-sponsor memo, “Providing for a network option is a reasonable middle ground approach that will help control costs, prevent and combat fraud and abuse and make Pennsylvania more competitive; all while helping to ensure that quality care and employee health remain the top priority.” It is important to note that existing state workers’ compensation regulations permit insurers to contract with pharmacies but prohibit them from requiring injured workers to use those designated pharmacies.
Tennessee workers’ compensation fee schedule rules updated
Amendments to medical fee schedule, medical payments and inpatient hospital fee schedule rules adopted by the Tennessee Bureau of Workers’ Compensation (BWC) were all recently approved. For pharmaceuticals, notable adopted changes included an amendment to the average wholesale price (AWP) publication frequency to be based on the “the current pricing information for that date of service” rather than the “appropriate monthly publication” and a correction to the “lesser of” pharmaceutical reimbursement calculation language to clarify it includes the provider’s usual charge.
The originally proposed rules would have added the Medicare negotiated price to the pharmaceutical “lesser of” reimbursement calculation. The “Medicare negotiated price” referred to a new program at the federal Medicare level that will only cover a very small amount of brand drugs (only 10 planned for 2026), several of which are of lower-to-no volume of use in workers’ compensation claims; negotiation is specific to coverage under the Medicare Part D program and only for drugs dispensed from pharmacies for Part D beneficiaries.
MyMatrixx and others submitted comments opposing the proposed addition of the “Medicare negotiated price” into the fee schedule, and the BWC accepted our comments and removed it from the final adopted language. MyMatrixx also recommended the BWC change the AWP publication frequency language from “monthly” to most recent and correct the “lesser of” pharmaceutical reimbursement calculation language to clarify it includes the provider’s usual charge; the BWC included both of those recommendations in the final adopted language.
IAIABC seeks help in researching new medical reporting format
The EDI Medical and ProPay Committee of the International Association of Industrial Accident Boards and Commissions (IAIABC) is forming a work group to explore the viability of developing and using XML for workers’ compensation payers to send medical bill data to states. Existing IAIABC Medical EDI (electronic data interchange) reporting standards, which are currently used by four states (California, Oregon, Texas and Washington), are based on the X12 medical billing standards.
At the IAIABC’s annual convention in October, it was discussed that X12 can be challenging to develop and may create entry barriers for some jurisdictions, while XML could offer a more flexible and accessible alternative. However, it was determined that a closer look was needed to understand what that would really involve. To that end, plans for the developing work group include digging into some key areas:
- How XML could work for medical data exchange
- What changes would be needed (like data element naming)
- Review of X12’s proprietary standards
Participation in the work group will be limited to individuals whose organizations are IAIABC EDI or jurisdictional members. To request to participate, or for more information, contact Katia Woerner, IAIABC’s Standards Development and Outreach Director (kwoerner@iaiabc.org). More information on the IAIABC’s EDI Medical and ProPay Committee and reporting standards can be viewed here. MyMatrixx is an IAIABC EDI member and involved in multiple committees, including the EDI Medical and ProPay Committee.