Pharmacy benefits for large group members

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 

You can focus on staying healthy, not the cost of getting there.

Specialty drug use affects less than 1% of the population. But it carries the highest cost of all medications. Moving from a three-tier to a four-tier formulary moves many specialty drugs to their own tier. And these drugs may include manufacturer coupons that can reduce your cost share.

Is there an out-of-pocket maximum for the 4th 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 in tier 4 will be offset by available manufacturer coupons. Lumicera, our mandatory specialty pharmacy, has processes in place to connect members beginning a new prescription with associated manufacturer coupons.
 

How does a member get a coupon?

When Lumicera (our preferred specialty pharmacy) receives a new tier 4 drug prescription request, they’ll look for an available coupon. If one is available, they’ll either automatically enroll the member or reach out to the member directly to enroll prior before their first fill.

Do manufacturer coupon programs have an annual maximum coverage limit?

Coupon programs vary significantly per drug and manufacturer. A few select drugs do have a maximum annual limit of coverage.* Our specialty pharmacy will share details and limitations of specific coupons with members upon enrollment.

* Coupon programs are subject to change at any time. 

For more information about this benefit enhancement, contact Customer Care at 1-877-230-7555.