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.
California proposed updates to workers’ compensation treatment guidelines
Following updates from the American College of Occupational and Environmental Medicine (ACOEM), the California Division of Workers’ Compensation (DWC) has proposed the following updates to its Medical Treatment Utilization Schedule (MTUS) treatment guidelines, which once adopted are to be presumed correct on the issue of extent and scope of medical treatment in California workers’ compensation claims:
- Shoulder Disorders
- Elbow Disorders
- Hand, Wrist, and Forearm Disorders
- Traumatic Brain Injury
A public hearing is scheduled for September 26, 2025, with written comments accepted no later than that date.
Colorado proposed workers’ compensation pharmaceutical fee schedule and billing changes
The Colorado Division of Workers’ Compensation (DWC) proposed annual updates to DWC Rule 18, the medical fee schedule regulations. Proposed changes include:
- Minimal reimbursement increases for both prescription-strength topical compounds and over-the-counter (OTC) topical medications.
- Removal of two state-specific OTC topical medication billing codes (“Z codes”), which are not necessary for medication identification and are not supported by the DWC-adopted national pharmacy billing standards. This change is in response to a recommendation from MyMatrixx by Evernorth.
- Minimally increased fees to authorized treating physicians for completion of a written report of certain opioid review services.
A public hearing on these proposed changes is scheduled for September 15, 2025, with written testimony being accepted up until the end of the hearing. MyMatrixx intends to submit public comments in support of removing the state-specific OTC topical medication billing codes. We have also been collaborating with the National Council for Prescription Drug Programs to submit comments as the national pharmacy transaction/billing standards organization.
Newly enacted New Jersey law requires employer coverage of work-related mental health counseling for first responders
A recently enacted New Jersey bill (A 5792) requires an employer to provide up to 12 hours of paid confidential counseling with a mental health professional to a first responder who experiences a “critical incident” in the course of their employment. The counseling is in addition to the benefits already provided by an employer-sponsored health plan or a group health insurance trust fund. The employer will also be required to pay for up to an additional 24 hours of counseling if the mental health professional determines the first responder would benefit from additional hours of licensed counseling. The bill outlines:
- The first responder may select the mental health professional who will conduct the counseling.
- All licensed counseling hours are required to be completed within one year after the first responder's first visit.
- A “critical incident” is defined by events such as firing a weapon, being involved in an exchange of gun fire, receiving a serious bodily injury, witnessing certain serious bodily injuries and deaths, hostage situations, terrorist attacks, and being involved in certain investigations related to minors.
- A “first responder” also includes a 9-1-1 dispatcher
Tennessee workers’ compensation claims handling rules updated and proposed fee schedule changes submitted for review
The Tennessee Bureau of Workers’ Compensation (BWC) adopted changes to its claims handling standards rules that will become effective November 10, 2025. Some of the changes require:
- Each adjusting entity to designate at least one contact person/liaison with the ability to provide information to medical providers, injured workers, and the BWC for the resolution of disputes about billing, bill review, preferred provider networks and associated discounts, and the status of medical benefits payments.
- Certain healthcare providers to, upon request by the BWC, designate at least one contact to provide complete information about medical coding and the submission and reimbursement of medical bills, records requests, and forms completion.
In separately proposed rule updates related to medical fee schedules, the BWC had also initially added “the Medicare negotiated price” in its “lesser of” pharmaceutical reimbursement methodology. Following a recommendation from MyMatrixx, the BWC agreed to hold off on including the Medicare negotiated price incorporation in the submitted changes. Any final, approved medical fee schedule rule changes would likely carry a 90-day implementation timeframe. Those updates are under a pending rulemaking process that involves review by the state Attorney General’s office before becoming final.
Washington workers’ compensation formulary updated
The Washington State Department of Labor & Industries (L&I) announced changes to its outpatient drug formulary, effective October 1, 2025. The changes include the addition of the following new drug classes:
- Factor XII Inhibitors
- Eye Antibiotic and NSAID Combinations
- Ophthalmic TRPM8 Agonists
- Topical Nitric Oxide Releasing Agents
- Antineoplastic - Systemic Enzyme Inhibitors Combinations
The drug formulary is a list of therapeutic classes and drugs that are covered under L&I's drug benefit. Drugs listed on the formulary do not guarantee coverage and may be subject to specific L&I policy and determination of appropriateness for the accepted conditions. Although Washington is a “monopolistic state,” it permits employers to self-insure their own workers’ compensation claims.