Specialty medications, used to treat rare and costly medical conditions, are continuing to increase in cost to the state-sponsored health insurance plans every month. In fact, 45% of total plan prescription costs are for specialty medications even though specialty medications are only 1% of all plan prescriptions.
Historically, the plan has paid approximately 98% of the overall cost of specialty medications. Due to the increasing cost of specialty pharmacy, the Insurance Committees that govern the three benefit plans (State, Local Education and Local Government), voted to institute a 30% coinsurance for each 30-day specialty medication filled in 2026. If the total cost of the medication is less than 30% coinsurance, the member will pay the lesser amount.
In 2026, all plans will have a separate maximum out-of-pocket (MOOP) for specialty medications in 2026, to help manage rising prescription costs and ensure fair cost-sharing. Here’s why this approach is used:
- Managing High-Cost Medications: Specialty medications are often much more expensive than traditional prescriptions. A separate specialty MOOP helps protect members who do not use specialty medications from being overwhelmed by these high costs.
- Balancing Coupon Use: Manufacturer coupons can reduce what members pay, but they may also allow members to reach their deductible or MOOP limit faster. A separate cap helps ensure cost-sharing remains balanced.
- Encouraging Smart Choices: By separating specialty medication and medical MOOP limits, plans can better manage spending and encourage members to consider more cost-effective non-specialty medication treatment options.
- Keeping Up with Market Trends: As prescription drug prices and rebates continue to grow, this approach helps health plans manage costs and maintain sustainable coverage.
In 2026, to help eliminate waste, the plan requires that specialty medications can only be filled for a 30-day supply.
Finally, in 2026, the plan requires all specialty medications to be filled by pharmacies in the Specialty Pharmacy Network. You can find participating specialty pharmacies by using the online Pharmacy Locator tool at info.caremark.com/stateoftn. You can also call CVS Caremark Customer Care at 1-877-522-8679 to find a list of the in-network pharmacies near you.
These changes to specialty pharmacy coverage help our self-insured insurance plans to better share the expense of costly specialty medications with plan members.