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, 43% of our total plan prescription costs are specialty medications from about 2% of plan members and 1% of all prescriptions.
Because, in aggregate, the plans had been paying approximately 98% of the overall cost of specialty medications, the Insurance Committees that govern the benefit plans (State, Local Education and Local Government), voted in spring 2022 to institute a tiered coinsurance cost sharing structure starting in 2023 on the Premier, Standard and Limited Preferred provider Organization plans.
For generic specialty drugs, 20% coinsurance with a minimum member out-of-pocket of $100 and a maximum of $200 will apply to each 30-day prescription. For all brand specialty drugs, 30% coinsurance with a minimum member out-of-pocket of $200 and a maximum of $400 will apply to each 30-day prescription.
If the total cost of the drug is less than the minimum member cost share, the member will pay the lesser amount. For CDHP members, the regular coinsurance applies, as it always has.
These changes will help our self-insured insurance plans better share the expense of costly specialty medications with plan members. Also, to help eliminate waste, the plan requires that any specialty medication only be filled for a 30-day supply. And all specialty medications must be filled through a pharmacy in the CVS Caremark Specialty Network (though not necessarily CVS Caremark’s own specialty pharmacy).
To find a specialty pharmacy, go to info.caremark.com/stateoftn and click on the “Specialty Pharmacy List” link under the Network Lists header.