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HB 5015 - State Group Insurance
by Budget Committee and Rep. V. Lopez
This summary is provided for information only and does not represent the opinion of any Senator, Senate Officer, or Senate Office.
Prepared by: Appropriations Committee (AP)
This bill amends provisions related to implementation of formulary management for prescription drugs and supplies under the State Employees’ Prescription Drug Program.
The bill requires the Department of Management Services (DMS) to submit recommendations to the Governor and the Legislative Budget Commission (LBC) by September 1, 2025, on the implementation of formulary management for prescription drugs and supplies for the 2026 plan year. The recommendations must relate to:
- Lists of excluded prescription drugs and supplies for a recommended formulary, with a comparison to the formulary in effect during the 2025 plan year. A recommended formulary is not required to authorize drugs to be made available for inclusion if a physician, advanced practice registered nurse, or physician assistant prescribing a pharmaceutical clearly states on the prescription that the excluded drug is medically necessary.
- Lists of included prescription drugs and supplies for a recommended formulary, with a comparison to the formulary in effect during the 2025 plan year.
- Prior authorization of specified prescription drugs and supplies.
- Step therapy of specified prescription drugs and supplies.
The DMS is required to submit supporting information for its recommendations: relevant information identifying the prescription drugs and supplies affected, the number of plan members and prescriptions affected for each identified drug or supply, and the cost savings expected for each recommended component implemented.
The bill prohibits prescription drugs and supplies first made available in the marketplace after January 1, 2026, from being covered by the prescription drug program until specifically included in the list of covered prescription drugs and supplies.
The LBC may consider the recommendations of the DMS in total or in part, and, beginning in the 2026 plan year, the DMS may only implement the recommendations approved by the LBC.
Effective January 1, 2026, and only if the LBC approves one or more of the recommendations of the DMS related to lists of excluded prescription drugs and supplies for a recommended formulary, the bill repeals the requirement for drugs excluded from the formulary to be available for inclusion if a physician, advanced practice registered nurse, or physician assistant prescribing a pharmaceutical clearly states on the prescription that the excluded drug is medically necessary. Additionally, the directive to the DMS to make the recommendations to the LBC is repealed. If the LBC approves one or more of the recommendations of the DMS related to lists of excluded prescription drugs and supplies for a recommended formulary, it must notify the Division of Law Revision of such approval.
The bill requires the DMS to submit on an annual basis the list of prescription drugs and supplies that will be excluded from program coverage during the next plan year. This list must be submitted by September 1 each year, instead of October 1 as provided under current law. Further, the list must include, for informational purposes only, the list of prescription drugs and supplies that are recommended to be subject to a higher copayment for the next plan year. Any prescription drugs and supplies that will be excluded from program coverage, whether on the list submitted or as proposed by the DMS during the plan year, must be approved by the LBC.
If approved by the Governor, or allowed to become law without the Governor’s signature, these provisions take effect on July 1, 2025, except as otherwise expressly provided.
Vote: Senate 25-9; House 98-5