SRX Advisors | PBM Regulatory Risk Map

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Has WC Fee Schedule

No Fee Schedule

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PBM LICENSING Pharmacy Benefit Manager Registration & Regulation · 52 Jurisdictions

LICENSE TYPE BREAKDOWN

PBM-Specific License

PBM Registration

TPA / Certificate Pathway

No Requirement

REGULATORY RISK INDICATORS

Spread Pricing Banned

4 states

Spread Ban Pending

1 state

Rebate Pass-Through Required

4 states

PBM Pharmacy Ownership Ban

1 state

New Laws Effective 2024–2026

10 states

SELF-FUNDED APPLICABILITY

Yes — 5

No / TBD — 47

STATE-BY-STATE PBM LICENSURE DETAIL

State	License Type	Classification	Self-Funded	Spread Ban	Rebate PT	Risk Score	Statute	Reg Code
Alabama	License – PBM	License	NO	YES	NO	—	—	—
Alaska	License – PBM	License	TBD	NO	NO	—	—	—
Arizona	License – PBM	License	TBD	NO	NO	—	—	—
Arkansas	License – PBM	License	NO	NO	NO	—	—	—
California	Registration – PBM	Registration	NO	YES	YES	—	—	—
Colorado	Registration – PBM	Registration	YES	NO	NO	—	—	—
Connecticut	Registration – PBM	Registration	TBD	NO	NO	—	—	—
Delaware	Registration – PBM	Registration	TBD	NO	NO	—	—	—
District of Columbia	None Currently	N/A	TBD	NO	NO	—	—	—
Florida	License – PBM	Registration + COA = License	TBD	NO	NO	—	—	—
Georgia	License – PBM	License	TBD	NO	NO	—	—	—
Hawaii	Registration – PBM	Registration	TBD	NO	NO	—	—	—
Idaho	Registration – PBM	Registration	TBD	YES	NO	—	—	—
Illinois	Registration – PBM	Registration	TBD	NO	NO	—	—	—
Indiana	License – PBM	License	TBD	NO	NO	—	—	—
Iowa	Certificate – TPA	TPA Certificate	TBD	NO	NO	—	—	—
Kansas	License – PBM	License	TBD	NO	NO	—	—	—
Kentucky	License – PBM	License	TBD	NO	NO	—	—	—
Louisiana	License – PBM	License (+ optional Board of Pharmacy Permit)	TBD	NO	NO	—	—	—
Maine	License – PBM	License	YES	NO	YES	—	—	—
Maryland	Registration – PBM	Registration	TBD	NO	NO	—	—	—
Massachusetts	License – PBM (+ TPA Registration)	License + TPA Reg	TBD	NO	NO	—	—	—
Michigan	License – PBM	License	TBD	NO	NO	—	—	—
Minnesota	License – PBM	License	TBD	NO	NO	—	—	—
Mississippi	License – PBM	License	TBD	Pending	NO	—	—	—
Missouri	License – PBM	License	TBD	NO	NO	—	—	—
Montana	License – PBM	License	TBD	NO	NO	—	—	—
Nebraska	License – PBM	License	TBD	NO	NO	—	—	—
Nevada	License – TPA	TPA License	TBD	NO	NO	—	—	—
New Hampshire	Registration – PBM	Registration	TBD	NO	NO	—	—	—
New Jersey	License – PBM	License	TBD	NO	NO	—	—	—
New Mexico	License – PBM	License	TBD	NO	NO	—	—	—
New York	License – PBM	License	YES	NO	NO	—	—	—
North Carolina	License – PBM	License	TBD	NO	NO	—	—	—
North Dakota	Registration – TPA	TPA Registration	TBD	NO	NO	—	—	—
Ohio	License – TPA	TPA License	TBD	NO	NO	—	—	—
Oklahoma	License – PBM	License	TBD	NO	NO	—	—	—
Oregon	License – PBM	License	TBD	NO	NO	—	—	—
Pennsylvania	Registration – PBM	Registration	TBD	NO	NO	—	—	—
Puerto Rico	License – PBM	License	TBD	NO	NO	—	—	—
Rhode Island	Certificate – TPA	TPA Certificate	TBD	NO	NO	—	—	—
South Carolina	License – PBM	License	TBD	NO	NO	—	—	—
South Dakota	License – TPA	TPA License	TBD	NO	NO	—	—	—
Tennessee	License – PBM	License	TBD	NO	NO	—	—	—
Texas	Certificate – TPA	TPA Certificate	TBD	NO	NO	—	—	—
Utah	License – PBM	License	TBD	NO	YES	—	—	—
Vermont	License – PBM (+ Registration)	License + Registration	TBD	YES	NO	—	—	—
Virginia	License – PBM	License	TBD	NO	NO	—	—	—
Washington	Registration – HCBM	HCBM Registration	TBD	NO	NO	—	—	—
West Virginia	License – PBM	License	TBD	NO	YES	—	—	—
Wisconsin	License – PBM	License	TBD	NO	NO	—	—	—
Wyoming	License – PBM	License	TBD	NO	NO	—	—	—

