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Subcommittee approves December–February formulary updates; members press staff to verify PBM compliance
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Summary
The subcommittee approved December, January and February pharmacy and medical formulary recommendations, including removing prior authorization for injectable CGRPs and removing Skyrizi and Rinvoq from the pharmacy formulary in favor of lower‑cost alternatives; members also asked EBD to investigate PBM (Navitus) compliance and to follow up on questions about affiliate vs. independent pharmacy reimbursements.
Members of the State Insurance Programs Oversight Subcommittee approved a package of December–February pharmacy and medical formulary recommendations and asked staff to investigate PBM compliance and pharmacy reimbursement concerns.
Grant Wallace, director of the Employee Benefits Division, presented the December recommendations and said the first three December items remove prior authorization for injectable CGRPs (migraine medications) because EBD found "almost 100 percent" of those requests were being approved; the change is intended to streamline access. He also noted replacements, re‑tierings and updates tied to FDA guidance and dosing changes.
Wallace then reviewed January and February recommendations. For February, he said the EBD proposes removing Skyrizi (guselkumab) and Rinvoq (upadacitinib) from the pharmacy formulary in favor of lower‑cost alternatives, including biosimilars as they become available. He said the division is aligning medical and pharmacy coverage where drugs can be administered in either setting and highlighted adding biosimilars on the medical side and adding a subcutaneous formulation of Keytruda to improve administration time and patient access. Wallace also described adding an anti‑seizure medicine that, he said, was developed by the Department of Defense for chemical‑warfare treatment and is currently in bulk packaging; EBD is adding it now in anticipation of commercial packaging.
Representative Pilkington asked whether emerging private pricing programs (referred to in the hearing as the "Trump Rx" plans and programs like Mark Cuban Cost Plus) will affect the state's formulary decisions or plan costs; Wallace said EBD is studying those programs and working with its pharmacy benefit manager, Navitus, to evaluate pricing and negotiate better manufacturer pricing. When members raised recent litigation involving PBMs in other states and whether Navitus complies with the state's PBM law, Wallace said Navitus reviewed Rule 118 and reported compliance but that EBD is conducting additional research and audits to verify compliance.
Senator Boyd said that at a prior committee hearing a company executive (referred to in her remarks as the "Novitas CEO" on the record) testified and that she has not received an answer to a question about whether affiliated pharmacies are paid more than independent pharmacies; she asked staff to follow up and locate the earlier testimony. Wallace acknowledged the outstanding request and the need to revisit video testimony and reporting.
The chair called for motions on each set of recommendations. The committee approved the December, January and February pharmacy recommendations and the February medical recommendations by voice vote; the transcript records "aye" and "motion carries" but does not include roll‑call tallies. Members directed staff to continue research and report back on PBM compliance and pharmacy reimbursement disparities.
Next steps: EBD will proceed with the approved formulary changes, continue investigations into PBM compliance and reimbursement questions, and return with findings or additional information if requested by committee members.
