Kilpatrick

Carrier News

Small Group Prescription Drug List Resources

The tables below summarize the structure of pharmacy benefits offered by carriers on small group fully insured and self-funded medical plans. The details here are limited to the small group arena. Drug lists and plan structures differ in the large group segment.

Small Group Fully Insured (ACA Compliant)

CarrierDrug PlanTier 1Tier 2Tier 3Tier 4Tier 5Tier 6
BCBS2019 HIMPreferred GenericNon-Preferred GenericPreferred BrandNon-Preferred BrandPreferred SpecialtyNon-Preferred Specialty
HumanaHumana Rx4Best ValueBetter ValueLesser ValueLeast ValueSpecialty
HumanaHumana Rx5Preferred GenericNon-Preferred GenericPreferred BrandNon-Preferred BrandSpecialty
Memorial HermannOptumRx EHBGenericPreferred BrandNon-Preferred BrandSpecialty
Scott & WhiteSWHP ACA CompliantPreferred GenericPreferred BrandNon-Preferred Generic & BrandSpecialty
UHCTexas PDL (Adv 3-Tier)Best ValueMid ValueLeast Value
UHCAdvantage 4-TierBest ValueBetter ValueLesser ValueLeast Value

Self-Funded / Alternative Funding

CarrierDrug PlanTier 1Tier 2Tier 3Tier 4Tier 5Tier 6
BCBSPerformancePreferred GenericNon-Preferred GenericPreferred BrandNon-Preferred BrandPreferred SpecialtyNon-Preferred Specialty
CignaPerformance 3-TierGenericPreferred BrandNon-Preferred Brand
CignaPerformance 4-TierGenericPreferred BrandNon-Preferred BrandSpecialty
CignaAdvantage 3-TierGenericPreferred BrandNon-Preferred Brand
CignaAdvantage 4-TierGenericPreferred BrandNon-Preferred BrandSpecialty
HumanaHumana Rx4Best ValueBetter ValueLesser ValueLeast ValueSpecialty
HumanaHumana Rx5Preferred GenericNon-Preferred GenericPreferred BrandNon-Preferred BrandSpecialty
Memorial HermannOptumRx EHBGenericPreferred BrandNon-Preferred BrandSpecialty
National GeneralCigna Advantage PDLGenericPreferred BrandNon-Preferred BrandSpecialty
UHCAll Savers Advantage 4-TierBest ValueBetter ValueLesser ValueLeast Value

Comments

All pharmacy programs with BCBS, National General, and UHC are mandatory generic. Humana, Memorial Hermann, and Scott & White are generic push (if provider indicated “brand necessary,” the plan will cover the cost of the brand under the respective tier). Cigna’s programs are flexible—mandatory generic, generic push, and traditional options are available.

Some of UHC’s drug plans require a higher copay for specialty medications in each tier. For plans that distinguish specialty drugs, the structure is three-dimensional. Three-tier plans have six copay levels and four-tier plans have eight copay levels.

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