PHARMACY FEE SCHEDULES WC Drug Reimbursement Methodology · 52 Jurisdictions

FEE SCHEDULE PRESENCE

Fee Schedule Exists — 37

Pay U&C / No FS — 15

BRAND RATE METHODOLOGY

AWP + Markup (payer risk)

AWP − Discount

Medi-Cal / Medicare-based

WAC-based

No FS / Billed at U&C

KEY COST DRIVERS

States paying AWP markup (above cost)

States with no FS (U&C exposure)

States with AWP discounts

STATE-BY-STATE FEE SCHEDULE DETAIL

State	Brand Rate	Generic Rate	Fee Schedule	Statute	Admin Code
Alabama	AWP +5% +$11.44	AWP +5% +$14.86	Lesser of FS or provider's U&C. Bills shall include original…	—	🔗 Open
Alaska	AWP +$5.00	AWP +$10.00	Lesser of FS, fee to general public, or negotiated fee. Reim…	🔗 Open	🔗 Open
Arizona	AWP -15% +$7.00	AWP -25% +$7.00	Reimbursement based on actual medication dispensed. Medicine…	🔗 Open	🔗 Open
Arkansas	AWP +$5.13	AWP +$5.13	Lesser of FS, provider's U&C, or MCO/PPO contract price. No …	🔗 Open	🔗 Open
California	Medi-Cal based drug rate	Medi-Cal based drug rate	DF: Large Medi-Cal volume pharmacies $10.05; small $13.20. D…	🔗 Open	🔗 Open
Colorado	AWP +$4.00	AWP +$4.00	If AWP ceases, substitute WAC +20%. Repackaged medications u…	—	🔗 Open
Connecticut	AWP +$5.00	AWP +$8.00	Reimbursement lesser of NDC for underlying medication from m…	—	—
Delaware	AWP -31.9% +$3.29 DF	AWP -38% +$4.10 DF	Lesser of provider's U&C, negotiated contract amount or FS. …	—	🔗 Open
District of Columbia	No fee schedule	No fee schedule	Paid at U&C.…	🔗 Open	🔗 Open
Florida	AWP +$4.18	AWP +$4.18	Reimbursement at FS except where employer/carrier directly c…	—	🔗 Open
Georgia	AWP +$4.83	AWP +$7.25	Reimbursement based on current published manufacturer's AWP …	🔗 Open	—
Hawaii	AWP +40%	AWP +40%	Repackaged medications reimbursed at FS based on original ma…	—	🔗 Open
Idaho	AWP +$5.00	AWP +$8.00	Reimbursement is lesser of FS, billed charge, or contract. R…	—	—
Illinois	No fee schedule	No fee schedule	Insurer pays all necessary and reasonable costs. Medications…	🔗 Open	🔗 Open
Indiana	No fee schedule	No fee schedule	Repackaged medications dispensed (other than retail/mail pha…	—	—
Iowa	No fee schedule	No fee schedule	Must be reasonable.…	—	—
Kansas	AWP -10% +$3.00	AWP -15% +$5.00	Lesser of FS or provider's U&C. Repackaged and compounds rei…	🔗 Open	—
Kentucky	AWP -10% +$5.00	AWP* -15% +$5.00	*Of lowest priced therapeutically equivalent in stock. Reimb…	—	🔗 Open
Louisiana	AWP +10% +$11.81	AWP +40% +$11.81	DF based on current state Medicaid DF. Physicians may only d…	🔗 Open	🔗 Open
Maine	No fee schedule	No fee schedule	Paid at U&C.…	🔗 Open	—
Maryland	No fee schedule	No fee schedule	For medications lacking FS, carriers can assign a relative v…	—	🔗 Open
Massachusetts	See description +$10.02	See description +$10.02	Single-source: lowest of MMAC, AAC or U&C plus DF. Multi-sou…	—	🔗 Open
Michigan	AWP -10% +$3.50	AWP -10% +$5.50	Lesser of MAR in FS or provider's U&C. Repackaged: billed/re…	🔗 Open	🔗 Open
