Attachment 15a-GIC Plan Design and Clinical Programs-Commercial.xlsx
XLSX spreadsheet 117 KB Posted
- Solicitation number
- BD-26-1049-GIC00-07GIC-130036
- Issued by
- Massachusetts
About this file
This is a pharmacy benefit plan design and clinical programs document for the Massachusetts Group Insurance Commission (GIC) Commercial plan, administered by the incumbent vendor CVS Caremark. The document outlines the 2025 and 2026 prescription drug plan designs covering 146,654 employees and retirees with 308,769 total members as of July 1, 2026. The plan features tiered copays with Tier-1 (Generic) at $10 for 30-day retail and $25 for 90-day retail/mail, Tier-2 (Preferred Brand) at $30/$75, Tier-3 (Non-Formulary Brand) at $65/$165, and Tier-4 (Specialty) at $10/$30/$65 with varying day supply limits. The plan includes a $100 individual/$200 family annual deductible and $5,000 individual/$10,000 family out-of-pocket maximum. Retail coverage utilizes the CVS Caremark National Network with a 90-day Maintenance Choice Network and mail-order option. The Standard Control Formulary with ACSF includes hard edits for exclusions with a Medical Necessity pathway, though GLP-1 weight loss products are covered through June 30, 2026, after which they are excluded except for supplemental indications beginning July 1, 2026. Vaccines are covered including both ingredient and administration costs.
The 2026 plan design introduces significant changes effective July 1, 2026, including the exclusion of GLP-1 weight loss products from formulary coverage, implementation of a PrudentRx copay maximizer program, and modification of specialty drug coverage from a one-grace-fill retail refill limit to a retail lockout model with zero grace fills allowed. Additional clinical programs added or modified include the Drug Savings Review program (effective January 1, 2026), Vida Weight Management program (added January 1, 2026 and discontinued December 31, 2026), and Hinge Health musculoskeletal management (effective July 1, 2025). The plan maintains comprehensive safety edits including concurrent and retrospective drug utilization reviews, fraud and waste management, opioid utilization management aligned with CDC criteria, and extensive quantity limit and prior authorization edits across multiple drug classes. The pharmacy benefit anticipates enrollment growth of 3,000 to 5,000 additional subscribers beginning January 1, 2027, with GIC medical carriers including Harvard Pilgrim, MGB, Unicare/Wellpoint, Health New England, and Medicare Holding.
View the file
Other files
Show all 22
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
GIC Rx Plan Client: Massachusetts GIC - Commercial Incumbent Vendor: CVS Caremark
| Plan Design Summary |
| