CurrentExecutive Office of Health and Human ServicesPolicy N/A

Pharmacy & Therapeutics Committee — PDL Recommendations and Coverage Criteria (meeting minutes)

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Meeting minutes documenting Pharmacy & Therapeutics Committee discussions, public testimony, and recommended changes to the Preferred Drug List (PDL) that affect Medicaid pharmacy coverage decisions and formulary placement.

Policy Summary

PayerExecutive Office of Health and Human Services

PolicyPharmacy & Therapeutics Committee — PDL Recommendations and Coverage Criteria (meeting minutes)

Policy CodePolicy N/A

Change TypeFormulary additions and removalsproduct-specific updates (PDL)

Effective DateN/A

Next Review DateN/A

Key ActionUse prior authorization and document recent utilization (within 90 days) to support grandfathering and access for affected products such as Synjardy XR.

SourceLink

POLICY UPDATE CHANGES

Recommend adding Colcrys to the PDL and removing colchicine/Mitigare tablets.

Recommend adding Renvela to the PDL and removing sevelamer.

Recommend addition of Trulicity (weekly) to the PDL and retain Victoza (daily); note Bydureon discontinued.

Changes to add multiple insulin products including SEMGLEE (insulin glargine) and LYUMJEV (insulin lispro-aabc) plus various insulin aspart and lispro formulations.

Recommend addition of Synjardy (and discussion about Synjardy XR availability via PA).

MultipleTherapeutic classes reviewed

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CurrentExecutive Office of Health and Human ServicesPolicy N/A

Pharmacy & Therapeutics Committee — PDL Recommendations and Coverage Criteria (meeting minutes)

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Policy Summary

PayerExecutive Office of Health and Human Services

PolicyPharmacy & Therapeutics Committee — PDL Recommendations and Coverage Criteria (meeting minutes)

Policy CodePolicy N/A

Change TypeFormulary additions and removalsproduct-specific updates (PDL)

Effective DateN/A

Next Review DateN/A

Key ActionUse prior authorization and document recent utilization (within 90 days) to support grandfathering and access for affected products such as Synjardy XR.

SourceLink

POLICY UPDATE CHANGES

Recommend adding Colcrys to the PDL and removing colchicine/Mitigare tablets.

Recommend adding Renvela to the PDL and removing sevelamer.

Recommend addition of Trulicity (weekly) to the PDL and retain Victoza (daily); note Bydureon discontinued.

Changes to add multiple insulin products including SEMGLEE (insulin glargine) and LYUMJEV (insulin lispro-aabc) plus various insulin aspart and lispro formulations.

Recommend addition of Synjardy (and discussion about Synjardy XR availability via PA).

MultipleTherapeutic classes reviewed

Preferred Drug List Recommendations and Coverage Decisions

PDL Recommendations by Therapeutic Class

PDL updates and recommendations accepted when committee votes "Yes" following discussion of clinical information and product availability.

Blood Modifying Agents: Recommendation to add Colcrys and remove colchicine/Mitigare tablets was accepted.

Vote: Yes - All

Phosphate Binders: Recommendation to add Renvela and remove sevelamer was accepted.

Vote: Yes - All

Incretin Mimetics/GLP-1 Agonists: Recommendation to add Trulicity and retain Victoza; motion passed. Bydureon (weekly) noted discontinued.

Vote: Yes - All

Insulins/Biologics: Additions include SEMGLEE (insulin glargine), LYUMJEV (insulin lispro-aabc), and multiple insulin aspart and lispro formulations; motion passed.

Vote: Yes - All; grandfathering for current users based on recent utilization (90 days)

SGLT2 and Combination Agents: Recommendation to add Synjardy was accepted; Synjardy XR was not included in the recommendation and remains a PA-accessible formulation.

Motion accepted; XR considered but not recommended for inclusion

The committee recommended adding Synjardy to the Preferred Drug List (PDL). The extended‑release formulation, Synjardy XR, was not included in the motion because current federal legislation related to the UROA program has made the XR presentation not cost‑effective for the program; however, the minutes state that the XR formulation remains available to members via prior authorization rather than through preferred placement on the PDL.