Minnesota	AWP -12% +$3.65*	AWP -12% +$3.65*	*Electronic billing. Paper billing: AWP +$5.14 for both BR a…	🔗 Open	🔗 Open
Mississippi	AWP +$5.00	AWP -5% +$5.00	Lesser of provider's total billed charge or FS unless contra…	🔗 Open	—
Missouri	No fee schedule	No fee schedule	Paid at U&C.…	—	—
Montana	AWP -10% +$3.00	AWP -25% +$3.00	Lesser of FS or provider's U&C. Physician dispensing practic…	🔗 Open	—
Nebraska	No fee schedule	No fee schedule	Paid actual charge billed unless payor has evidence it excee…	—	—
Nevada	AWP +$13.70	AWP +$13.70	Lesser of FS, U&C, or contracted rate. May dispense initial …	🔗 Open	—
New Hampshire	No fee schedule	No fee schedule	Pay reasonable value.…	—	—
New Jersey	No fee schedule	No fee schedule	Paid at U&C. Physician dispensing limited to 7-day supply un…	—	—
New Mexico	AWP -10% +$5.00	AWP -10% +$5.00	Lesser of FS, U&C, or contract. Physician dispensed: AWP -10…	🔗 Open	🔗 Open
New York	AWP -12% +$4.00	AWP -20% +$5.00	FS or lower contracted rate. Physician dispensing limited to…	🔗 Open	🔗 Open
North Carolina	AWP -5%	AWP -5%	Lesser of FS or provider/payer agreement. Original manufactu…	🔗 Open	🔗 Open
North Dakota	$4.00 DF (WAC-based)	$5.00 DF (WAC-based)	Based on markup above WAC, except compounds. Compounds: AWP …	—	🔗 Open
Ohio	AWP -15% +$3.50	AWP -15% +$3.50	Lesser of U&C or FS. Medications supplied in physician's off…	—	🔗 Open
Oklahoma	AWP -10% +$5.00	AWP -10% +$5.00	Lesser of FS or provider's U&C. Repackaged: AWP of original …	🔗 Open	🔗 Open
Oregon	AWP -16.5% +$2.00	AWP -16.5% +$2.00	Lesser of FS, provider's U&C, or contract. Physician dispens…	🔗 Open	🔗 Open
Pennsylvania	AWP +10%	AWP +10%	If actual charge less than FS, pay actual charge. Repackaged…	—	🔗 Open
Puerto Rico	—	—	Puerto Rico not covered in Optum WC Pharmacy Resource Guide.…	—	—
Rhode Island	AWP -10%	AWP -10%	Physicians cannot bill for dispense, only to administer medi…	—	—
South Carolina	AWP +$5.00	AWP +$5.00	Lesser of FS or provider's U&C. Practitioner dispensed OTCs …	🔗 Open	—
South Dakota	No fee schedule	No fee schedule	Not to exceed U&C.…	—	—
Tennessee	AWP +$5.10	AWP +$5.10	Lesser of FS, provider's U&C, or contracted rate. Reimbursem…	🔗 Open	🔗 Open
Texas	AWP +9% +$4.00	AWP +25% +$4.00	Reimbursement at compliant contracted rate or lesser of FS/b…	🔗 Open	🔗 Open
Utah	No fee schedule	No fee schedule	A reasonable fee. Physician dispensing permitted only in ver…	—	—
Vermont	AWP +$3.15	AWP +$3.15	Lesser of FS or actual charge.…	🔗 Open	—
Virginia	No fee schedule	No fee schedule	Disputes use prevailing community rate. Physician dispensing…	🔗 Open	🔗 Open
Washington	AWP -10% +$4.50	AWP -50% +$4.50	L&I (state fund) does not pay for medication dispensed in ph…	🔗 Open	🔗 Open
West Virginia	No fee schedule	No fee schedule	No Controlling Rx FS – providers bill U&C. NADAC or WAC if N…	🔗 Open	—
Wisconsin	AWP +$3.00	AWP +$3.00	DF only payable to pharmacist. Reimbursed at existing pharma…	🔗 Open	—
Wyoming	AWP -10% +$5.00	AWP -10% +$5.00	Lesser of FS or provider's U&C. Physicians billing compounds…	—	🔗 Open

