State insurance oversight panel adopts draft rules, approves April and May drug formularies

The State Insurance Programs Oversight Committee adopted draft rules and approved the April and May pharmacy formularies and the May medical formulary during a committee meeting called to order by the chair. Committee members voted to approve the items after staff from the Employee Benefits Division reviewed each formulary and answered questions from legislators.

The decisions affect roughly 160,000 covered lives in the state insurance program and include changes intended to align quantity limits with clinical guidance, add or remove coverage for specific products, and temporarily restore access to a medical-administered drug with known access issues.

Amanda Land, deputy director of the Employee Benefits Division, presented the packet of formularies and walked the committee through highlights for each month. On the April pharmacy formulary, Land said the division is "adjusting the quantity limits on that to be more in line with CDC recommendations." She identified multiple new-to-market drugs listed as not covered while the division monitors clinical efficacy and data, and noted one new-to-market product that staff would keep as a specialty drug so steps-therapy controls could be applied; she prefaced that item by saying, "I'm going to butcher the name. It's nimble. We will be keeping that as a specialty drug so that we can have some steps therapy in place for that drug."

On cost and clinical review processes, Land described the division’s review partners: "EBD, in conjunction with its partnership at, with EBRX, it's the evidence based prescription program through the College of Pharmacy at UAMS. We have pharmacists on-site, at EBD and we review those monthly," and she added that those reviews are performed with contractor Navitus.

Legislators pressed for specifics. Senator Boyd praised a change to Paxlovid limits, saying the committee’s move to change coverage "to per 90 days" was a "common sense approach." Representative Kavanaugh asked how many lives the program insures; Land replied, "Approximately 160,000 give or take." Representative Eves asked about how many members would be affected by exclusions on the medical formulary (Exhibit C1C); Land said she did not have that number on hand but offered to provide it later.

Specific formulary actions discussed and recorded in committee remarks included: - April pharmacy formulary: staff adjusted quantity limits for Paxlovid and identified several new-to-market drugs to remain not covered while being monitored for efficacy; one new specialty product was placed on the formulary with steps-therapy controls. The committee approved the April pharmacy formulary by motion and voice vote. - May pharmacy formulary: rivaroxaban was moved from not covered to covered as the brand is going generic; several multivitamin prescription products were moved to not covered because they are now available over the counter. The committee approved the May pharmacy formulary by motion and voice vote. - May medical formulary (drugs administered in clinical settings): the committee restored one drug to the medical formulary for a one-year period because of access issues and the presence of a partner biosimilar, and will continue to monitor access and continuity of care. The committee approved the May medical formulary by motion and voice vote.

Committee business opened with a separate motion to adopt draft rules; the chair called for a motion and the committee approved the draft rules. At the close of the agenda there were no further items and the chair adjourned the meeting.

The committee discussion repeatedly emphasized monitoring new-to-market drugs rather than immediately expanding coverage for them, and staff committed to supplying follow-up data requested by legislators, including counts of impacted members for excluded medical drugs and information on brand-versus-generic use for high-cost products. The committee did not take any binding action beyond the formulary approvals and rule adoption recorded in the meeting.

Looking ahead, staff told the committee they will continue monthly reviews of new drugs and report back with requested membership impact data and any new clinical information that would support changes to coverage.