About the Project

The Access and Nondiscrimination in the States Awareness Project provides public education and awareness of how states are currently valuing health care, the use of value assessments in their health care systems, and potential implications for discrimination and barriers to patient access. As our policymakers at the federal and state level explore avenues to address the cost of prescription drugs, they are frequently turning to solutions that would be detrimental to patient access, like international reference pricing, or reliance on third-party cost-effectiveness analyses to determine the “value” of prescription drugs. Cost-effectiveness analyses generally rely on the Quality-Adjusted Life Year (QALY). The QALY, along with similar metrics that treat patients as averages, is known to discriminate against people who are chronically ill or disabled.
 
We strongly believe that comparative clinical effectiveness research should work for patients to improve their health decisions, not against them by limiting their access in a one-size-fits-all health system. Therefore, policies to advance value-based health care must mitigate against the misapplication of research in ways that restrict patient access to optimal care, undermine physician/patient shared decision-making, and discourage continued medical progress. This project allows patients and people with disabilities to see where and how states may be using or considering using discriminatory metrics that would limit their access to needed care.

State Awareness Tracker

​Latest Updates:
All States
  • Many states have or are considering adoption of a prescription drug affordability board (PDAB). Their goal is to allow the state to review and evaluate the reimbursement rate and/or coverage for pharmaceuticals. Most have fairly broad parameters of how they can assess a drug’s value, and specifically permit the state to rely on third-party research or contract directly with a third-party for the purpose of fulfilling its duties. The PDAB landscape has changed and evolved rapidly. This landscape analysis gives updates on PDABs and their potential to rely on discriminatory value assessments as of March 11, 2025.
  • The updated final rule governing Section 504 of the Rehabilitation Act, which protects the rights of people with disabilities in programs and activities receiving federal financial assistance, bars health care decisions made using measures that discount gains in life expectancy — which would likely include the quality-adjusted life year (QALY), and the combined use of QALYs, and equal value of life years gained (evLYG). State Medicaid programs will be challenged to be compliant with the rule if states simultaneously advance legislative templates from the National Association of State Health Policy (NASHP), as they intentionally allow for reference to QALYs and similar measures.  ​

Colorado
  • The full PDAB Board's next meeting will take place April 11, 2025. The next meeting of the Prescription Drug Affordability Advisory Council is on April 24, 2025. The Colorado PDAB released its 2025 meeting and staff office hour schedule, which can be accessed here.

Illinois
  • Illinois introduced SB 66 / HB 1443, the Health Care Availability and Access Board Act, on January 13 and January 28, 2025, respectively. This legislation provides Board authority to establish Upper Payment Limits. Provisions related to use of QALYs and similar measures reference their use in identifying subpopulations and in life extension. The language is modeled on other state bills and does not clearly bar their use. The House bill was referred to a new committee called a Prescription Drug Affordability Board that includes three representatives.

Kansas
  • ​Kansas introduced SB 212 on February 5, 2025, which would create a PDAB and provide authority to establish Upper Payment Limits. Provisions related to use of QALYs and similar measures reference their use in identifying subpopulations and in life extension. The language is modeled on other state bills and does not clearly bar their use.

Maryland
  • The Maryland Senate Finance Committee advanced S 357 on March 12, 2025, along party lines. The bill may be considered on the floor of the Senate as early as this week. Originally passed by the House of Delegates as HB 424 on February 21, 2025, in a 98-34 vote, the legislation would require the PDAB to establish a process for setting upper payment limits for all purchases of prescription drugs that the Board deems would lead to affordability challenges.
    • While the Senate committee amended the legislation to require limited retrospective impact analysis on patient cost and access, the bill still does not bar the use of QALYs and similar measures, nor the consideration of information from third parties that utilize such measures. 
​
  • Maryland’s Prescription Drug Affordability Board Stakeholder Council (PDASC) CANCELED its next meeting on February 24, 2025. Meanwhile, the next meeting of Maryland's Prescription Drug Affordability Board meeting has been scheduled for March 24, 2025.
    • To provide oral comment, email [email protected]​ at least five days before the meeting and provide: (1) your name; (2) your address; and (3) the agenda item your comment will address. 
    • Written comments may be sent to [email protected]​ at least five days before the meeting with subject line “March 2025 Board Comments.” 

New Hampshire
  • The New Hampshire PDAB is meeting on March 24, 2025. More information can be found here.
 
Oregon 
  • The next meeting of the Oregon PDAB is April 16, 2025. Register to attend here. 
    • Public comments for the meeting, either oral or written, must be submitted through the PDAB public comment form. Oral comments must be submitted at least 24 hours before the meeting, while written comments are due 48 hours in advance.

Virginia
  • Virginia's HB 1724, which would create a Prescription Drug Affordability Board, has passed both chambers of the state legislature and now awaits the governor's approval by the March 24, 2025, deadline. 

Washington State
  • The Washington PDAB will meet again on March 19, 2025. At the Nov. 18, 2024 meeting, the PDAB staff discussed its use of ICER Analytics and cost effectiveness as part of its deliberations, indicating an intent to reference QALYs and similar measures in its assessments. Click here to view more information about the meeting, its agenda and transcripts. 
 
  • During last month's PDAB meeting, the Washington PDAB advisory group recommended seven drugs for affordability reviews, referencing ICER analyses that informed their decisions. View transcript here.
Alabama
Drug Utilization Review (DUR) Board
  • The DUR Board ensures that covered outpatient prescription drugs are “appropriate, medically necessary, and are not likely to result in adverse medical results.”
  • The next DUR Board meeting is April 23 at 1pm.
    • Testimony: No instructions available for either oral or written testimony and past agendas indicate that time is not allocated to any public comment.
    • Accommodations: No instructions available for ADA accommodations.
  • The regulations creating Alabama’s DUR Board do not reference cost effectiveness in their intended considerations or activities.
 
Pharmacy & Therapeutics (P&T) Committee
  • Alabama’s P&T Committee develops preferred drug list recommendations by considering the “clinical efficacy, safety, and cost effectiveness of a product.”
  • The next P&T Committee meeting is May 7.
    • Testimony: Details on commenting procedures for manufacturers can be found here.
    • Accommodations: No instructions available for ADA accommodations.
  • Instructions for manufacturers comments, both written or oral, specify that references may not be made to “cost or general drug- or disease-specific economic information.”
 
Notable Activity
  • The state Medicaid program does not openly reference QALYs or ICER studies. However, many of the state’s prescription drug coverage policies demonstrate that treatments that were assessed by ICER and deemed to not be cost effective or for which ICER recommended step therapy tend to be covered with prior authorization requirements or not covered at all.​
Alaska
Drug Utilization Review (DUR) Committee
  • The DUR Board oversees prospective and retrospective drug utilization reviews, implementing prior authorizations and quantity limits to prevent fraud, waste, and misuse while periodically reviewing criteria for medical relevance.
  • The next DUR Committee meeting is TBD.
    • Testimony: Members of the public may submit materials related to agenda items by sending an email to [email protected], accompanied by a conflict of interest form. Meanwhile manufacturers are directed to submit materials through the clinical submission form. More details can be found in the meeting notices.
    • Accommodations: Those seeking accommodations are instructed to contact Matthew Parrott at 907-334-2425.
  • The state of Alaska contracts with Healthcare Management Solutions (HMS) to conduct the DUR program.
  • The DUR Board considers cost-effectiveness in its analyses. Alaska Medicaid prior authorization clinical criteria for use and standards of care are developed under the authority granted to the Alaska Medicaid DUR Committee in compliance with 7 AAC 120.120, 7 AAC 120.130, 7 AAC 120.140, 42 USC 1396r-8, and 42 CFR 456 Subpart K. 
 
Pharmacy & Therapeutics (P&T) Committee
  • The P&T Committee is a team of Alaskan doctors and pharmacists tasked with reviewing drug classes for the state Medicaid program, determining which drugs are safe, effective, and “cost less than other drugs in the same class.”  
  • The next P&T Committee meeting is April 18, 2025. The list of drugs to be considered can be found here.
    • Testimony: No instructions available for public comment.
    • Accommodations: No instructions available for ADA accommodations.

Notable Activity
  • In 2019, Alaska reported to the Kaiser Family Foundation that the state is considering “the use of comparative effectiveness review in drug coverage review," and that the state Medicaid program uses ICER studies.
Arizona
Pharmacy & Therapeutics (P&T) Committee
  • The Arizona Health Care Cost Containment System (AHCCCS) P&T Committee is advisory to the AHCCCS Administration and is responsible for evaluating scientific evidence of the relative safety, efficacy, effectiveness and clinical appropriateness of prescription drugs. This Committee provides recommendations to AHCCCS on the development and maintenance of a statewide drug list.
  • The next P&T Committee meeting is May 21, 2025.
  • Magellan Medicaid Administration, Inc. (MMA), part of the Magellan Rx Management division of Prime Therapeutics LLC, manages the preferred drug list (PDL) and supplemental rebate processes.
  • The operational policy document states that Committee members will “evaluate information regarding individuals drugs and therapeutical classes of drugs in an impartial manner emphasizing the best clinical evidence and cost effectiveness.”

Ongoing Legislative Activity
  • SB 1403: Automatically sets Medicare’s maximum fair price as the upper payment limit (UPL) for drugs whose price has been negotiated at the federal level. By doing so, the legislation removes opportunities for public input on potential access issues, raising concerns that treatment options will be limited without guaranteed cost savings for beneficiaries.
    • The bill references Medicare drug prices, for which CMS has indicated a reliance on QALYs and similar measures.
    • Status: Introduced February 3, 2025. 
 
Drug Utilization Review (DUR) Board
Notable Activity
  • The state Medicaid program does not openly reference QALYs or ICER studies, though Arizona reported to the Kaiser Family Foundation that the state is considering “the use of comparative effectiveness review in drug coverage review.”
  • In 2022, the legislature introduced SB 1680, creating a Prescription Drug Affordability Board with authority to consider value and cost effectiveness of drugs. The legislation did not ban use of QALYs and similar measures, raising concerns that the state could partner with entities such as PORTAL and ICER that historically support the use of QALYs and evLYGs to value health care. 
Arkansas
 Drug Utilization Review (DUR) Board
  • The Arkansas DUR Board aims to “improve client safety and conserve program funds while ensuring therapeutically and medically appropriate pharmacy care for clients” by developing and maintaining the preferred drug list (PDL).
  • The DUR Board meets quarterly on the 3rd Wednesday of January, April, July, and October. While Arkansas does not have a designated DUR Board site, agendas are posted ahead of the meeting here.  
    • Testimony: Requests to speak at DUR Board meetings must be made in writing to the DUR Chairperson at least two weeks before the DUR Board meeting date. Comments must pertain to an agenda item and are limited to a total of three minutes per drug.
    • Accommodations: No instructions available for ADA accommodations. 
  • Arkansas contracts with Prime Therapeutics to conduct the DUR program.
  • The DUR Board does not publish meeting minutes. 