PHYSICIAN DISPENSING In-Office Drug Dispensing Rules · 52 Jurisdictions

RESTRICTION LEVEL

Prohibited / Emergency Only ✓

Restricted (supply/DF limits)

Permitted with Restrictions

Not Covered / Unknown

COST CONTROL INDICATORS

Effectively prohibited (WA, OH + 2)

Restricted — no DF to physicians

Supply-limit only (7/10/14/30-day)

Permitted with FS controls

Permissive — no controls

PAYER EXPOSURE SUMMARY

51%of states permit physician dispensing with minimal controls

52%of states have meaningful restrictions reducing payer exposure

STATE-BY-STATE PHYSICIAN DISPENSING DETAIL

State	Status	Citation	Key Rule	Statute	Reg Code
Alabama	Permitted with restrictions	Ala. Code § 27-45A-3; Ala. Admin. Code r	Physician dispensing is permitted but DF payable only to pharmacies. B…	🔗 Open	🔗 Open
Alaska	Permitted with restrictions	8 AAC 45.082; AS 23.30.095	Physician dispensing permitted. Reimbursement must use original manufa…	🔗 Open	🔗 Open
Arizona	Permitted – FS controls	A.R.S. § 23-908; A.A.C. R20-5-1303	Medicines dispensed by either pharmacy or physician are subject to fee…	🔗 Open	🔗 Open
Arkansas	Restricted – permit required	Ark. Code Ann. § 11-9-508; Ark. Code Ann	Dispensing practitioners must obtain a permit from the state and demon…	🔗 Open	—
California	Permitted – FS controls & proposed reform	Cal. Lab. Code § 5307.1; 8 CCR § 9789.40	Physician dispensing permitted but subject to Medi-Cal-based fee sched…	🔗 Open	🔗 Open
Colorado	Restricted – controlled substances	Colo. Rev. Stat. § 8-42-101; 7 CCR 1101-	Opioids, scheduled controlled substances, gabapentin, and benzodiazepi…	🔗 Open	🔗 Open
Connecticut	Permitted with restrictions	Conn. Gen. Stat. § 31-279; Conn. Agencie	Physician dispensing permitted. OTC dispensed in practitioners' office…	🔗 Open	🔗 Open
Delaware	Restricted – limited dispensing	19 Del. C. § 2322B; CDR 18-1400-1411	Physicians dispensing from office do not receive a dispensing fee. No …	🔗 Open	🔗 Open
District of Columbia	Permitted – no FS	D.C. Code § 32-1507	No pharmacy fee schedule. Paid at U&C. No specific WC restrictions on …	🔗 Open	—
Florida	Permitted – repackaging controls	Fla. Stat. § 440.13(12); Fla. Admin. Cod	Physician dispensing permitted and has been a major cost driver. AWP f…	🔗 Open	🔗 Open
Georgia	Permitted – FS controls	O.C.G.A. § 34-9-200; Ga. Comp. R. & Regs	Physician dispensing permitted. Bills must include NDC of original man…	🔗 Open	🔗 Open
Hawaii	Permitted	HRS § 431S-3; HAR § 12-15-32	Physician dispensing permitted. Repackaged medications reimbursed at f…	🔗 Open	🔗 Open
Idaho	Restricted – no DF for physicians	IDAPA 17.02.09; Idaho Code § 72-803	Physicians are not reimbursed a DF or compounding fee—a significant fi…	🔗 Open	🔗 Open
Illinois	Permitted – repackaging controls	820 ILCS 305/8(a); 50 Ill. Adm. Code 711	No pharmacy fee schedule, but medications dispensed outside of license…	🔗 Open	🔗 Open
Indiana	Restricted – 7-day limit	Ind. Code § 22-3-3-4.5; 631 IAC 1-1-34	Doctors dispensing medications from their offices are only entitled to…	🔗 Open	🔗 Open
Iowa	Permitted – no FS	Iowa Code § 85.27	No pharmacy fee schedule. Must be "reasonable." No specific WC restric…	🔗 Open	—
Kansas	Permitted – prior auth required	K.S.A. § 44-510h; K.A.R. 51-9-7	Physician-dispensed repackaged medications reimbursed at fee schedule …	🔗 Open	—
Kentucky	Restricted – 48-hour CII/CIII limit	KRS § 342.020; 803 KAR 25:200	Doctors restricted to dispensing only a 48-hour supply of any CII or C…	🔗 Open	🔗 Open
Louisiana	Restricted – 48-hour controlled substances	La. R.S. § 23:1034.2; La. R.S. § 40:2867	Physicians may only dispense controlled substances or medications of c…	🔗 Open	—
Maine	Permitted – no FS	39-A M.R.S. § 206; 24-A M.R.S. § 4348	No pharmacy fee schedule. Paid at U&C. No specific WC restrictions on …	🔗 Open	—
Maryland	Permitted – no FS	Md. Lab. & Empl. Code § 9-660; COMAR 14.	No controlling pharmacy fee schedule. Carriers can assign relative val…	🔗 Open	🔗 Open
Massachusetts	Restricted – emergency only	M.G.L. ch. 152, § 13; 452 CMR 6.05	Physician dispensing permitted only when necessary for immediate and p…	🔗 Open	🔗 Open
Michigan	Permitted – FS controls	MCL § 418.315; Mich. Admin. Code R 418.1	Physician dispensing permitted. Repackaged medications billed and reim…	🔗 Open	🔗 Open
Minnesota	Restricted – profit limitation	Minn. Stat. § 176.135; Minn. R. 5221.050	Physician dispensing permitted if not for profit, or if for profit, ph…	🔗 Open	🔗 Open
