We are just one month into 2025, and already several states are off and running by introducing bills to add new laws or amend existing ones. Below, we’ve outlined some of these bills that, if passed and enacted, would have notable impact on pharmacy reimbursement and medical services coverage in workers’ compensation claims.
Workers’ comp pharmacy reimbursement bills
Several states have introduced bills regarding the provision and reimbursement of pharmaceuticals in workers’ compensation to address who can be reimbursed and for how much.
- New York S 306 is a unique bill that would entitle an out-of-network pharmacy providing causally related medications to an injured worker to be reimbursed at the same rate negotiated between the workers’ comp. carrier and the carrier’s established pharmacy network IF that network provides mail-order service or is located within a reasonable distance from the injured worker. For context, current New York law allows carriers to establish pharmacy networks and require injured workers to obtain medications from network pharmacies.
- Illinois HB 1256 is another attempt to allow custom compound medications to only be prescribed in a one-time, 7-day supply, but beyond that require preauthorization by the employer. With this, the preauthorization could only be approved if the compound meets specific standards outlined in the bill. The bill also states:
- Provider bills would need to include the original manufacturer's NDC for each compound ingredient and the ingredient reimbursement would be based on the average wholesale price (AWP) of that NDC (ingredients without an NDC are not to be charged).
- A single dispensing fee, determined by the Workers’ Compensation Commission, would be paid for the compound, with a state-specific dispensing fee billing code outlined.
- Arizona HB 2429 would permit an employer to establish a “pharmacy management network” to provide necessary medications to injured workers and require those injured workers to obtain medications through that network. The bill would require an employer to notify employees of the network and to register the network with the Industrial Commission. Also, third-party billers would be reimbursed only at the contractual amount agreed by that network pharmacy.
- Maryland SB 306 would require adoption of a pharmacy fee schedule, where none exists today. Under current workers’ compensation regulations, pharmaceutical reimbursement is determined by the carrier based on "nationally recognized and published relative value studies, or on the values assigned for services involving similar work and resources." This bill would direct the Workers’ Compensation Commission to adopt a fee schedule limiting reimbursement to "an index or indexes based on acquisition cost" and may include "reasonable" dispensing fees.
- Hawaii HB 205 would provide that workers’ compensation payments for non-prescription, over-the-counter, or non-legend drugs be at cost plus 40%. For comparison, under current law, prescription medications are reimbursed at AWP plus 40%. The bill also states:
- Payment shall not be authorized unless the drug has been clinically established as necessary by the provider to treat the injured employee for a work injury
- Providers may seek reimbursement for any applicable Hawaii general excise tax.
Other legislation
Several other newly introduced bills would impact the provision of medical services in workers’ compensation, including bills related to:
- Presumptive coverage for first responders for conditions such as cancer and PTSD
- Physician networks
- Medical fee schedules
In addition, there are bills seeking to further regulate pharmacy benefits managers (PBMs) as a whole, some of which would apply to workers’ compensation.
MyMatrixx is tracking it all
The MyMatrixx Regulatory Affairs team continually tracks and monitors the growing list of newly introduced and pending legislation throughout the year. Statistically, most bills introduced each year do not make it through the legislative process to become law, and accurately predicting their chances of becoming law early on is not always possible. However, several bills we will track this year will pass. Our team will engage with policymakers and clients where appropriate and advantageous to ensure good public policy for our industry.
For a broader snapshot−or the details−of the legislation we are tracking across the country, visit the Legislative and Regulatory Policy Tracker on our Statehouse Watch webpage where you can sort bills by topic and state.
Questions for our Regulatory Affairs team can be sent to MMXRegulatoryAffairs@MyMatrixx.com. For more information on policy developments in workers’ compensation impacting pharmacy across the country, please visit and bookmark Statehouse Watch at MyMatrixx.com.