Notable Activity
  • The state Medicaid program reported to Kaiser Family Foundation that the state references published studies from ICER, which rely on QALY and evLYG metrics to determine value and cost effectiveness.
  • Litigation in Arkansas held that, “DHS had no legal authority to make a threshold decision that there was a ‘lack of medical necessity’ for a prescription of Exondys, a ‘covered outpatient drug.”
  • Arkansas is reported to rely on reference pricing since 2005 for its state employee program for 12 classes of drugs including antihyperlipidemic-HMG, angiotensin II rec antagonists/direct renin inhibitors, long-acting amphetamines, fibromyalgia-related anticonvulsants, serotonin norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, migraine medications, sedatives, proton pump inhibitors, overactive bladder agents, nasal steroids, and osteoporosis-calcium regulators.​
California
Drug Utilization Review (DUR) Board
  • The Global Medi-Cal DUR Board advises and makes recommendations to the State on common drug therapy problems, develops criteria to evaluate and improve the quality of drug therapy, reviews evaluations and utilization reports, and recommends educational interventions, as needed, in order to improve prescribing and dispensing practices.
  • The next DUR Board meeting is May 20th at 9:30am.
    • Testimony: The last ten minutes of each meeting are reserved for public comments, which are limited to five minutes per individual.
    • Accommodations: Those in need of accommodations are instructed to contact Pauline Chan at 1-916-345-8591, no later than 5 working days before the meeting.
 
Pharmacy & Therapeutics (P&T) Committee
  • The P&T Committee reviews and consults with the Administrative Director on available evidence of the relative safety, efficacy, and effectiveness of drugs within a class of drugs, for purposes of updating California's Medical Treatment Utilization Schedule (MTUS) drug list.
  • The next P&T Committee meeting is TBD.
    • Testimony: Individuals may present oral comments during the meeting. To do so, meeting attendees must indicate their desire in the chat feature of the conference application and specify whether the comment pertains to a specific agenda topic or during the general Public Comment period. Comments are limited to three minutes per speaker.
    • Accommodations: Disability accommodation is available upon request. Any person with a disability requiring an accommodation, auxiliary aid or service, or a modification of policies or procedures to ensure effective communication and access to the public hearings/meetings should contact the Statewide Disability Accommodation Coordinator at 1-866- 681-1459 (toll free), or through the California Relay Service by dialing 711 or 1-800- 735-2929 (TTY/English) or 1-800-855-3000 (TTY/Spanish).
  • The P&T Committee meeting minutes do not describe the evidence base for making decisions.

Notable Activity
  • In 2022, California formally established the Office of Health Care Affordability (OHCA) to develop policies for lowering health care costs for consumers, set and enforce cost targets, and create a state strategy for controlling the cost of health care.
    • There is currently no safeguard in place against the Office using QALYs and similar metrics. 
  • ICER has received a grant from the California Health Care Foundation to develop annual unsupported price increase reports as well as a policymaker guide for using its research to determine “fair” access and pricing to drugs. Advocates have expressed concern about this partnership.
  • The state Medicaid program reported to the Kaiser Family Foundation that the state references published studies from ICER, which rely on QALY and evLYG metrics to determine value and cost effectiveness.
  • Proposed QALY Authority: The state has proposed policies that would further codify its ability to reference QALYs:
    • Proposed, 2021: The California Health Care Quality and Affordability Act and a state budget proposal to create an Office of Health Care Affordability empowered to analyze and determine strategies to address costs in a manner that may rely on QALY-based cost effectiveness studies.
    • Proposed, 2020-2021: The California Governor’s proposed budget sought to expand the state's ability to consider the best prices offered by manufacturers internationally, potentially referencing countries that rely on QALYs in considering price, reimbursement and coverage.
    • Proposed, 2019: The California Legislative Analyst’s Office (LAO) proposed the state use formal use of cost- effectiveness analysis for preference of drugs in Medi-Cal and use of a drug spending cap, similar to the State of New York that relies on ICER’s QALY-based cost-effectiveness analyses.
  • The state has not proposed to bar the use of QALYs, though advocates have reached out to policymakers requesting a QALY ban be added to the proposed legislation and budget creating an Office of Health Care Affordability.
Colorado
Prescription Drug Affordability Board (PDAB)
  • The Colorado PDAB's next meeting will take place April 11, 2025. 
    • Oral comments are limited to two minutes per person. To provide verbal comments, attendees must fill out the sign-up form available at each meeting.
    • Written comments may be emailed to [email protected] and must be submitted at least 48 hours before each meeting. Submissions received after the deadline will be considered for the following meeting.
    • Accommodations: No instructions available for ADA accommodations. 
  • The next meeting of the Prescription Drug Affordability Advisory Council (PDAAC) is April 24, 2025.
Meeting Materials
  • ​​PDAB meeting materials are available on a Google documents site. Materials citing QALYs, similar measures, health technology assessment (HTA), entities supporting QALYs (ICER, PORTAL, etc) to the PDAB are below:
    • Joint letter on PDAB Violations of State and Federal Law, January 7, 2025.
    • Presentation from Program on Regulation, Therapeutics, and Law (PORTAL), October 18, 2024.
    • Joint letter calling for nondiscrimination, opposing QALYs and evLYGs, June 28, 2024.
    • Reference to HTA sources developed domestically and internationally, June 14, 2024.
    • PIPC letter highlighting new Section 504 rules barring use of discriminatory value assessments, May 23, 2024.
    • Reference to entities using QALYs and similar measures in review of Stelara and Cosentyx (ICER, NICE, CADTH, IQWiG), March 2024.
    • Joint letter opposing use of QALYs and similar measures, October 11, 2023.
    • PORTAL referenced as providing research support, August 4, 2023.
Policies Adopted 
  • Colorado state law bars use of QALYs in establishing Upper Payment Limits:
    • “The methodology determined by the board pursuant to subsection (2) of this section: (a) shall not consider research or methods that employ a dollars-per-quality adjusted life year, or similar measure, that discounts the value of a life because of an individual's disability or age;”
  • PDAB Rule 3 CCR 702-9 allows the Board to use information that uses QALYs and cost effectiveness:
    • “The Board may identify if the literature uses a quality-adjusted life-year analysis or a similar measure that discounts the value of a life because of an individual's disability or age. The Board may use information that uses a quality-adjusted life year analysis to evaluate relative financial effects, but will not use quality adjusted life year analysis to determine an upper payment limit or other appropriate costs of a prescription drug. If quality-adjusted life year analysis is used during affordability review, the Board will acknowledge any health equity impacts to priority populations.”​
    • “The Board may also consider documents and information relating to the manufacturer’s selection of the introductory price or price increase of the prescription drug including information related to… Estimated cost-effectiveness of the prescription drug"
  • The PDAB recently deemed three drugs — Stelara, Cosentyx and Enbrel — unaffordable and is now considering UPLs. 
    • During their board meeting on Dec. 6, the Colorado PDAB confirmed that they will be proceeding with a UPL rulemaking for Enbrel. While initially scheduled to begin in January, the rulemaking process has been delayed to April 11, 2025, with at least three rulemaking hearings expected. 

Existing State Statute
  • SB 21-175, 2021: The legislation that created Colorado's PDAB included a provision that barred the use of QALYs as part of the methodology for establishing an upper payment limit for a prescription drug. 

Drug Utilization Review (DUR) Board
  • The DUR Board serves in an advisory capacity to the Department of Health Care Policy & Financing and makes recommendations regarding drug utilization, educational interventions, and application of standards. The DUR Board also provides recommendations to the Department regarding prior authorization criteria for a wide range of drug classes and medications. 
  • The next DUR Board meeting is May 6, 2025 at 1pm. 
    • ​Testimony: The website states, “Parties interested in presenting testimony during a quarterly DUR Board meeting must register at least 24 hours in advance by contacting Jeffrey Taylor at [email protected].”
    • Accommodations: The website states, “Auxiliary aids and services for individuals with disabilities and language services for individuals whose first language is not English may be provided upon request. Please notify the 504/ADA Coordinator or send an email to [email protected] at least one week prior to the meeting to make arrangements.”
  • The DUR Board does not provide details about the evidence base in its meeting minutes.

Pharmacy and Therapeutics (P&T) Committee
  • The P&T Committee is an advisory board performing clinical reviews of drug classes and makes recommendations which help the Department develop and manage the Medicaid Preferred Drug List (PDL).
  • The next P&T Committee meeting is April 8, 2025 at 1pm. 
    • ​Testimony: The website states, “Interested parties who want to present at the meeting shall give at least 3 business days notice (by 5 p.m. MST), prior to the meeting, to Jessica Czechowski, Pharmacist Account Executive, by email at [email protected] and carbon copy Greg Miller, PDL Pharmacist, by email at [email protected].”  
    • Accommodations: The website states, “Auxiliary aids and services for individuals with disabilities and language services for individuals whose first language is not English may be provided upon request. Please notify Greg Miller at [email protected].”
  • Prime Therapeutics is the pharmacy benefit manager tailoring the Colorado PDL. The PBM does not publicly provide the evidence for their recommendations but participates in P&T committee meetings. 
  • The meeting minutes of the P&T Committee do not describe details about the evidence base for making decisions.

Other Notable Activity
  • Proposed QALY Authority, 2020: The Colorado Department of Health Care Policy and Financing released a report entitled “Reducing Prescription Drug Costs in Colorado,” which proposed “monitoring new ways to price prescription drugs, including QALY pricing methodologies” from ICER.
    • Citation to the 1st edition report is no longer available. 
Connecticut
Ongoing Legislative Activity
  • SB 11: Requires state drug purchasing agencies to incorporate Medicare’s maximum fair prices when negotiating drug prices for state-subsidized healthcare programs. It also prohibits pharmaceutical manufacturers and wholesalers from selling certain prescription drugs at prices exceeding a designated reference price, adjusted for inflation.
    • The bill references Medicare drug prices, for which CMS has indicated a reliance on QALYs and similar measures. 
    • Status: Passed by the Joint Committee on Human services on March 14, 2025.

Drug Utilization Review (DUR) Board
The Connecticut Medical Assistance Pharmacy DUR program states that its goal is to facilitate the “appropriate and cost effective delivery of pharmaceutical care with non-biased, independent professional reviews of published literature for advisement on educational programs” and does not make any statement restricting use of QALY-based cost effectiveness analyses. The next DUR Board meeting is June 12, 2025, at 6:30pm.
  • Testimony: No instructions available for public comments, but the bylaws state that “non-members will be given limited comment time for verbal contributions prior to the regular meeting.
  • Accommodations: No instructions available for ADA accommodations. 
 
Pharmacy & Therapeutics (P&T) Committee
The P&T Committee develops and implements a voluntary Medicaid preferred prescribed drug designation program. The committee recommends prescription products that they deem to be efficacious, safe, and cost effective choices when prescribing for Medicaid patients. The next P&T Committee meeting is TBD.
  • Testimony: Requests to provide public testimony, written comments, or attend the meeting must be received two weeks before the meeting. Only one speaker per company, group, or organization is permitted and comments must be limited to two minutes.
  • Accommodations: No instructions available for ADA accommodations. 
 