Mississippi	Restricted – no DF for physicians	Miss. Code Ann. § 71-3-15; Miss. WC Comm	Physician dispensing permitted but DF not payable to doctors. Repackag…	🔗 Open	—
Missouri	Permitted – no FS	Mo. Rev. Stat. § 287.140	No pharmacy fee schedule. Paid at U&C. No specific WC restrictions on …	🔗 Open	—
Montana	Restricted	Mont. Code Ann. § 39-71-704; ARM 24.29.1	Physician dispensing practice limited to certain exceptions. Montana h…	🔗 Open	—
Nebraska	Permitted – no FS	Neb. Rev. Stat. § 48-120	No pharmacy fee schedule. Paid actual charge billed unless payor has e…	🔗 Open	—
Nevada	Permitted – initial supply limit	NRS § 616C.260; NAC 616C.025	May dispense initial supply (15 days) of CII or CIII controlled substa…	🔗 Open	—
New Hampshire	Permitted – no FS	RSA 281-A:23	No pharmacy fee schedule. Pay "reasonable value." No specific WC restr…	🔗 Open	—
New Jersey	Restricted – 7-day limit	N.J. Stat. § 34:15-15; N.J.A.C. 12:235	Physician dispensing limited to only a seven-day supply unless the pat…	🔗 Open	🔗 Open
New Mexico	Restricted – 10-day initial limit	N.M. Stat. Ann. § 52-4-1; NMAC 11.4.7	Physician-dispensed medications reimbursed at AWP -10% with no DF. Ini…	🔗 Open	🔗 Open
New York	Restricted – 72-hour limit	WCL § 13(a); 12 NYCRR § 325-1.8; N.Y. Ed	Physician dispensing limited to 72 hours with exceptions. Repackaged m…	🔗 Open	🔗 Open
North Carolina	Restricted – 5-day CII-CV limit	N.C. Gen. Stat. § 97-25.6	No outpatient provider (other than pharmacies) may receive reimburseme…	🔗 Open	—
North Dakota	Permitted – WAC-based FS	N.D. Cent. Code § 65-02-08; N.D. Admin.	Fee schedule based on markup above WAC rather than AWP—typically resul…	🔗 Open	🔗 Open
Ohio	Effectively prohibited (state fund)	ORC § 4123.66; OAC 4123-6-21.3	Medications supplied to injured worker in physician's office are not c…	🔗 Open	🔗 Open
Oklahoma	Permitted – FS controls	85A O.S. § 50; OAC 810:15-1-1	Physician-dispensed (non-repackaged) lesser of AWP -10% or payer contr…	🔗 Open	🔗 Open
Oregon	Restricted – 10-day initial limit	ORS § 656.248; OAR 436-009-0060	Compensability of physician dispensing limited to initial 10-day suppl…	🔗 Open	🔗 Open
Pennsylvania	Restricted – supply limits	77 P.S. § 531; 34 Pa. Code § 127.132	Outpatient providers (other than licensed pharmacies) limited to initi…	🔗 Open	🔗 Open
Puerto Rico	Not covered	N/A	Puerto Rico physician dispensing rules not covered in available source…	—	—
Rhode Island	Restricted – injectables only	R.I. Gen. Laws § 28-33-5; 260-RICR-40-00	Physicians cannot bill for dispensing, only to administer medications …	🔗 Open	🔗 Open
South Carolina	Permitted – FS controls	S.C. Code Ann. § 42-15-90; S.C. Code Reg	Physician dispensing permitted. Practitioner-dispensed OTCs require pr…	🔗 Open	🔗 Open
South Dakota	Permitted – no FS	SDCL § 62-4-1	No pharmacy fee schedule. Reimbursement not to exceed U&C. No specific…	🔗 Open	—
Tennessee	Restricted – no physician DF	Tenn. Code Ann. § 50-6-204; Tenn. Comp.	Physician should not receive a DF—significant financial disincentive. …	🔗 Open	🔗 Open
Texas	Restricted – limited situations	Tex. Lab. Code § 413.011; 28 TAC § 134.5	Physician dispensing only permitted to meet immediate needs or in rura…	🔗 Open	🔗 Open
Utah	Restricted – very limited	Utah Code Ann. § 34A-2-407; Utah Admin.	No pharmacy fee schedule but "a reasonable fee." Physician dispensing …	🔗 Open	—
Vermont	Permitted	21 V.S.A. § 640; CVR 21-000-005	No specific WC restrictions on physician dispensing identified. Fee sc…	🔗 Open	—
Virginia	Restricted – Practice Act controls	Va. Code § 65.2-603; Va. Code § 54.1-330	No controlling Rx fee schedule. Physician dispensing only permitted wi…	🔗 Open	—
Washington	Effectively prohibited (state fund)	RCW § 51.36.010; WAC 296-20-03001	L&I (state fund) does not pay for medication dispensed in physician's …	🔗 Open	🔗 Open
West Virginia	Restricted – emergency only	W. Va. Code § 33-51-8; W. Va. CSR § 85-2	Legend medications dispensed by a physician will not be reimbursed exc…	🔗 Open	🔗 Open
Wisconsin	Restricted – no physician DF	Wis. Stat. § 102.42; Wis. Admin. Code DW	DF only payable to pharmacist. Reimbursed at existing pharmacy fee sch…	🔗 Open	🔗 Open
Wyoming	Restricted – invoice required	Wyo. Stat. § 27-14-401; WY Rules & Regs.	Physicians billing for compounds must provide pharmacy invoice and pay…	🔗 Open	—

