Workers’ comp pharmacy changes

Three April legal shifts are forcing workers’ compensation payers to revisit how they price, approve, and audit prescription claims. (workerscompensation.com) The first two are operational now: Florida’s February 26 court ruling against physician-dispensing reimbursement is already in effect, and Pennsylvania carriers can already use the Commonwealth Court’s Federated decision to challenge Average Wholesale Price, or AWP, bills. (workerscompensation.com) Florida’s First District Court of Appeal said the state’s workers’ compensation rule could not keep paying doctors to dispense drugs under the overturned framework, and the Legislature ended its March 13 session without passing a fix. Dennis Sponer wrote that enforcing the ruling over five years could save Florida payers about $43 million. (workerscompensation.com) Pennsylvania’s dispute is about the benchmark itself. The Commonwealth Court held in Federated Insurance v. Bureau of Workers’ Compensation that Red Book Average Wholesale Price was not a reliable basis for workers’ compensation drug reimbursement, yet the state had not replaced it more than two years later. (workerscompensation.com) That gap leaves claims teams deciding whether to keep paying under a benchmark the court rejected or to build review systems around newer measures such as the National Average Drug Acquisition Cost, known as NADAC. Sponer cited Workers Compensation Research Institute findings that some workers’ compensation prescription prices were 10 times higher than NADAC. (workerscompensation.com) The third change is federal, and it does not directly regulate workers’ compensation. The Department of Labor published a proposed rule on January 30 that would require pharmacy benefit managers serving self-insured Employee Retirement Income Security Act plans to disclose direct and indirect compensation, and comments are due by April 15. (federalregister.gov) Congress also moved on pharmacy benefit managers this year. The Consolidated Appropriations Act of 2026, signed February 3, added new reporting, audit, and compensation rules for employer plans and Medicare Part D, with many employer-plan provisions taking effect for plan years beginning 30 months after February 3, 2026. (lockton.com) (pharmacytimes.com) The Federal Trade Commission added another pressure point on February 4, when it announced a settlement with Express Scripts that requires changes to formulary practices and more pricing transparency after an insulin-pricing case. The agency said the order could cut patients’ out-of-pocket insulin costs by as much as $7 billion over 10 years. (ftc.gov) Workers’ compensation sits outside those federal group-health rules, but it buys pharmacy services from the same companies. Sponer wrote that Optum, Express Scripts, and CVS Caremark fill about 80% of U.S. prescriptions, so changes in rebate, spread-pricing, and disclosure rules in one market can alter contracting in another. (workerscompensation.com) State lawmakers are also writing broad pharmacy benefit manager bills that can collide with workers’ compensation fee schedules if they do not carve the system out. MyMatrixx by Evernorth said proposals in Hawaii, Mississippi, and Oklahoma this year could raise costs or create conflicting payment deadlines for workers’ compensation pharmacy claims. (mymatrixx.com) For adjusters and third-party administrators, April’s message is procedural, not theoretical: update Florida prescription workflows, decide how Pennsylvania bills will be reviewed, and reread pharmacy benefit manager contracts before the federal transparency push reaches the workers’ compensation market indirectly. (workerscompensation.com)