Notable Activity
  • The state Medicaid program has not openly referenced QALYs or ICER studies in recent years.
  • ICER recommendations helped shape the state’s Medicaid coverage on topics such as sleep apnea treatment, breast cancer imaging, and Proprotein Convertase Subtilisin/Kexin Type 9 inhibitors according to an agency presentation to the Connecticut Healthcare Cabinet in 2017. Such detailed information was not found in public records over the 2019-2021 period identifying the evidence used for Medicaid decision-making on drug coverage.
  • Proposed QALY legislation:
    • Proposed QALY Authority, 2019: H.B. 7174 would have called for maintaining a list of “cost effective” drugs as determined by the State Comptroller, with no bar on use of metrics such as QALYs.
    • Proposed QALY Ban, 2021: H.B. 6242 would prohibit any “insurer, health care center, fraternal benefit society, hospital service corporation, medical service corporation or other entity that delivers, issues for delivery, renews, amends or continues a health insurance policy” from using a dollars-per-quality adjusted life year or any similar measure as a threshold for coverage, reimbursement or incentives. The bill is not limited to prescription drugs, but applies broadly to health care services. 
Delaware
Drug Utilization Review (DUR) Board
  • The DUR Board evaluates standards of drug use in Delaware’s Medical Assistance Programs, responsible for conducting both retrospective and prospective drug use reviews.
  • The next DUR Board meeting is TBD.
    • Testimony: Opportunities are provided for individuals, or citizens representing a group or groups, to appear on the agenda. Requests to appear before the DUR Board must be made in writing and received ten days before a scheduled meeting, including subject matter and speaker name for inclusion on the agenda. The ten day requirement may be waived by the Chairperson. The DUR Board will limit presentations to ten (10) minutes, unless an extension is granted by the DUR Board.
    • Accommodations: No instructions available for ADA accommodations. 
  • The state’s DUR Board description does not include reference to cost effectiveness, stating, “The Board makes recommendations for which combination of interventions would most effectively lead to improvement in the quality of drug therapy, and periodically re-evaluates and, if necessary, modifies the recommended interventions.”
 
Pharmacy & Therapeutics (P&T) Committee
  • The P&T Committee’s “objective is to achieve quality pharmaceutical care for recipients enrolled in Delaware’s Medical Assistance programs while providing significant taxpayer savings.” 
  • The next P&T Committee meeting is April 10, 2025, at 12:30pm.
    • Testimony: Prior registration for public comments is required at least seven days prior to the meeting. To register, potential speakers must submit a Registration Application to the Delaware Pharmacy Program, disclosure statement, and copy of the testimony. These forms can be found here and must be submitted to [email protected].
    • Accommodations: No instructions available for ADA accommodations. 
 
Notable Activity
  • The state Medicaid program reported that the state references published studies from ICER, which rely on QALY and evLYG metrics to determine value and cost effectiveness.
District of Columbia
Drug Utilization Review (DUR) Board
  • The district’s DUR Board “shall ensure that prescribed drugs are clinically appropriate, medically necessary, cost effective, and not fraudulently obtained or prescribed.”
  • DC does not provide additional details about its DUR Board.
 
Pharmacy & Therapeutics (P&T) Committee
  • The P&T Committee reviews and maintains DC’s preferred drug list (PDL).
  • The next P&T Committee meeting is March 6, 2025, at 2:30pm.
    • Testimony: Any person or organizations who wish to make a presentation to the DHCF P&T Committee should furnish his or her name, address, telephone number, and name of organization represented by calling (202) 442-9076 no later than 4:45 PM on Thursday, February 27 th, 2025. The person or organization may also submit the aforementioned information via e-mail to Charlene Fairfax ([email protected]).
    • Accommodations: No instructions available for ADA accommodations. 
  • DC contracts with Prime Therapeutics to conduct the P&T program.
 
Notable Activity
  • The district’s Medicaid program reported that the state references published studies from ICER, which rely on QALY and evLYG metrics to determine value and cost effectiveness.
Florida
Drug Utilization Review (DUR) Board
  • The DUR Board  reviews and approves drug use criteria and standards for both prospective and retrospective drug use reviews. It applies these criteria and standards in the application of DUR activities, reviews and reports the results of the drug use reviews, and recommends and evaluates the educational intervention programs.
  • The next DUR Board meeting is tentatively set for June 26, 2025.
    • Testimony: Interested parties can request a 2-minute speaker slot by completing an online form available here.
    • Accommodations: No instructions available for ADA accommodations. 
  • Florida contracts with Prime Therapeutics to conduct its DUR program.
 
Pharmacy & Therapeutics (P&T) Committee
  • The P&T Committee develops and implements Florida’s Medicaid preferred drug list (PDL), which the website describes as a listing of “cost-effective, safe, and clinically efficient medications for each of the therapeutic classes on the list.”
  • The next P&T Committee meeting is tentatively set for June 27, 2025.
    • Testimony: Interested parties can request a 2-minute speaker slot by completing an online form available here.
    • Accommodations: No instructions available for ADA accommodations. 
  • Florida contracts with Prime Therapeutics to conduct its DUR program.
 
Notable Activity
  • The state Medicaid program does not openly reference QALYs or ICER studies.
  • Vida Health and Florida Alliance for Healthcare Value recommended employer use of QALYs at the Florida Alliance’s 26th Annual “Best of the Best” Showcased Innovation in Achieving Value in Employer-Sponsored Healthcare, stating that employers should, "Consult reports from the Institute for Clinical and Economic Review (ICER) when making decisions within the drug space as they provide valued intellectual perspectives and analysis, especially with regard to exceedingly high drug pricing.”
  • State statute says, “The agency shall purchase goods and services for Medicaid recipients in the most cost-effective manner consistent with the delivery of quality medical care” and “The agency shall implement a Medicaid prescribed-drug spending-control program that includes…A Medicaid preferred drug list, which shall be a listing of cost-effective therapeutic options recommended by the Medicaid Pharmacy and Therapeutics Committee established pursuant to s. 409.91195 and adopted by the agency for each therapeutic class on the preferred drug list” and “The agency may specify the preferred daily dosing form or strength for the purpose of promoting best practices with regard to the prescribing of certain drugs as specified in the General Appropriations Act and ensuring cost-effective prescribing practices.”
  • The state PDL is described as “a listing of cost-effective, safe and clinically efficient medications for each of the therapeutic classes on the list.”​
Georgia
Drug Utilization Review (DUR) Board
  • The DUR Board “reviews drug therapy, drug studies and utilization information, thus enabling the Department to identify the most cost-effective policies for its members.”
  • The next DUR Board meeting is April 16, 2025, at 10am.
    • Testimony: Comments may be made in person or submitted in writing. A disclosure statement, which will be available at the meeting and here, must be completed and signed prior to any presentation or submission of written comments in order to ensure that all financial and other pertinent relationships have been publicly disclosed.
      • Written Comments: Must be submitted, along with the disclosure statement, at least five days prior to the meeting and mailed to: DCH Pharmacy Unit, 2 Martin Luther King Jr. Drive SE, East Tower, 19th Floor, Atlanta, GA 30334.
    • Accommodations: No instructions available for ADA accommodations. 
  • Georgia contracts with OptumRx to conduct its DUR program.
 
Pharmacy & Therapeutics (P&T) Committee
  • The P&T Committee’s charter states, ““The decisions from P&T will proceed to the Strategy Development committee (SDC) who will make PDL decisions through financial analyses that are consistent with P&T decisions. The SDC will manage drug cost using a multi-disciplinary standardized approach to identify, develop, and implement long and short-term strategies in support of health plan financial and other business objectives. Data and analytics will optimize decision-making.”​
  • Georgia does not provide additional details about its P&T Committee.
 
Notable Activity
  • The state Medicaid program reported that the state references published studies from ICER, which rely on QALY and evLYG metrics to determine value and cost effectiveness.
Hawaii
​Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program does not openly reference QALYs or ICER studies.
  • The DUR Board and P&T Committee meeting minutes are not published nor is the evidence base for decisions publicly available.
  • The DUR Board is described on the state website as, “The Prospective Drug Utilization Review (ProDUR) process promotes optimal and cost-effective use of pharmaceuticals, lessens the chance of unnecessary or inappropriate use of medications, helps identify possible drug-related problems, and promotes optimal clinical outcomes.”
  • A duty of the DUR Board is described in state regulations as, “Determine the content and mix of educational programs and interventions for practitioners, designed to enhance the clinical appropriateness and cost effective use of prescription drugs with primary emphasis on therapeutic outcomes and quality of care.”
  • Introduced, HB 18, 2021: Hawaii introduced legislation modeled on a NASHP template bill to reduce prescription drug costs for residents by establishing maximum wholesale drug prices that are the same as the prices in Canada, which relies on QALYs in pricing and coverage decision-making.​
Idaho
Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program does not openly reference QALYs or ICER studies.
  • The state relies on third parties in establishing its formulary, including Provider Synergies, which describes itself as developing preferred drug list recommendations using a process that “combines clinical and financial information in a competitive contracting process.” They also state, “These recommendations also consider an analysis of disruption and savings models based on the expected impact of alternative PDL recommendations.” Their model emphasizes cost savings stating, “Provider Synergies uncovers cost saving opportunities for our clients through our financial modeling process. We provide quarterly reports detailing preferred drug list recommendations to optimize the net cost of drugs for our clients.”
  • In meeting minutes, the Idaho P&T Committee referenced cost effectiveness in its decision-making but did not discuss specific studies referenced.
  • The DUR Board website states, “The goals of the program are to reduce potentially inappropriate prescribing and dispensing of medications, enhance the counseling of patients, and reduce growth in expenditures for drugs.
  • The P&T Committee website states, “The Idaho Medicaid Pharmacy and Therapeutics Committee (P&T Committee) is comprised of Idaho health practitioners – physicians, physician assistants, and pharmacists – who are committed to providing the right care at the right price.”
  • The law states, “The Director of the Department of Health and Welfare, acting upon the recommendation of the Pharmacy and Therapeutics Committee, may determine that a non-prescription drug product is covered when the non-prescription product is found to be therapeutically interchangeable with prescription drugs in the same pharmacological class following evidence-based comparisons of efficacy, effectiveness, clinical outcomes, and safety, and the product is deemed by the Department to be a cost-effective alternative.”
  • The law states, “The purpose of supplemental rebates is to enable the Department to purchase prescription drugs provided to Medicaid participants in a cost-effective manner.
  • There are no legislative proposals to reference QALYs, whether by referencing ICER or foreign prices.
Illinois
Ongoing Legislative Activities
  • SB 66 / HB 1443: Illinois introduced the Health Care Availability and Access Board Act on January 13 and January 28, 2025, respectively. The bill would establish a board to evaluate prescription drug costs and determine whether to impose Upper Payment Limits.
    • Provisions related to use of QALYs and similar measures reference their use in identifying subpopulations and in life extension. The language is modeled on other state bills and does not clearly bar their use.
    • Status: Introduced.
 
Drug and Therapeutics (D&T) Advisory Board
  • The D&T Advisory Board provides the state’s health department with “recommendations on the prior approval status of new drugs and Preferred Drug List (PDL) policies that promote the clinically appropriate and evidence-based use of cost-effective drugs for Medicaid customers.”
  • According to the state, Illinois’ PDL is “based upon clinical efficacy, safety, and cost effectiveness,” as the P&T Advisory Board “reviews the Department’s PDL proposals in each therapeutic class for clinical soundness.”
  • The next D&T Advisory Board meeting is April 10, 2025, at 8:30am.
  • The Board’s meeting minutes do not specifically reference the evidence being relied on to make recommendations.
 
Other Notable Activity
  • The Illinois Medicaid program does not openly reference QALYs or ICER studies.
  • The state uses “drug monographs and clinical reviews provided by the University of Illinois Chicago.” The University has contracted in the past with ICER to conduct cost effectiveness analyses but does not have public information available on the methods used in its work for the state.
Indiana
Landscape for Cost Effectiveness & QALY Considerations:
  • The state uses “primary literature” in drug coverage decisions.
  • The state does not publish meeting minutes from the Drug Utilization Review Board.
  • The DURB is authorized to consider health economic data and cost data (see IC 12-15-35-19 and IC 12-15-35-35).​
Iowa
Ongoing Legislative Activities
  • SF 264: Establishes a Prescription Drug Affordability Board (PDAB) to evaluate prescription drug costs and determine whether to impose upper payment limits (UPLs), which may include assessing the “estimated value of cost-effectiveness.”
    • The bill does not bar the use of QALYs and similar measures, nor the consideration of information from third parties that utilize such measures.
    • Status: Introduced on February 11, 2025.
 