DIRECTION OF CARE Choice of Physician & Employer Network Control · 52 Jurisdictions

EMPLOYER CONTROL MODEL

Employer Controls ✓

Hybrid / Conditional

Employee Choice ✗

Unknown

LITIGATION & COST RISK

High Risk — 14

Moderate — 26

Low Risk — 10

KEY INSIGHT

67%of states give employers limited or no initial physician control

48%of states are hybrid — control depends on timing and compliance

STATE-BY-STATE DIRECTION OF CARE DETAIL

State	Choice Model	Panel Timing	Litigation Risk	Statute	Reg Code
Alabama	Employer Control (panel/network)	Varies	Lower medical cost variability; disputes tend to shift to ch…	—	—
Alaska	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	—	—
Arizona	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	—	—
Arkansas	Hybrid / Conditional	Employee selects	Moderate; risk concentrates around compliance with notice/pa…	—	—
California	Hybrid / Conditional	Employee selects	Moderate; risk concentrates around compliance with notice/pa…	🔗 Open	—
Colorado	Employee Choice (network/panel constraints)	Employee selects	Higher cost variability; more disputes over authorization/UR…	—	—
Connecticut	Employee Choice (network/panel constraints)	Employee selects	Higher cost variability; more disputes over authorization/UR…	—	—
Delaware	Employee Choice	Employee selects	Higher cost variability; more disputes over authorization/UR…	—	—
District of Columbia	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	—	—
Florida	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	🔗 Open	—
Georgia	Employer Choice	Varies	Lower medical cost variability; disputes tend to shift to ch…	🔗 Open	—
Hawaii	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	—	—
Idaho	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	—	—
Illinois	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	🔗 Open	—
Indiana	Employer Choice	Varies	Lower medical cost variability; disputes tend to shift to ch…	—	—
Iowa	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	🔗 Open	—
Kansas	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	—	—
Kentucky	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	🔗 Open	—
Louisiana	Employee Choice	Employee selects	Higher cost variability; more disputes over authorization/UR…	🔗 Open	—
Maine	Employer Choice	Employee selects	Lower medical cost variability; disputes tend to shift to ch…	🔗 Open	—
Maryland	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	—	—
Massachusetts	Employer Choice	Employee selects	Lower medical cost variability; disputes tend to shift to ch…	—	—
Michigan	Hybrid / Conditional	Employee selects	Moderate; risk concentrates around compliance with notice/pa…	—	—
Minnesota	Employee Choice (network/panel constraints)	Employee selects	Higher cost variability; more disputes over authorization/UR…	—	—
Mississippi	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	—	—
Missouri	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	🔗 Open	—
Montana	Employee Choice (network/panel constraints)	Employee selects	Higher cost variability; more disputes over authorization/UR…	—	—
Nebraska	Employee Choice (network/panel constraints)	Employee selects	Higher cost variability; more disputes over authorization/UR…	—	—
Nevada	Unknown (not in source PDF)	Varies	Moderate; risk concentrates around compliance with notice/pa…	🔗 Open	—
New Hampshire	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	—	—
New Jersey	Hybrid / Conditional	Employee selects	Moderate; risk concentrates around compliance with notice/pa…	—	—
New Mexico	Employee Choice (network/panel constraints)	Employee selects	Higher cost variability; more disputes over authorization/UR…	🔗 Open	—
New York	Employee Choice (network/panel constraints)	Employee selects	Higher cost variability; more disputes over authorization/UR…	🔗 Open	—
North Carolina	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	—	—
North Dakota	Hybrid / Conditional	Employee selects	Moderate; risk concentrates around compliance with notice/pa…	—	—
Ohio	Hybrid / Conditional	Employee selects	Moderate; risk concentrates around compliance with notice/pa…	—	—
Oklahoma	Employee Choice (network/panel constraints)	Employee selects	Higher cost variability; more disputes over authorization/UR…	—	—
Oregon	Hybrid / Conditional	Employee selects	Moderate; risk concentrates around compliance with notice/pa…	—	—
Pennsylvania	Employee Choice (network/panel constraints)	Employee selects	Higher cost variability; more disputes over authorization/UR…	🔗 Open	—
Puerto Rico	—	Varies	…	—	—
Rhode Island	Employee Choice (network/panel constraints)	Employee selects	Higher cost variability; more disputes over authorization/UR…	—	—
South Carolina	Employer Choice	Varies	Lower medical cost variability; disputes tend to shift to ch…	🔗 Open	—
South Dakota	Employee Choice	Employee selects	Higher cost variability; more disputes over authorization/UR…	🔗 Open	—
Tennessee	Employer Control (panel/network)	Varies	Lower medical cost variability; disputes tend to shift to ch…	—	—
Texas	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	🔗 Open	—
Utah	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	🔗 Open	—
Vermont	Employer Choice	Varies	Lower medical cost variability; disputes tend to shift to ch…	—	🔗 Open
Virginia	Employer Control (panel/network)	Varies	Lower medical cost variability; disputes tend to shift to ch…	🔗 Open	—
Washington	Employee Choice	Employee selects	Higher cost variability; more disputes over authorization/UR…	🔗 Open	—
West Virginia	—	Varies	…	—	—
Wisconsin	Hybrid / Conditional	Varies	Moderate; risk concentrates around compliance with notice/pa…	🔗 Open	—
Wyoming	Employer Choice	Varies	Lower medical cost variability; disputes tend to shift to ch…	—	—

