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)

Carrier Drug Plan Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 6
BCBS 2018 HIM Preferred Generic Non-Preferred Generic Preferred Brand Non-Preferred Brand Preferred Specialty Non-Preferred Specialty
Humana Humana Rx4 Best Value Better Value Lesser Value Least Value Specialty
Memorial Hermann OptumRx EHB Generic Preferred Brand Non-Preferred Brand Specialty
Scott & White SWHP ACA Compliant Preferred Generic Preferred Brand Non-Preferred Generic & Brand Specialty
UHC Texas PDL (Adv 3-Tier) Best Value Mid Value Least Value
UHC Advantage 4-Tier Best Value Better Value Lesser Value Least Value

Self-Funded / Alternative Funding

Carrier Drug Plan Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 6
BCBS Performance Preferred Generic Non-Preferred Generic Preferred Brand Non-Preferred Brand Preferred Specialty Non-Preferred Specialty
Cigna Performance 3-Tier Generic Preferred Brand Non-Preferred Brand
Cigna Performance 4-Tier Generic Preferred Brand Non-Preferred Brand Specialty
Cigna Advantage 3-Tier Generic Preferred Brand Non-Preferred Brand
Cigna Advantage 4-Tier Generic Preferred Brand Non-Preferred Brand Specialty
Humana Humana Rx4 Best Value Better Value Lesser Value Least Value Specialty
National General Cigna Advantage PDL Generic Preferred Brand Non-Preferred Brand Specialty
UHC All Savers Advantage 4-Tier Best Value Better Value Lesser Value Least 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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