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Board approves 2026 plan document updates and accepts PBM market pricing amendment
Summary
The PEP board approved technical updates to master plan documents for 2026 (behavioral interventions, genetic counseling, speech therapy age expansion, wig eligibility for alopecia, behavioral health visit clarifications) and accepted a consultant recommendation to amend the Express Scripts contract to improve net pricing for plan year 2026, retroactive to July 1, 2025 if executed.
The Public Employees Benefits Program board approved a package of master plan document (MPD) updates and technical changes affecting plan year 2026, and separately approved a market‑check amendment to the pharmacy benefit manager contract.
MPD updates presented by Leslie Biddleston include: clarifying behavioral interventions language and visit limits (already effective July 1); explicitly adding eating disorders and licensed dietitian coverage for those treatments; a genetic counseling enhancement tied to recent legislation and effective 01/01/2026; IRS‑driven increases to certain CDHP deductibles effective 07/01/2026; HSA contribution limit adjustments; expanding speech therapy coverage to age 26 (estimated cost increase up to $50,000 annually); autism spectrum disorder language updates per SB 257 (no age change to treatment availability); and expanding wig coverage to include alopecia (estimated cost below $5,000 annually). The board approved the package and allowed staff to make technical adjustments when finalizing plan documents.
On pharmacy pricing, Siegel consultant Richard Ward presented a PBM market check comparing Express Scripts contract terms to peer benchmarks. The analysis found the current contract had relatively competitive discounts but trailed benchmark peers on rebate income. Express Scripts proposed improved pricing guarantees that would move net contract value roughly halfway toward the benchmark and yield an estimated $1.5 million improvement for plan year 2026. The board voted to accept the consultant’s recommendation and pursue the amendment; staff noted the new terms could be applied retroactively to July 1, 2025 if implemented promptly.
The meeting record shows the board also authorized contract amendments (including Express Scripts pricing updates and a one‑year extension for Diversified Dental) and noted delays in the State Controller’s master audit that affected when the SFY24 audit can be completed.
