Board approves EBD formulary changes; most specialty medical drugs excluded with appeals allowed

The State Board of Finance approved medical drug formulary recommendations presented by the Employee Benefits Division (EBD). The EBD presenter said the month-to-month changes focus on quantity limits and adding prior-authorization requirements for certain drugs, and that most medically administered specialty drugs on the new list would be excluded initially to require review and an appeals path.

The presenter explained the operational distinction under current contracts: Navitus handles prescriptions similar to retail pharmacies, while Health Advantage covers medically administered drugs delivered in a clinical setting. For medically administered specialty drugs, EBD proposed exclusions so that a provider or member would need to submit an appeal for coverage in cases where earlier treatments were ineffective or clinical evidence changes. The presenter said 423 members listed under the impact column would be grandfathered on their current prior-authorizations.

Board members asked procedural questions about monitoring appeals and reporting; EBD said it could provide periodic reports (likely annually) to show how many appeals were approved and to help the board evaluate whether to add specific drugs back onto the formulary. The presenter noted one specific addition under consideration: use of Botox for urinary incontinence.

Secretary Fiskin moved to approve the EBD medical formulary recommendations and the motion was seconded; the board approved the motion by voice vote. The presenter said appeals and future data could prompt changes to the formulary over time.

The formulary packet and medical-drug recommendation document were referenced as included in the meeting materials.