TPA LICENSING Third-Party Administrator Registration Requirements · 52 Jurisdictions

LICENSE REQUIRED

License Required — 48

No Requirement — 4

LICENSE TYPE BREAKDOWN

License / Certificate of Authority

Registration

No Formal Requirement

SELF-FUNDED PLAN APPLICABILITY

Applies to self-funded plans

44 states

No TPA license required

4 states

Unclear / TBD

4 states

STATE-BY-STATE TPA LICENSING DETAIL

State	Required	License Type	Reg Body	Fee	Self-Funded	Statute	Reg Code
Alabama	YES	Certificate of Authority	AL DOI	$200	YES	🔗 Open	—
Alaska	YES	Certificate of Authority	AK DOI	$	YES	🔗 Open	—
Arizona	YES	Certificate of Authority	AZ DOI	$	YES	🔗 Open	—
Arkansas	YES	Registration	AR DOI / AR WC Commission	$	Partial — ERISA plans register only	🔗 Open	—
California	YES	Certificate (WC: OSIP)	CA DOI (health/life) + CA OSIP (WC self-insured)	$1,000+/yr (WC)	YES	🔗 Open	🔗 Open
Colorado	NO	N/A — No TPA licensing statute	N/A	N/A	TBD	—	—
Connecticut	YES	Certificate of Authority	CT DOI	$	YES	🔗 Open	—
Delaware	YES	Registration	DE DOI	$	Partial	🔗 Open	—
District of Columbia	YES	Certificate of Authority	DC DOI	$	YES	🔗 Open	—
Florida	YES	Certificate of Authority	FL OIR	$	YES	🔗 Open	—
Georgia	YES	Certificate of Authority	GA OCI	$50 renewal	YES	🔗 Open	🔗 Open
Hawaii	YES	Certificate of Authority	HI DOI	$	YES	🔗 Open	—
Idaho	YES	Certificate of Authority	ID DOI	$	YES	🔗 Open	—
Illinois	NO	N/A	N/A	N/A	TBD	—	—
Indiana	YES	Certificate of Authority	IN DOI	$	YES	🔗 Open	—
Iowa	YES	Certificate of Registration	IA DOI	$50 annual	YES	🔗 Open	🔗 Open
Kansas	YES	Certificate of Authority	KS DOI	$400	YES	🔗 Open	—
Kentucky	YES	Certificate of Authority	KY DOI	$	YES	🔗 Open	—
Louisiana	YES	Certificate of Authority	LA DOI	$	YES	🔗 Open	—
Maine	YES	Certificate of Authority	ME DOI	$100	YES	🔗 Open	—
Maryland	YES	Certificate of Authority	MD MIA	$	YES	🔗 Open	—
Massachusetts	YES	Certificate of Authority	MA DOI	$	YES	🔗 Open	—
Michigan	YES	Certificate of Authority	MI DIFS	$	YES	🔗 Open	—
Minnesota	YES	Certificate of Authority	MN DOC	$	YES	🔗 Open	🔗 Open
Mississippi	YES	Certificate of Authority	MS DOI	$	YES	🔗 Open	—
Missouri	YES	Certificate of Authority	MO DOI	$	YES	🔗 Open	🔗 Open
Montana	YES	Certificate of Authority	MT OCI	$	YES	🔗 Open	—
Nebraska	YES	Certificate of Authority	NE DOI	$	YES	🔗 Open	—
Nevada	YES	Certificate of Authority	NV DOI	$	YES	🔗 Open	🔗 Open
New Hampshire	YES	Certificate of Authority	NH DOI	$	YES	🔗 Open	🔗 Open
New Jersey	YES	Certificate of Authority	NJ DOI	$	YES	🔗 Open	—
New Mexico	YES	Certificate of Authority	NM OSI	$	YES	🔗 Open	—
New York	YES	Dual-track: WCB License (WC) + No separate TPA license (DFS)	NY WCB (WC) + NY DFS (health)	No fee	YES	🔗 Open	🔗 Open
North Carolina	YES	License (general) or Registration (ERISA-only)	NC DOI	$	Partial — ERISA-only entities register	🔗 Open	—
North Dakota	YES	Certificate of Authority	ND DOI	$	YES	🔗 Open	—
Ohio	YES	Certificate of Authority	OH DOI	$	YES	🔗 Open	🔗 Open
Oklahoma	YES	Certificate of Authority	OK DOI	$	YES	—	🔗 Open
Oregon	YES	TPA License (health/life) + Adjuster License (WC)	OR DFR (health) + OR WCD (WC)	$45 biennial	YES	🔗 Open	🔗 Open
Pennsylvania	NO	N/A — No TPA licensing statute	PA DOI (adjuster licensing governs)	N/A	TBD	—	—
Puerto Rico	YES	Certificate of Authority	PR OCS	$	YES	—	—
Rhode Island	YES	Certificate of Authority	RI DOI	$	YES	🔗 Open	—
South Carolina	YES	Certificate of Authority	SC DOI	$	YES	🔗 Open	—
South Dakota	YES	Certificate of Authority	SD DOI	$	YES	🔗 Open	—
Tennessee	YES	Certificate of Authority	TN TDCI	$	Partial — self-insured employers historically excluded; expanding	🔗 Open	—
Texas	YES	Certificate of Authority	TX TDI	$200 filing fee	YES	🔗 Open	—
Utah	YES	Certificate of Authority	UT DOI	$	YES	🔗 Open	—
Vermont	YES	Certificate of Authority	VT DFR	$	YES	🔗 Open	—
Virginia	YES	Certificate of Authority	VA BOI	$	YES	🔗 Open	—
Washington	YES	Registration (WC) + separate health/life licensing	WA OIC (health) + WA L&I (WC)	$	YES	—	🔗 Open
West Virginia	YES	Certificate of Authority	WV OIC	$	YES	🔗 Open	—
Wisconsin	NO	N/A — No standalone TPA statute	N/A	N/A	TBD	—	—
Wyoming	YES	Certificate of Authority	WY DOI	$	YES	🔗 Open	—