Drug Utilization Review (DUR) Board
  • Iowa’s DUR Board “is charged with promoting the appropriate and cost-effective use of medications within the Iowa Medicaid member population.”​
  • The next DUR Board meeting is May 7, 2025.
    • Testimony: For oral comments, individuals must pre-register and submit a completed conflict of interest disclosure. More information on their public comment policy can be found here. Written comments must also be accompanied by a completed conflict of interest disclosure and may be emailed to [email protected].
    • Accommodations: No instructions available for ADA accommodations.
  • Iowa contracts with OptumRx to conduct its DUR program.
  • The DUR Commission meeting minutes do not explicitly refer to the evidence relied on for its recommendations.
 
Pharmacy & Therapeutics (P&T) Committee
  • The P&T Committee was established for the purpose of “developing, recommending, and providing ongoing review of a preferred drug list (PDL).”
  • The next P&T Committee meeting is April 17, 2025, at 9:30am.
    • Testimony: For oral comments, individuals must pre-register and submit a completed conflict of interest disclosure. Written comments must also be submitted with a conflict of interest disclosure. All submissions should be sent to [email protected].
    • Accommodations: No instructions available for ADA accommodations.
  • Iowa contracts with OptumRx to conduct its P&T program.
 
Notable Activity
  • The state Medicaid program reported that the state references published studies from ICER, which rely on QALY and evLYG metrics to determine value and cost effectiveness.
  • In 2024, the legislature introduced HF 2408 / SF 2238, creating a PDAB authorized to engage third parties and create criteria for assessing affordability and recommending UPL. QALYs and similar measures are not banned from use, opening the door to third-party contracts with entities supporting their use, including ICER and PORTAL. 
Kansas
Landscape for Cost Effectiveness & QALY Considerations:
  • The state refers to “analyses published in the literature” in drug coverage decisions.
  • The DUR Board meeting minutes do not explicitly refer to the evidence relied on for its recommendations.
  • The website states, “The Kansas Medical Assistance Program (KMAP) has created a preferred drug list (PDL) to promote clinically appropriate utilization of pharmaceuticals in a cost-effective manner without compromising the quality of care.” 
  • The website also states, “A Preferred Drug List Advisory Committee, composed of practicing physicians and pharmacists, ensures that extensive clinical review of drug products takes place. The Advisory Committee's review and recommendations are based on evidence-based clinical information, not cost. Evidence-based medicine means providing treatments that have been shown to be effective, beneficial and have high value and not providing treatments that have been shown to be ineffective, harmful or have poor value.”
  • ​Kansas introduced SB 212 on February 5, 2025, which would create a PDAB and provide authority to establish Upper Payment Limits. Provisions related to use of QALYs and similar measures reference their use in identifying subpopulations and in life extension. The language is modeled on other state bills and does not clearly bar their use.
Kentucky
​Landscape for Cost Effectiveness & QALY Considerations:​
  • The state Medicaid program does not openly reference QALYs or ICER studies.
  • The Kentucky Preferred Drug Listing (PDL) is defined by Kentucky law as “a listing of selected drugs available to fee-for-service recipients that have been included based on proven clinical and cost effectiveness and that prescribers are encouraged to prescribe if medically appropriate.”
  • The state law calls for drug review considerations to include an “assessment of the cost of the drug compared to other drugs used for the same therapeutic indication and if the drug offers a substantial clinically-meaningful advantage in terms of safety, effectiveness, or clinical outcome over other available drugs used for the same therapeutic indication. Cost shall be based on the net cost of the drug after federal rebate and supplemental rebates have been subtracted.”
  • The Pharmacy and Therapeutics Advisory Committee (P&T) does not publish meeting minutes, only an agenda, options, recommendations and decisions.​
  • In 2024, the legislature introduced HB 823 to create a Prescription Drug Affordability Board. The bill bars use of QALYs or similar measures “to identify subpopulations for which a treatment would be less cost-effective due to severity of illness, age, or preexisting disability” and limits use of cost effectiveness to studies “that weigh the value of all additional lifetime gained equally for all patients.
Louisiana
​Landscape for Cost Effectiveness & QALY Considerations:
Maine
Prescription Drug Affordability Board (PDAB)
  • The next meeting of the Maine PDAB is March 24, 2025 at 10:30am.  Register to attend here.
    • Public Comments: No instructions available for public comment.
    • Accommodations: No instructions available for ADA accommodations. 
Meeting Materials
  • ​​PDAB meeting materials citing QALYs, similar measures, health technology assessment (HTA), entities supporting QALYs (ICER, PORTAL, etc) to the PDAB are below:
    • The Affordability Board was presented with information from ICER about its QALY-based reports and how they are used by State Medicaid programs and the Department of Veterans Affairs.
    • The Affordability Board was presented with information from NASHP about its model legislation to use a “Canadian Reference Rate” without raising Canada’s reliance on QALYs.
Policies Adopted
  • A treatment for hereditary amyloidosis, Onpattro, was deemed “not preferred” because it did not meet ICER’s cost effectiveness threshold, despite also being deemed as providing benefit to some patients.

Ongoing Legislative Activities
​
  • LD 697: Directs the Maine Prescription Drug Affordability Board to explore cost-lowering strategies, including upper payment limits (UPLs) and reference-based pricing.
    • Status: Introduced on February 20, 2025. The Committee on Health Coverage, Insurance, and Finance Services is scheduled to hold a hearing on this bill on March 19, 2025. 
 
Existing State Statute
  • LD 1499, 2019: The state enacted legislation to create a Prescription Drug Affordability Board that did not bar reference to QALYs.
 
Drug Utilization Review (DUR) Committee
  • The next DUR Committee meeting is TBD.
  • Testimony: The public may sign up to address the committee during the Public Comments portion of the agenda either by emailing Carla Quinlivan at [email protected] and Mike Ouellette at [email protected] ahead of the meeting or signing up as a walk-in speaker at the beginning of the meeting.
    • Website provides guidelines, including that speakers must: (1) provide a concise synopsis of the product, either submitted via email or by brining copies to the meeting; (2) provide the Committee with the name of their organization and their relationship to it, as well as their topic area; (3) limit speaking tiem to less than three minutes; and (4) direct comments toward how the product is clinically superior or offers specific advantages.
  • The Maine DUR Committee meeting minutes do not consistently provide detail on the evidence being used to make recommendations.
 
Other Notable Activity
Maryland
Prescription Drug Affordability Board (PDAB)
  • Maryland's PDAB will hold its next meeting on March 24, 2025 at 8:00 AM.
    • Oral comments must be emailed to [email protected]​ at least five days before the meeting and must include: (1) your name; (2) your address; and (3) the agenda item your comment will address. 
    • Written comments must be sent to [email protected]​ at least five days before the meeting with subject line “[Meeting Month] 2025 Board Comments.” 
    • Accommodations: No instructions available for ADA accommodations. 
  • The next Prescription Drug Affordability Board Stakeholder Council (PDASC) meeting is TBD.
Meeting Materials
  • PDAB meeting materials are made available as part of the meeting schedule. Materials citing QALYs, similar measures, health technology assessment (HTA), entities supporting QALYs (ICER, PORTAL, international policies, etc) to the PDAB are below:
    • EACH/PIC Coalition comment letter on the impacts of upper payment limits on patients, January 22, 2025. 
    • At the November 25, 2024, PDAB meeting, cost effectiveness analysis and international reference pricing continued to be listed among the methodologies that could be used by the Board to establish a UPL, potentially incorporating their use of QALYs and similar measures.
    • PIPC comment letter highlighted nondiscrimination laws, May 13, 2024.
    • Joint letter with Value of Care Coalition highlighted federal law and QALYs, May 15, 2024.
    • ICER submitted comments related to its studies on selected drugs that rely on QALYs and evLYGs, May 8, 2024.
    • Presentation by the Program on Regulation, Therapeutics and Law (PORTAL) referencing use cost effectiveness, health technology assessment and studies from Institute for Clinical and Economic Review (ICER), June 26, 2023.
    • Presentation on Leveraging ICER Reports for Prescription Drug Affordability, May 24, 2021
    • Comments were not posted in 2021-2022. 
Policies Adopted
  • The Maryland Legislative Policy Committee approved the PDAB’s UPL Plan. 
    • Comments from 38 organizations opposed approval of a revised UPL Plan based on its reference to international prices from countries that use QALYs and similar measures and cost effectiveness analyses, with no legal safeguards against use of discriminatory value assessments. Commenters, argued the policy potentially violates federal law under Section 504 of the Rehabilitation Act. 
  • Six drugs have been chosen for affordability reviews:

Ongoing Legislative Activities
  • HB 424/SB 357: Requires the PDAB, under certain circumstances, to establish a process for setting upper payment limits for all purchases and payor reimbursements of prescription drug products in the State that the Board determines have led or will lead to affordability challenges. 
    • While the Senate committee has amended the legislation to require limited retrospective impact analysis on patient cost and access, the bill still does not bar the use of QALYs and similar measures, nor the consideration of information from third parties that utilize such measures. 
    • Status: The Maryland Senate Finance Committee advanced S 357 on March 12, 2025, along party lines. The bill may be considered on the floor of the Senate as early as this week. Maryland’s House of Delegates passed HB 424 on February 21, 2025, in a 98-34 vote. 

Existing State Statute
  • HB 768, 2019: The state enacted legislation to create a PDAB. The bill did not bar reference to QALYs and allows the Board to enter into a contract with a qualified, independent third party for any service necessary to carry out the powers and duties of the board.

Drug Utilization Review (DUR) Board
  • The DUR Board, made up of volunteer physicians and pharmacists, meets quarterly to advise the Maryland Pharmacy Program. Based on their analysis of patterns of drug use among Medicaid recipients and their professional experience, the Board recommends policies, medical criteria, and programs to guide prescribers, providers and patients.
  • The next DUR Board meeting is June 5, 2025 at 9:15am. ​​​
    • Public Comments: No instructions available for public comment.
    • Accommodations: No instructions available for ADA accommodations. 
  • The DUR Board does not publish meeting minutes. 

Pharmacy and Therapeutics (P&T) Committee
  • The P&T Committee selects and manages the Preferred Drug List (PDL). 
  • The next P&T Committee meeting is May 1, 2025, at 9am. Registration is not yet available. 
    • ​Testimony: Maryland provides very detailed instructions and timelines to register to testify, including the following which may impact patients: 
      • Testimony must be limited to only those drugs contained in the therapeutic classes under review or the single drug review.
      • Public testimony at the P&T Committee meeting is limited to 15 presentations: 12 speakers from the pharmaceutical industry and three representing consumer interests.
      • Each selected company, pharmaceutical manufacturer, organization, group, or consumer will be allocated a single five-minute time slot for their presentation. Multiple speakers from the same entity may register to speak, but the total speaking time cannot exceed five minutes.
      • In the event more speakers have registered than there are spaces available, a lottery will be held to select companies and consumers at random on the day after the deadline. 
      • MDH requires a written copy of the selected speaker’s public testimony be submitted via email to [email protected] no later than five (5) business days prior to the meeting.
      • There will be no question and answer period.​
    • ​​​Written Comments: Stakeholders, including, pharmaceutical manufacturers, organizations, groups or consumers, have the opportunity to present comments to the P&T Committee through written material relating to only the therapeutic class and single drug (if, applicable) under review.
      • See website for format requirements. 
    • Accommodations: There are no instructions for accommodations for people with disabilities.
  • The P&T committee works with Conduent LLC, a subsidiary of Magellan Healthcare, as well as Provider Synergies, in development of a PDL. These entities do not publicly provide the evidence for their recommendations but participate in P&T committee meetings. 
  • The P&T Committee meeting minutes do not provide details on the evidence base for decisions. 

