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 | 2020 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 | |
| Humana | Humana Rx5 | Preferred Generic | Non-Preferred Generic | Preferred Brand | Non-Preferred Brand | 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 | ||
| UHC | Essential 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 | |
| Humana | Humana Rx5 | Preferred Generic | Non-Preferred Generic | Preferred Brand | Non-Preferred Brand | Specialty | |
| Memorial Hermann | OptumRx EHB | Generic | Preferred Brand | Non-Preferred Brand | 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.