The minutes do not record any explicit determinations that specific products or classes are not medically necessary. Across the therapeutic reviews summarized in the document, motions and votes relate to PDL additions, removals, or no‑change recommendations, but there are no discrete “not medically necessary” findings documented in the meeting notes.

Provider Requirements, Prior Authorization, and Grandfathering

Prior Authorization

Use of Prior Authorization for Certain Formulations

Some formulations of recommended products remain accessible only through prior authorization; the minutes cite Synjardy XR as an example of a formulation available via PA rather than added to the PDL.

Step Therapy

Step Therapy discussion — no new mandates

The committee discussed step therapy practices used in other states for classes such as growth hormone and diabetes agents but did not implement any new step therapy mandates in these minutes.

Discussion noted other states use step therapy/workup for growth hormone and diabetes agents.
No new specific step therapy requirements were added in this meeting; referrals to the DUR committee were noted for related considerations.

Committee Context and Clinical Guidance Considered

These meeting minutes document the Pharmacy & Therapeutics Committee’s review of multiple therapeutic classes and PDL recommendations. The committee considered clinical information, public testimony, and product availability when voting on formulary changes. Discussions referenced guideline and safety contexts (for example, broader clinical updates and FDA communications are noted elsewhere in the materials), and motions recorded votes to add, retain, or remove products across classes including incretin mimetics, insulins, phosphate binders, and others. Availability and federal program considerations (for example the federal UROA impact on XR formulations) were explicitly noted as factors affecting whether a formulation is placed on the PDL or left available only via prior authorization.

Key Definitions and Acronyms

PDL — definition and role

DefinitionPreferred Drug List (PDL): the formulary used to guide Medicaid pharmacy coverage and preferred product placement.

Primary roleGuides which products are preferred for Medicaid pharmacy coverage and informs formulary additions/removals based on clinical review and product availability.

Decision processPDL updates are recommended by the Pharmacy & Therapeutics committee following clinical discussion and then accepted by committee vote (e.g., motions recorded as 'Pass' with vote outcomes).

Impact on coverageInclusion on the PDL supports preferred placement and routine coverage; removal or non‑inclusion may require prior authorization or affect access pathways.

Examples from meetingCommittee recommended adding Colcrys and Renvela and removing colchicine (Mitigare) and sevelamer; motions to accept recommendations were recorded as 'Pass' with Vote: Yes = All.

First-line Therapy Context

First-line therapy context

Discussion of standard first-line therapies where noted.

Diabetes first-line: Metformin is referenced as the general cornerstone of initial therapy for type 2 diabetes; other agents (e.g., incretin mimetics, SGLT2 combinations, insulin formulations) are considered add-on or subsequent therapy.

Context provided during discussion of alpha-glucosidase inhibitors and incretin mimetics

Continuation and Grandfathering Policies

Grandfathering for Current Users

Continuation of therapy for patients currently using affected products when the PDL is changed.

Grandfathering: Patients currently using affected products will be grandfathered based on documented current utilization within the recent 90 days.90 days

Ensures continuity of therapy when formulary changes occur; absence of documentation of recent use may risk denial or need for PA

Step Therapy Discussions

Topic	Discussion summary	Decision / Effect on policy
Growth Hormones	Committee noted other states use step therapy or work‑up for growth hormone products; question raised whether Rhode Island has similar requirements.	No new step therapy requirements were implemented in these minutes; motion to accept recommendations passed (Vote: Yes - All).
Diabetes agents (including incretin mimetics and insulins)	Discussion referenced new clinical guidance (ACC, ADA, KDIGO) and practices in other states that have introduced step therapy for certain diabetes therapies; question whether new algorithms warrant step changes.	Committee did not establish new step therapy mandates here; specific formulary changes (e.g., add Trulicity, add Synjardy) were accepted, and DUR committee referral noted for step therapy considerations.
Synjardy XR formulation	Members asked about including Synjardy XR given potential improved compliance with less frequent dosing; other states' approaches to step therapy were considered.	Recommendation did not include Synjardy XR in the PDL; XR formulation remains available only via prior authorization as discussed separately. No new step therapy requirement set.