Other Notable Activity
  • HB 1167, 2021: Maryland proposed a QALY Ban bill – it did not pass into law.
Massachusetts
Ongoing Legislative Activities
  • SD 2055 / S 875: State Senator Edward Kennedy has introduced legislation to establish a Prescription Drug Affordability Board (PDAB). The bill allows the Board to consider “the estimated cost-effectiveness” when conducting affordability reviews and authorizes it to contract with third parties for “any service necessary,” including cost-effectiveness analysis.
    • The legislation explicitly prohibits the use of measures that assign a reduced value to life extension based on a patient’s pre-existing disability or chronic health condition.
    • Status: Introduced.
  • HB 1358: Directs the Massachusetts Health Policy Commission and the Division of Medical Assistance to ensure that any research and analysis used for decision-making — whether conducted by a state agency or a third party — meets patient-centered standards.
    • This bill includes an explicit ban on using, either directly or indirectly, a dollars-per-quality adjusted life year or any similar discriminatory measures or research.
    • Status: Referred to the committee on Health Care Financing on February 27, 2025. 
 
Drug Utilization Review (DUR) Board
  • The DUR Board functions in an advisory capacity to ensure that prescribed drugs are “appropriate, medically necessary, and not likely to result in medication-related problems.” The DUR Board makes recommendations about types of ongoing interventions and evaluates the results.
  • The next full DUR Board meeting is June 11, 2025, at 6pm.
    • Testimony: The DUR Board sets aside 15 minutes at the end of each meeting for public comments, limited to five minutes per speaker.
    • Accommodations: The Massachusetts Commission for the Deaf and Hard of Hearing will assist with arrangements for a sign language interpreter. The Commission may be reached at (617) 740-1600 (voice) and (617) 740-1700 (TTY).
  • The DUR Board publicly relied on ICER studies in evaluating a mental health treatment in 2019.
 
Health Policy Commission (HPC)
  • Massachusetts’ HPC supports the state’s Medicaid program when negotiating with drug manufacturers. If the state is unable to reach a supplemental rebate agreement with a drug manufacturer, they may refer the drug to the HPC.
  • Upon a referral from the state, the HPC is authorized to assess a referred drug’s pricing and value, identify a proposed value of the drug, and ultimately determine whether the drug’s price is reasonable.
  • The HPC’s next meeting is April 17, 2025, at 12pm. A calendar of upcoming meetings can be found here.
  • The Massachusetts Health Policy Commission has indicated directly to patient and disability representatives that ICER has a contract to help the commission develop its value framework.
 
Other Notable Activity
  • The state Medicaid program has openly referenced QALYs or ICER studies, with accounts of verbal confirmation that they are used to make coverage decisions. 
  • In 2017, the state sent a letter to CMS requesting authority to adopt a closed formulary and allow MassHealth to select drugs that “meet the clinical needs of the vast majority of members and that they are cost effective...” CMS denied the application but responded to MassHealth in June 2018 that it would consider a demonstration allowing certain drugs to be excluded based on cost-effectiveness or other approved criteria."
Michigan
Ongoing Legislative Activities
  • SB 3: This legislation would establish a Prescription Drug Affordability Board (PDAB) for Michigan. The bill includes language limiting the use of QALYs only to identifying subpopulations and focuses on discrimination related to life extension, raising concerns that the legislation would allow the PDAB to partner with entities such as PORTAL and ICER that support the use of QALYs and evLYGs to value health care, as seen in other states.  
    • Status: Introduced and referred to the Committee on Finance, Insurance, and Consumer Protection.
 
Drug Utilization Review (DUR) Board
  • The next DUR Board meeting is June 3, 2025, at 3pm. A schedule of upcoming meetings can be found here. 
    • Testimony: The last ten minutes of every DUR meeting is reserved for public comment, however no further instructions are provided.
    • Accommodations: For accommodations, contact the MDHHS Section 1557 Coordinator at 517-284-1018 or [email protected].
  •  Michigan contracts with Prime Therapeutics to administer and lead DUR meetings. ++
 
Pharmacy & Therapeutics (P&T) Committee
  • The next P&T Committee meeting is June 3, 2025, at 6pm. A schedule of upcoming meetings can be found here. 
    • Testimony: To request being added to the agenda to present your public comment in person, a written request must be received at least 6 business days before the meeting. Information regarding what these requests must include and where to send them can be found here.
    • Accommodations: No instructions available for ADA accommodations. 
  • The preamble of the statute creating the P&T Committee says, “the state of Michigan desires to provide the greatest possible access to cost effective prescription drug coverage for all of its citizens, including, but not limited to, those receiving services through its Medicaid Program” and the law allows the committee to consult “with outside experts in order to perform its duties.”
 
Other Notable Activity
  • The state Medicaid program reported that they reference the QALY through use of ICER studies in drug coverage reviews.
  • In 2020, the Governor’s Prescription Drug Task Force issued a report that indicated support for referencing other countries that use QALYs by recommending, “As an alternative, legislative action could be taken to establish a process for setting an upper payment limit for certain prescription drugs based on rates set by other countries, such as Canada, as a reference.”
    • The same report supported creation of a drug affordability review board that was touted in the news by state legislators as supporting the creation of a Prescription Drug Affordability Board similar to the one created in Maryland.
Minnesota
Prescription Drug Affordability Board (PDAB)
  • The next meeting of the Minnesota PDAB is TBD. 
    • Public Comments: Comments can be submitted here.
    • Accommodations: No instructions available for ADA accommodations. 
  • The next meeting of the Minnesota Prescription Drug Affordability Advisory Council (PDAAC) is TBD.
Meeting Materials
  • ​​PDAB meeting materials citing QALYs, similar measures, health technology assessment (HTA), entities supporting QALYs (ICER, PORTAL, etc) to the PDAB are below:
    • Presentation by the Program on Regulation, Therapeutics, And Law (PORTAL) referencing use cost effectiveness, health technology assessment and studies from Institute for Clinical and Economic Review (ICER), July 23, 2024.
 
Existing State Statute
  • SF 2744, 2023: The Minnesota state legislature passed legislation establishing a process for setting upper payment limits for prescription drugs that included a provision barring the use of a cost effectiveness analysis using the quality-adjusted life year or similar measure in determinations related to affordability or upper payment limits. It also sets the upper payment limit for some drugs at the Medicare maximum fair price. The bill was signed into law by the governor on May 24, 2023.
 
Drug Formulary Committee
  • The Drug Formulary Committee reviews and recommends the drugs covered by Medicaid and MinnesotaCare through the uniform preferred drug list (PDL) and determine which of those drugs requires prior authorization or an approval before payment.
  • The next Drug Formulary Committee meeting is March 19, 2025, at 9:15am.
    • Comments: Public comment period for each meeting begins on the day the agenda is posted and continues until 15 days after each meeting.
    • Testimony: Attendees wishing to provide live testimony must email [email protected] before the meeting and include a completed disclosure form. Testimonies are limited to three minutes, but if more than 20 people register to speak, the time may be reduced to accommodate all participants.
  • The Drug Formulary Committee contracts with Magellan Medicaid Administration to support the development of the state's PDL. Magellan provides clinical reviews — including cost effectiveness analyses — and evidence-based recommendations for drug coverage decisions but does not publicly disclose the evidence used in its recommendations.
 
Drug Utilization Review (DUR) Board
  • The DUR Board selects specific drug entities or therapeutic classes to target for providers’ and Minnesota Health Care Programs members’ educational interventions, and provides guidelines for their use. 
  • The next DUR Board meeting is TBD, but will be held in April.
    • Testimony: Comments occur at 1pm, before the start of the meeting, and are limited to three minutes per each representative organization.
  • Magellan Medicaid Administration participates in DUR Board meetings to support retrospective drug utilization review interventions.
 
Other Notable Activity
  • The Health Services Advisory Council provides advice on health care benefit and coverage policies and “shall consider available evidence regarding quality, safety, and cost-effectiveness when advising the commissioner.” This is not limited to prescription drugs. 
Mississippi
Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program reported that they reference the QALY through use of ICER studies in drug coverage reviews.
  • The P&T Committee states that “Drugs and drug classes are evaluated for their safety, efficacy, and overall cost value and the committee will make subsequent recommendations to the Executive Director regarding prior authorization criteria for these drugs and classes.”
  • The P&T Committee meeting minutes do not describe the evidence used to support its decisions.
  • The DUR Board meeting minutes do not detail the evidence used to make recommendations.
Missouri
Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program reported that they reference the QALY through use of ICER studies in drug coverage reviews.
  • The DUR Board meeting minutes do not detail the evidence used to make recommendations.
Montana
  ​
Nebraska
Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program reported that they reference the QALY through use of ICER studies in drug coverage reviews.
  • The P&T Committee by-laws state, “The purpose of the PDL is to provide appropriate pharmaceutical care to Medicaid recipients in a cost-effective manner.”
  • The P&T Committee meeting minutes do not detail the evidence used to make decisions.
  • “The goals of the DUR Board are to improve the quality of pharmacy services and to ensure rational, cost-effective medication therapy for Nebraska Medicaid recipients.” 
  • The DUR Board meeting minutes do not detail the evidence used to make recommendations.
Nevada
Ongoing Legislative Activities
  • AB 259: Automatically sets Medicare’s maximum fair price as the upper payment limit (UPL) for drugs whose price has been negotiated at the federal level. By doing so, the legislation removes opportunities for public input on potential access issues, raising concerns that treatment options will be limited without guaranteed cost savings for beneficiaries.
    • The bill references Medicare drug prices, for which CMS has indicated a reliance on QALYs and similar measures.
    • Status: Introduced February 19, 2025.
 
Existing State Statute
  • SB378, 2019: The legislature passed a law enacting changes to its P&T Committee from prior existing law that required the Committee to make its decisions based on evidence of clinical efficacy  and  safety  without  consideration  of  cost.  The new law changed the P&T Committee to the Silver State Scripts Board and authorized the  Board  to  consider  cost  if  there  is  no  significant difference  in  the  clinical  efficacy,  safety  and  patient  outcomes  of  two  or  more drugs.
 
Drug Utilization Review (DUR) Board
  • The DUR Board meets quarterly to monitor drugs for “therapeutic appropriateness, over or under-utilization, therapeutic duplications, drug-disease contraindications, and quality care.”
  • It accomplishes this goal by “establishing prior authorization and quantity limits to certain drugs/drug classes based on utilization data, experience, and testimony presented at the DUR Board meetings.”
  • The next DUR Board meeting is April 17, 2025.
    • Testimony: Anyone wishing to address the DUR Board may do so. Public comment is limited to three minutes per speaker/organization (due to time constraints). Anyone presenting documents for consideration must provide sufficient copies for each board member and a copy (electronic preferred) for the official record.
    • Accommodations: No instructions available for ADA accommodations.
  • In January 2020, the DUR Board referenced ICER’s study of MS drugs according to its meeting minutes.
 
Silver State Scripts Board
  • Nevada’s Silver State Scripts Board is the state’s equivalent to a pharmacy & therapeutics (P&T) committee. The Board develops and maintains the preferred drug list (PDL) for Nevada Medicaid Fee-for-Service (FFS).
  • The next P&T Committee meeting is June 12, 2025.
    • Testimony: Anyone wishing to address the Silver State Scripts Board may do so. Public comment is limited to three minutes per speaker/organization (due to time constraints). Anyone presenting documents for consideration must provide sufficient copies for each Board member and an electronic copy to the DHCFP Coordinator for official record.
    • Accommodations: No instructions available for ADA accommodations.
New Hampshire
Prescription Drug Affordability Board (PDAB)
  • The next meeting of the New Hampshire PDAB is March 24, 2025, at 10:30am. 
    • Public Comments: No instructions available for public comments. 
    • Accommodations: No instructions available for ADA accommodations. 
Meeting Materials
  • ​​PDAB meeting materials citing QALYs, similar measures, health technology assessment (HTA), entities supporting QALYs (ICER, PORTAL, etc) to the PDAB are below:
    • Presentation from the Institute for Clinical and Economic Review (ICER), February 24, 2025.
 
Ongoing Legislative Activities
  • HB 645: The bill requires reports issued by the prescription drug affordability board to describe the source of the data, encourages the use of memorandums of understanding between the board and state agencies regarding data collection, and directs the board to use data gathered by other agencies or entities whenever feasible to meet reporting requirements. 
    • The bill does not bar the use of QALYs and similar measures.
    • Status: Introduced on January 21, 2025, and referred to the House Health, Human Services, and Elderly Affairs Committee.
  • SB 119-FN: This bill directs pharmacists to dispense brand name drugs to Medicaid beneficiaries when the brand name drug is on PDL.  The bill also directs the department of health and human services to develop a standing order for certain Medicaid-covered, over-the-counter medications, medical supplies, and laboratory tests when deemed medically necessary and cost effective by the department.
    • The bill does not bar the use of QALYs and similar measures. It states that cost effectiveness will be determined by the Department’s chief medical officer.  
    • Status: Passed the Senate Health and Human services Committee [5-0] on February 7, 2025.
 
Existing State Statute
  • HB 1280, 2020: The state established a PDAB that may consider “Data compiled by the department of health and human services” which is not precluded from including QALY-based cost effectiveness analyses.
 
Drug Utilization Review (DUR) Board
  • The next DUR Board meeting is TBD
    • Testimony: Notice of intent to testify at the public hearing, and/or submittal of written comments, should be directed to Margaret ‘Peg’ Clifford, NH Department of Health and Human Services, 129 Pleasant Street, Concord, NH, 03301, (603) 271-9098, or e-mail at: [email protected]. 
New Jersey
Landscape for Cost Effectiveness & QALY Considerations:
  • Introduced, A583, 2018-2019 and A2418, 2020-2021: The legislature introduced a bill that would create a Prescription Drug Affordability Board that would not bar reference to QALYs and would explicitly authorize the Board to contract with an “independent third party” that could include ICER.
  • The DUR Board meeting minutes do not detail the evidence used to make recommendations.
  • On January 11, 2022, the state legislature reintroduced a bill creating a Prescription Drug Affordability Board. Bill, SB 329. The bill does not include provisions barring the use of quality-adjusted life years in determining the value of treatments that may be subject to payment limits.      
New Mexico
Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program does not openly reference QALYs or ICER studies.
  • The DUR Board does not publish meeting notes or minutes.​
New York
Ongoing Legislative Activities
  • AB 2126 / SB 1351: Establishes a pilot program to evaluate the feasibility of controlling excessive prescription drug prices by setting a referenced rate based on wholesale acquisition cost and Canadian drug pricing benchmarks. Under the program, state entities and health plans would be prohibited from purchasing or reimbursing for selected high-cost drugs at prices exceeding the referenced rate.
    • Canada relies on cost-effectiveness assessments that utilize QALYs to set their prices.
    • Status: Introduced.
 
Existing State Statute
  • State Budget, FY2020: codified authority for the state to reference a third party such as ICER in its decisions stating, “Such rebate may be based on evidence-based research, including, but not limited to, such research operated or conducted by or for other state governments, the federal government, the governments of  other  nations, and third party payers or multi-state coalitions.”
 
Drug Utilization Review (DUR) Board
  • The DUR Board provides clinical guidance to the Commissioner of Health regarding the utilization of pharmaceuticals and the evaluation of drug expenditures within the New York State Medicaid program. Its activities include the “review of drug cost information."
  • The next DUR Board meeting is May 15, 2025.
    • Testimony: Any interested party may request and may be permitted to provide oral comments or make a presentation during a public comment segment of the meeting on any item under consideration by the Board at that meeting. Individuals interested in providing public comments must complete the Department’s registration process at least one week in advance of a meeting to be added to the agenda. Requests to provide public comment may be made by calling 518-486-3209 or e-mailing [email protected].
    • Written Comments: Written statements and clinical information can be sent to [email protected] at least one week before the meeting. Any studies cited should be referenced, with the primary source of funding included. Written statements should summarize key points and may not exceed two (2) pages in length.
    • Accommodations: No instructions available for ADA accommodations. 
  • Notable Activity:
    • The state has referenced ICER in DUR Board decisions related to cystic fibrosis treatments in creating a supplemental rebate target, interpreted by the media as the state saying the drug was “not worth its price.”
    • The state referenced ICER’s assessment of migraine treatments on September 20, 2018.
    • The state heard a presentation from ICER in making a DUR Board decision related to spinal muscular atrophy, resulting in a recommended supplemental rebate target amount.
  • The DUR Board meeting minutes do not consistently provide details on the evidence base for making decisions.
 
Notable Activity
  • The state Medicaid program reported that they reference the QALY through use of ICER studies in drug coverage reviews.
  • ICER has published information touting New York’s use of ICER as “as an independent arbiter of cost-effectiveness.”
North Carolina
​Landscape for Cost Effectiveness & QALY Considerations:
North Dakota
​Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program does not openly reference QALYs or ICER studies.
  • The Drug Use Review Board did not include reference to evidence from ICER to make recommendations, though the handouts did include footnotes to supportive evidence.
  • DUR Board meeting minutes do not provide references. 
  • Enacted, SB 2212, 2021: The bill provides for a legislative management study of prescription drug pricing, importation, and reference pricing, and the role pharmacy benefit managers play in drug pricing.
  • Introduced, SB 2170, 2021: The legislature introduced a bill directly referencing the prices paid for drugs in five Canadian provinces. In Canada, before applying for coverage by the provinces, all drugs must complete a Common Drug Review by CADTH, which uses QALYs. 
Ohio
Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program reported that they reference the QALY through use of ICER studies in drug coverage reviews.
  • Ohio has instituted a “Prescription drug transparency and affordability advisory council” to provide recommendations to the state related to the purchasing of prescription drugs.
  • Among the council’s recommendations was an emphasis on “health equity when developing prescription drug policies.”
  • The P&T Committee meeting minutes do not detail the evidence used to make decisions.
  • The DUR Board meeting minutes do not detail the evidence used to make recommendations.
Oklahoma
​Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program does not openly reference QALYs or ICER studies.
  • DUR Board meeting minutes indicate that the Oklahoma Drug Utilization Review Board used ICER’s QALY-based studies to invoke prior authorization in March, 2019 for treatments for long-term prophylaxis for hereditary angioedema and again in July, 2019 for treatment of spinal muscular atrophy.
  • Enacted, HB2587, 2020: The state legislature responded to the DUR Board’s consideration of QALYs when it passed and the state enacted the Nondiscrimination in Health Care Coverage Act barring the use of QALYs as a threshold to establish what type of health care is cost effective or recommended, or as a threshold to determine coverage, reimbursement, incentive programs or utilization management decisions, whether it comes from within the agency or from any third party.
  • Introduced, SB734, 2021: The state legislature introduced a bill allowing reference to the ceiling price for drugs, as reported by the Government of Canada Patented Medicine Prices Review Board, for the purpose of determining the referenced rate to pay for prescription drugs. The Patented Medicine Prices Review Board explicitly establishes prices based on a cost-utility analysis model in which health outcomes are expressed as QALYs.
  • Oklahoma’s DUR Board packet provides detailed information and references to the evidence base to be considered and is publicly available.​
Oregon
Prescription Drug Affordability Board (PDAB)
  • The next meeting of the Oregon PDAB is February 19, 2025, at 9am. Register to attend here.
    • Oral and written comments must be submitted through the PDAB public comment form. Oral comments must be submitted at least 24 hours before the meeting, while written comments are due 48 hours in advance.
    • Accommodations: The Board materials state, “Anyone needing assistance due to a disability or language barrier can contact Melissa Stiles at least 48 hours ahead of the meeting at [email protected] or 971-374-3724.”
  • Oregon's PDAB does not have a stakeholder advisory committee. 
Meeting Materials
  • ​​PDAB meeting materials citing QALYs, similar measures, health technology assessment (HTA), entities supporting QALYs (ICER, PORTAL, etc) to the PDAB are below:
    • Comment letter from PIPC opposing use of QALYs and similar measures such as evLYG, January 13, 2025.
    • A Board presentation lists “value-based pricing” as a purpose of reviews without discussing federal and state law restrictions on use of discriminatory value assessments, December 18, 2024.
    • Comment letters from advocacy organizations opposing the use of QALYs and similar measures, including their incorporation by reference to the Veterans Health System, international pricing and Medicare, November 15, 2024.
    • Comment letter from PIPC opposing use of QALYs and similar measures, including international references and the VA, October 13, 2024.
    • Joint letter from patient advocates opposing use of QALYs and evLYGs, October 30, 2024.
    • Presentation from the Center for Evidence-Based Policy at OHSU (has funding from Arnold Ventures which supports entities using QALYs and similar measures), October 2, 2024.
    • A Board presentation lists “value-based pricing” as a purpose of reviews without discussing federal and state law restrictions on use of discriminatory value assessments, August 21, 2024.
    • The affordability review for drug Ocrevus referenced the evLYG, June 26, 2024.
    • PIPC letter opposing use of QALYs and evLYG, May 14, 2024.
    • Joint letter to legislature, copying PDAB, opposing use of QALYs and evLYG, February 29, 2024.
    • Joint letter opposing QALYs and similar measures, supporting transparency, December 4, 2023.
    • ICAN comment against use of QALY, October 6, 2023.
    • Feedback on affordability rule opposing emphasis on cost effectiveness, QALYs and similar measures, July 19, 2023.
    • Presentation from ICER advocating its QALY and evLYG measures, May 17, 2023.
    • Board discussion related to use of QALYs, April 19, 2023.
    • PORTAL advocated the Board use QALYs and evLYG, February 15, 2023. Presentation here.
    • Board explanation of QALY ban in statute, January 18, 2023.
    • Board recommended hearing from ICER and contracting with PORTAL, December 14, 2022.
    • Board reviewed international use of QALYs and similar measures, November 16, 2022.
    • Board reviewed proposed use of QALY, October 19, 2022.
Policies Adopted and Other Materials
  • During an October 2024 meeting, Members of the Board verbally stated that the Oregon PDAB is permitted to reference ICER studies and measures similar to QALYs such as evLYGs, despite federal nondiscrimination law and regulations and Oregon state law barring use of “quality of life in general” measures. QALY use is implicated in referencing entities that rely on QALYs and similar measures, including foreign countries and the Veterans Health System. 
  • The Board approved a UPL Plan at the meeting on November 20, 20244. As examples of Reference pricing to existing benchmarks, the UPL Plan states:
    • The plan states that "methodologies for calculating a UPL may include cost-effectiveness analysis" and that, to determine value, "notwithstanding federal or state laws, tools for deriving value-based UPL could include costs per life year gained, cost per equal value life year gained, or a measure of health gain."
    • As examples of reference pricing to existing benchmarks, the UPL Plan states: 
      • “Use of drug prices negotiated in other countries is an option, but is controversial and would be challenging to evaluate and implement.”
      • “Using a U.S. published reference pricing file, such as VA federal supply schedule pricing, offers the benefit of being publicly available and easily accessible and could serve as a benchmark for state-level negotiations with manufacturers.”
  • The PDAB 2024 Annual Report for the Legislature extends the scope of impact, and potentially scope of influence of QALYs and similar measures, through the following proposals:
    • “Require Oregon Health Plan FFS and coordinated care organizations to purchase through a statewide purchasing group - Statewide purchasing groups shall use programs that leverage the collective buying power of state agencies to secure better prices and terms for goods and services. These programs are designed to make procurement more efficient and cost effective for state and local government entities.”
    • “Extend Oregon Health Plan’s preferred drug list for all classes of prescription drugs - Oregon Health Plan FFS has a uniform preferred drug list for some classes; however, to use the most cost-effective medications and to reduce administrative burdens for providers, it is recommended to extend the current preferred drug list for all classes to CCOs for coverage of prescription drugs.”
  • The PDAB 2024 Annual Report for the Legislature does not address recommendations related to engagement of patient stakeholders or use of QALYs and similar measures such as evLYG.