NCM LICENSING Nurse Case Manager Credentialing & WC-Specific Rules · 52 Jurisdictions

NLC COMPACT STATUS

NLC Compact — 41

Non-Compact — 10

WC-SPECIFIC REQUIREMENTS

WC Registration Required

WC Certification Required

Telephonic CM Covered by Rules

No WC-Specific Mandate

HIGH-PRIORITY STATES

TN — Bureau registration mandatory

Enforced

TX — Certification per 28 TAC §180

Enforced

GA — Board registration required

Active

FL — Certification per Rule 69L-24

Active

IN — CCM/URAC cert + Board rules

Active

STATE-BY-STATE NCM LICENSING DETAIL

State	NLC Compact	WC Cert	WC Reg	Telephonic CM	Accepted Certs	Statute	Reg Code
Alabama	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Alaska	NO	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Arizona	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Arkansas	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
California	NO	No specific WC mandate	No	No specific rule	CCM, CDMS, CRRN	🔗 Open	🔗 Open
Colorado	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Connecticut	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Delaware	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
District of Columbia	NO	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Florida	YES	Yes	No	Yes—applies to rehab providers	CRRN, CRC, CCM, CDMS, CVE, COHN	🔗 Open	—
Georgia	YES	Yes	Yes—Board registration	Yes—registration applies to telephonic CM	Certifications per Board Rule 200.1	🔗 Open	—
Hawaii	NO	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Idaho	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Illinois	NO	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Indiana	YES	Yes	No formal registration, but Board guidelines	Yes—Board guidelines apply to all NCM activity	CCM (primary); URAC-recognized cert	🔗 Open	—
Iowa	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Kansas	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Kentucky	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Louisiana	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Maine	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Maryland	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Massachusetts	NO	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Michigan	NO	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Minnesota	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Mississippi	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Missouri	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Montana	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Nebraska	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Nevada	NO	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
New Hampshire	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
New Jersey	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
New Mexico	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
New York	NO	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
North Carolina	YES	Yes—per IC Rules	No formal registration	Yes—IC rules apply to all rehabilitation professionals	Certifications per NC Industrial Co	🔗 Open	—
North Dakota	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Ohio	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Oklahoma	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Oregon	NO	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Pennsylvania	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Puerto Rico	—	—	—	—	—	—	—
Rhode Island	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
South Carolina	YES	Yes—per WC Act & Regs	No formal registration	Yes—rules apply to all CM communication with providers	Certifications per license/Code of	🔗 Open	—
South Dakota	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Tennessee	YES	Yes	Yes—Bureau registration required	Yes—explicitly applies to telephonic and field CM	CCM or equivalent; CMA under superv	🔗 Open	🔗 Open
Texas	YES	Yes	No formal registration	Yes—certification required for all CM in WC system	CCM and other certifications per 28	🔗 Open	🔗 Open
Utah	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Vermont	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Virginia	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Washington	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
West Virginia	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Wisconsin	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—
Wyoming	YES	No specific WC mandate	No	No specific rule	CCM preferred by industry	—	—

↑ Click any state to view its full regulatory profile

Jurisdictions: 52

PBM License: 51

Spread Banned: 4

Has WC FS: 37

Phys Disp Restricted: 27

Employer Controls MD: 10

SRX Advisors · Regulatory Risk Monitor · Updated Feb 2026