Pharmacy benefits for large group members

Hand holding several medication blister packs.

Our new pharmacy package focuses on preventive medicine and vital supplies that improve overall health and wellness. It also shifts costs of members’ specialty medications to manufacturers all while providing convenience and savings. 

The pharmacy benefits in this package take effect for group members on their renewal date or effective date in 2023 and create access to more medications and supplies at $0. 

For more information about the Pharmacy Benefits Package for group members, contact Customer Care at 877-230-7555.

Now more medications are covered at $0 for large group members. This helps you manage health costs—and helps your provider choose the right drugs for your needs.

New drugs added to the preventive drug list (PDL) include:

  • Preferred mental health medications

  • Preferred brand diabetes medications

  • Preferred diabetic supplies

  • Preferred insulin and non-insulin injectables

  • Preferred inhalers and nebulizer solutions

See a PDF of the full list.

Our goal is to remove the worry about running out of medication and reduce your medication costs.

By providing you with 90-day supplies of maintenance drugs you need, you're spending less and getting more of the medication you need. 

Member cost share for 90-day refills*: 
  • 2 times your copay for all tier 1 and tier 2 medications through a mail-order pharmacy 
  • 2.5 times your copay for tier 1 and tier 2 generic maintenance medications at retail pharmacies 
  • Tier 3 at 3 times your copay (both mail-order and retail) 
  • Tier 4 is not eligible for 90-day supply 

*Members with tier 1 or tier 2 pharmacy benefits with coinsurance will still be charged the full coinsurance amount.
Keeping diabetes under control can be a tall task – cost should not be a barrier. That's why all formularies will include preferred diabetic supplies at $0 for large group members. They include:
  • Blood glucose test strips 
  • Ketone test strips 
  • Continuous glucose monitoring supplies 
  • Syringes 
  • Lancets 
  • Pen needles 
  • Glucagon 

Focus on staying healthy, not the cost of getting there.

Specialty drug utilization affects less than 1% of the population but carries the highest cost of all medications. Moving from a three-tier to four-tier formulary moves many specialty drugs to their own tier and includes manufacturer coupons that can reduce members’ cost share.

Is there an out-of-pocket maximum for the fourth tier specialty drugs? 

No. The intent is to shift expenses from members by maximizing savings through manufacturer coupons.

Is there a way to offset the increased costs in the 4th tier?

Yes, the increase in copay or coinsurance to the member in the 4th tier will be offset by using the manufacturer coupons available. Lumicera, the mandatory specialty pharmacy, already has processes in place to connect members beginning a new prescription that has an associated manufacturer coupon.

How does a member get set up with a coupon?

When specialty pharmacy Lumicera (or preferred Limited Distribution Drug (LDD) Specialty Pharmacy) receives a new prescription request for a tier 4 drug, they will look for an available coupon and either automatically enroll the member or reach out to the member directly to facilitate enrollment prior to dispensing the first fill of the specialty medication.

Do manufacturer coupon programs have an annual maximum limit for coverage?

Coupon programs vary significantly per drug/ manufacturer. There are a few select drugs that have a maximum annual limit of coverage*. The specialty pharmacy will share details and limitations of specific coupon programs with the member upon enrollment. 

* Coupon programs are subject to change at any time. 

For more information about this benefit enhancement, contact Customer Care at 877-230-7555.