Existing State Statute
  • SB 1508, 2024: The legislation barred Oregon Health Authority (OHA) and Health Evidence Review Commission from considering a quality of life in general measure, directly or indirectly:
    • “In making the determinations under subsection (1) of this section and in the imposition of any utilization controls on access to health services, the authority may not consider a quality of life in general measure, either directly or by considering a source that relies on a quality of life in general measure.”
  • SB 844, 2021: The bill that created Oregon's PDAB barred consideration of QALYs and similar measures: 
    • “(4)(a) If the board considers the cost-effectiveness of a prescription drug in criteria adopted by the board under subsection (1) of this section, the board may not use quality- adjusted life-years, or similar formulas that take into account a patient’s age or severity of illness or disability, to identify subpopulations for which a prescription drug would be less cost-effective. For any prescription drug that extends life, the board’s analysis of cost- effectiveness must weigh the value of the quality of life equally for all patients, regardless of the patients’ age or severity of illness or disability.”
  • SB 192, 2023: The bill that expanded Oregon's PDAB barred consideration of QALYs and similar measures:
    • “(4)(a) If the board considers the cost-effectiveness of a prescription drug in criteria adopted by the board under subsection (1) of this section, the board may not use quality-adjusted life-years, or similar formulas that take into account a patient’s age or severity of illness or disability, to identify subpopulations for which a prescription drug would be less cost-effective. For any prescription drug that extends life, the board’s analysis of cost-effectiveness must weigh the value of the quality of life equally for all patients, regardless of the patients’ age or severity of illness or disability.”

Pharmacy and Therapeutics (P&T) Committee
  • The P&T Committee is an 11-member advisory committee that performs drug use reviews and advises the OHA on which prescription drugs should be included on any preferred drug list (PDL) established by OHA.
  • The next P&T Committee meeting is April 3, 2025, at 1pm. 
    • ​Testimony and Written Comments: The website summarizes as, “Policies for public comment can be found here. To submit written comments or to sign up to provide verbal public comment during the P&T meeting, please use this email address and submit of a completed Conflict of Interest form. Please submit COI forms with written comments at least 2 weeks prior to the meeting, or sign up for verbal testimony and submit COI forms at least 24 hours prior to the start of a meeting.”
    • Accommodations: No instructions available for ADA accommodations.
  • OHA contracts with Drug Use Research and Management (DURM) to administer and lead P&T meetings. 
  • Preferred sources for developing a PDL include several entities that use QALYs and similar measures, including:
    • U.S. Department of Veterans Affairs/Department of Defense
    • Agency for Healthcare Research and Quality (AHRQ)
    • Canadian Agency for Drugs and Technologies in Health (CADTH)
    • National Institute for Clinical Excellence (NICE)
    • Scottish Intercollegiate Guidelines Network (SIGN)
  • Cost effectiveness is often raised in committee deliberations without recognition of laws barring use of QALYs and similar measures.
  • The P&T Committee meeting minutes do not provide details on the evidence base for decisions. 

Health Evidence Review Commission (HERC)
  • Oregon's HERC has ceased its use of QALYs and similar measures to develop the prioritized list of services under Medicaid in compliance with state and federal law.
  • Oregon will cease its use of a prioritized list of services as the basis for covered services under Medicaid and is currently developing a transition plan in response to the CMS waiver.
Pennsylvania
Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program reported that they reference the QALY through use of ICER studies in drug coverage reviews.
  • The bylaws state, “The P&T Committee will ensure that PDL management is based on sound clinical evidence and is both safe and cost-effective.”
  • According to a letter from the Office of Medical Assistance Programs, “When drugs within a class are clinically equivalent, the P&T Committee considers the comparative cost-effectiveness of all drugs in the class.”
  • The P&T Committee meeting minutes do not detail the evidence used to make decisions.
  • The DUR Board meeting minutes do not detail the evidence used to make recommendations.​
  • In 2021, the legislature introduced HB 1722 creating a Prescription Drug Affordability Board authorized to perform cost reviews relying on cost-effectiveness analyses. The bill does not bar reference to QALYs or similar measures. 
Rhode Island
Ongoing Legislative Activities
  • S 0468 / H 5860: Automatically sets Medicare’s maximum fair price as the upper payment limit (UPL) for drugs whose price has been negotiated at the federal level. By doing so, the legislation removes opportunities for public input on potential access issues, raising concerns that treatment options will be limited without guaranteed cost savings for beneficiaries.
    • The bill references Medicare drug prices, for which CMS has indicated a reliance on QALYs and similar measures.
    • Status: Introduced on February 28, 2025.
 
Drug Utilization Review (DUR) Board
  • The next DUR Board meeting is April 8, 2025, at 10:30am. This meeting will be held at the RI Executive Office of Health and Human Services and there is no virtual option to attend.
    • Testimony: No instructions available for public comment.
    • Accommodations: No instructions available for ADA accommodations.
 
Pharmacy & Therapeutics (P&T) Committee
  • The P&T Committee seeks to ensure that the preferred drug list (PDL) is based on “sound clinical evidence that is both safe and cost-effective.”
  • The next P&T Committee meeting is April 8, 2025, at 8am. This meeting will be held at the RI Executive Office of Health and Human Services and there is no virtual option to attend.
    • Testimony: To testify, individuals must register in person on the day of the meeting on a first-come, first-served basis. Testimony is limited to agenda items and must be disclosed if influenced by a drug manufacturer. Each speaker or organization is allowed up to four minutes, and written testimony must follow specific formatting guidelines. More details can be found in the Committee’s bylaws.
    • Accommodations: No instructions available for ADA accommodations.
  • The P&T Committee does make references to cost effectiveness but not the evidence being referenced. (influenza, diabetes, antipsychotics, and CNS agents) 
  • The meeting minutes of the P&T Committee do not describe details about the evidence base for making decisions.
 
Notable Activity
  • The state Medicaid program does not openly reference QALYs or ICER studies. 
South Carolina
​Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program reported that they reference the QALY through use of ICER studies in drug coverage reviews.
  • There is no public record of their use.
  • The law establishing the P&T Committee states, “In determining safety and efficacy, the committee may consider all submitted public comment or clinical information including, but not limited to, scientific evidence, standards of practice, peer-reviewed medical literature, randomized clinical trials, pharmacoeconomic studies, and outcomes research data.”
  • The P&T Committee meeting minutes do not detail the evidence used to make decisions.
South Dakota
​Landscape for Cost Effectiveness & QALY Considerations:
  • The state reported use of information from OptumRx in drug reviews.
  • The Optum website touts being a “trusted partner in nearly every state.”
  • The P&T Committee provides details on the evidence being used to make decisions. 
  • The P&T Committee meeting minutes specifically reference ICER studies.
  • The Preferred Drug List (PDL) is a list developed by North Dakota Medicaid in conjunction with the North Dakota Drug Use Review Board (DUR Board) and adopted by the Department.. 
Tennessee
Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program does not openly reference QALYs or ICER studies. Tennessee reported the Kaiser Family Foundation that the state is considering “the use of comparative effectiveness review in drug coverage review.”
  • The state requested that CMS allow TennCare to adopt a commercial-style closed formulary, which may cover only one drug in each therapeutic area, potentially allowing for reference to QALY-based cost-effectiveness analyses. With regard to drugs approved through the accelerated pathway at the FDA, “The state proposes that it have flexibility to exclude these new drugs from its formulary until market prices are consistent with prudent fiscal administration or the state determines that sufficient data exist regarding the cost effectiveness of the drug.” The waiver was approved on January 8, 2021 and but reopened for federal public comments in August, 2021.
  • TennCare also relies on OptumRx to manage its Drug Utilization Review Board activities.
  • The Pharmacy Advisory Committee, making PDL recommendations, lists ICER as a preferred source of high quality evidence.
  • The law creating the TennCare Pharmacy Advisory Committee states, “The committee may receive written studies, data and information relative to the cost-effectiveness of drugs being considered for placement on the preferred drug list.”
  • The pharmacy advisory committee did not have publicly available meeting minutes.
Texas
Landscape for Cost Effectiveness and QALY Considerations: 
  • The state Medicaid program does not openly reference QALYs or ICER studies.
  • According to Provider Synergies, “The Texas Health and Human Services Commission (HHSC) has retained Magellan Medicaid Administration to provide Preferred Drug List (PDL) development and management and Supplemental Rebate contracting services. Provider Synergies, LLC is an affiliate of Magellan Medicaid Administration, and became a wholly-owned subsidiary of Magellan Health Services in 2009.”
  • The DUR Board does not specifically identify the evidence supporting its recommendations.
Utah
Landscape for Cost Effectiveness & QALY Considerations:
  • According to the P&T Committee bylaws, “If clinical and therapeutic considerations are substantially equal, then the P&T Committee shall recommend to DMHF that it consider only cost.”
  • The P&T Committee meeting minutes do not detail the evidence used to make decisions.
  • The DUR Board meeting minutes do not detail the evidence used to make recommendations.
Vermont
​Current Activities: 
  • On May 31, Vermont Governor Phil Scott signed S. 98 into law. The initial bill directed the Green Mountain Care Board to conduct an affordability review using cost-effectiveness studies, which included language limiting the use of quality-adjusted life years (QALYs) that was modeled on language used in other states to allow for use of cost effectiveness measures, such as the equal value of life year gained (evLYG). However, the final version passed into law directs the Board to instead create a framework for a program that regulates the cost of prescription drugs in Vermont. The final bill details considerations for the Board in developing this cost-regulating framework, but these considerations do not include limiting the use of QALYs or other cost-effectiveness measures. As required by the bill, the Board must provide its preliminary framework by January 15, 2025. 

Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program reported that they reference the QALY through use of ICER studies in drug coverage reviews.
  • The Vermont Legislature enacted the Pharmacy Best Practices and Cost Control Program from the Fiscal Year 2002 Appropriations Act, H 485, which mandated the establishment of a pharmacy best practices and cost control program designed to reduce the cost of providing prescription drugs.
  • The DUR Board cited high net cost to Medicaid and lack of cost-effectiveness to justify its recommendation of continuing prior authorization for MAT medication (Meeting notes on April 6, 2021).
  • The DUR Board deferred coverage of a treatment for polyneuropathy of hereditary transthyretin-mediated amyloidosis in adults despite showing “some benefit to patients with this disease” citing that it is “more than ten times the cost required to meet the ICER cost-effectiveness threshold.”
  • The Green Mountain Care Board is appointed by the Governor for six-year terms and is tasked to oversee the health care payment and delivery system reforms designed to control the rate of growth in health care costs in Vermont.
  • The Green Mountain Care Board Prescription Drug Technical Advisory Group was presented with information about the model legislation being proposed by NASHP, including the New York drug cap model and international reference pricing.
Virginia
Current Activities:
  • Virginia's HB 1724, which would create a Prescription Drug Affordability Board, has passed both chambers of the state legislature and now awaits the governor's approval by the March 24, 2025, deadline. 
​​
Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program reported that they reference the QALY through use of ICER studies in drug coverage reviews.
  • The DUI Board meeting minutes do not consistently provide details on the evidence base for making decisions. 
  • The P&T Committee meeting materials referenced ICER’s study related to rheumatoid arthritis treatments in its decisions related to coverage.
  • The P&T Committee materials are not made available in the archives, and the meeting minutes do not detail the evidence used to make decisions.
  • The DUR Board referenced hepatitis C treatments being cost effective in support of coverage of treatments.
  • Legislation creating a Prescription Drug Affordability Board was passed in the Virginia legislature (HB 570 and SB 274), and subsequently vetoed by the Governor on April 8, 2024.  The language limiting the use of quality-adjusted life years (QALYs) was modeled on language used in other states to allow for use of cost effectiveness measures such as the equal value of life year gained (evLYG). As drafted, the language limited the use of QALYs only to identifying subpopulations and only focused on discrimination related to life extension, raising concerns that the state could partner with entities such as PORTAL and ICER that support the use of QALYs and evLYGs to value health care.


Washington
Prescription Drug Affordability Board (PDAB)
  • The next meeting of the Washington PDAB is March 19, 2025.  Register to attend here.
    • Oral Comments: To speak on any topic listed on the agenda, email HCA PDAB by the Monday before the meeting date with: (1) your name; (2) the organization you represent, and (3) the topic name on the agenda. If you do not sign up ahead of time, there will still be an opportunity to participate. Comments will be limited to three minutes.
    • Accommodations: To make a request for special accommodations, call the ADA Coordinator at 1-855-682-0787. 
  • The next meeting of the Washington PDAB Advisory Group is TBD.
Meeting Materials
  • ​​PDAB meeting materials citing QALYs, similar measures, health technology assessment (HTA), entities supporting QALYs (ICER, PORTAL, etc) to the PDAB are below:
    • PDAB staff discussed its use of ICER Analytics and cost effectiveness as part of its deliberations, indicating an intent to reference QALYs and similar measures in its assessments, November 13, 2025.
    • Advisory group drug selection summary, which referenced ICER analyses to guide their decisions, January 15 2025.
    • Presentation by the Program on Regulations, Therapeutics, And Law (PORTAL) on “Considerations for Conducting Affordability Reviews,” including cost effectiveness, September 18, 2024.
    • PDAB discussion on its affordability review process, including the potential reference to premiums as a component of affordability reviews, September 18, 2024.
    • PDAB discussion on upper payment limit methodology and the role of cost effectiveness analyses, May 22, 2024.
    • Presentation from PORTAL on the identification and selection of drugs, March 20, 2024.
    • Comment letters from PIPC (October, 2024); PhRMA (September, 2024)
Policies Adopted
  • Washington’s PDAB is in the process of selecting prescription drugs for affordability review. A stakeholder webinar meeting is being held on February 27, 2025, at 1pm (link) to discuss the affordability review process.
  • During the January 2025 PDAB meeting, the advisory group shared their recommended drugs for affordability reviews, referencing ICER analyses that informed their decisions. A total of seven drugs were recommended:
    • Enbrel (4 votes)
    • Cabometyx (3 votes)
    • Xtandi (3 votes)
    • Taltz (3 votes)
    • Xeljanz (2 votes)
    • Orencia (2 votes)
    • Humira (2 votes)
 
Existing State Statute
  • SB 5532, 2022: The legislation created Washington's PDAB and included some language limiting the use of quality-adjusted life years (QALYs). This language has been the model for other states, where it has been found to allow for use of cost effectiveness measures such as the equal value of life year gained (evLYG).  The language limits the use of QALYs only to identifying subpopulations and only focuses on discrimination related to life extension, raising concerns that the state could partner with entities such as PORTAL and ICER that support the use of QALYs and evLYGs to value health care. 
 
Pharmacy & Therapeutics (P&T) Committee / Drug Utilization Review (DUR) Board
  • Washington’s P&T Committee, which also fulfills the role of the DUR Board, evaluates available evidence regarding the relative safety, efficacy, and effectiveness of prescription drugs in a class and makes recommendations for the state’s Preferred Drug List (PDL).
  • The next meeting is April 16, 2025, at 11am.
    • Testimony: To speak on any topic listed on the agenda, email the WPDP program by the Friday before the meeting date with: (1) your name; (2) the organization you represent, and (3) the drug class name on the agenda. If you do not sign up ahead of time, there will still be an opportunity to participate. Comments will be limited to three minutes.
    • Written Comments: If you would like to give testimony, but cannot attend a meeting, please email a two-page maximum letter to the WPDP program at least one week before the meeting. If you provide new drug information that has not been reviewed by the Drug Effectiveness Review Project (DERP), it cannot be considered by the committee.
    • Accommodations: To make a request for special accommodations, call the ADA Coordinator at 360-725-9976.
  • Washington contracts with the Oregon Health & Science University, Evidence-Based Practice Center to conduct evidence-based reviews and make its findings available for the P&T Committee.
  • Recommendations by the P&T Committee are solely based on available evidence, not on cost considerations. The cost analysis is performed after the meeting and does not include the P&T Committee.
 
State References to QALYs
Use of QALYs in Drug and Treatment Coverage Decisions
  • The state Medicaid program reported that they reference the QALY through use of ICER studies in drug coverage reviews.
  • The Emerging Therapies Workgroup is charged with providing input to HCA on funding related to emerging therapies, and relies on information from ICER in its deliberations.
    • A workground member stated, “I think those of us who are methodologists really respect NICE’s process and think of it as being fairly state of the art. They’ve really kept up.”
  • The Health Technology Clinical Committee (HTCC) used QALYs in evaluating treatments for epilepsy and depression in 2019.
    • In 2020, the HTCC recommended that vagal nerve stimulation (VNS) for epilepsy be covered with conditions, but that VNS for depression & transcutaneous VNS not be covered.
  • The state referenced ICER and QALYs in assessing non-pharmacologic pain treatments, leading to recommendations for adding acupuncture and chiropractic benefits.
  • HTCC considered evidence on the QALY-based cost effectiveness of non-pharmacologic tinnitus treatments. The final report stated, “Evidence is lacking with respect to cost outcomes.
  • The state referenced QALYs in its assessment of proton beam therapy in 2019.
Use of QALYs in Genetic and Diagnostic Testing
  • QALYs were used to help the state make a coverage decision related to whole exome sequencing.
  • The HTCC commissioned a report on Sacroiliac joint fusion, which highlighted QALY considerations.
  • The state considered an evidence report considering QALYs in reviewing Cell-free DNA Prenatal Screening for Chromosomal Aneuploidies.
  • QALYs informed the decision to designate Cardiac Artery Calcium Scoring as a non-covered benefit.
Use of QALYs in Evaluations of Specific Procedures
  • The state referenced QALYs in its 2019 assessment of hip surgery procedures for treatment of femoroacetabular impingement syndrome.
  • The HTCC used QALYs in assessing Vertebroplasty, Kyphoplasty, and Sacroplasty, recommending that they should not be covered.
West Virginia
Ongoing Legislative Activities
  • HB 2831: Establishes a West Virginia Prescription Drug Affordability Board to conduct cost reviews of prescription drugs with affordability challenges. The bill states that cost reviews may include assessments of a drug’s “estimated value or cost-effectiveness.”
    • The bill does not bar the use of QALYs and similar measures, nor the consideration of information from third parties that utilize such measures.
    • Status: Introduced on February 24, 2025.
 
Drug Utilization Review (DUR) Board
  • The DUR Board seeks to “improve the quality of health care for Medicaid members and to assist in containing health care costs.”
  • To accomplish this, the Board is responsible for the establishment of standards and criteria for the DUR programs, as well as making recommendations for educational interventions to prescribers and pharmacists to “identify and reduce overuse, abuse, fraud, and inappropriate or medically unnecessary care.”
  • The next DUR Board meeting is May 21, 2025.
    • Testimony: Recently, the DUR Board has only been accepting public comments in writing. Written comments must be sent to [email protected] and [email protected].
    • Accommodations: No instructions available for ADA accommodations.
  • The DUR Board meeting minutes do not detail the evidence used to make recommendations.
 
Pharmacy & Therapeutics (P&T) Committee
  • The P&T Committee is committed to “objectively recommending drugs for inclusion on the WV Preferred Drug List (PDL) that are effective and cost efficient, while providing maximum safety.”
  • The next P&T Committee meeting is April 23, 2025 at 2pm.
    • Testimony: Speaker Sign-up will begin one hour prior to the start of the P&T Committee meeting and will conclude after 45 minutes. Comments are limited to topics on the agenda and must be limited to three minutes. Speakers must also complete a disclosure form before commenting. More details on this process can be found here.
    • Manufacturers: Representatives of drug manufacturers being presented at P&T can register to be on hand to answer any questions put forth by P&T committee members. Registrants must provide a name, email address, name of drug and company they are representing, and provide a completed disclosure form via email to Vicki Cunningham ([email protected]).
    • Accommodations: No instructions available for ADA accommodations.
  • The P&T Committee meeting minutes do not detail the evidence used to make decisions.
 
Notable Activity
Wisconsin
Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program references ICER studies as part of its drug reviews.
  • The Wisconsin Department of Health Services - Division of Medicaid Services (DMS) is implementing a preferred drug list and supplemental rebate program for Wisconsin Medicaid, BadgerCare, and SeniorCare. DMS has retained Provider Synergies and the Medicaid fiscal agent, DXC Technology, to provide PDL management and supplemental rebate contracting services.
  • The DUR Board meeting minutes do not detail the evidence used to make recommendations.
  • In 2023, the legislature introduced AB 747 to create a Prescription Drug Affordability Board with authority to set an UPL. The criteria for the Board’s consideration did not exclude QALYs and similar measures.
Wyoming
Landscape for Cost Effectiveness & QALY Considerations:
  • The state Medicaid program references ICER studies as part of its drug reviews.
  • It is a goal of the P&T Committee that, “The costs of drug therapy shall be considered after clinical and patient considerations are addressed.”
  • The P&T Committee and DUR Board merged in 2010, and the meeting minutes are not detailed.
Funding for this project provided by Biogen, Gilead, Genentech, Merck, and Pfizer.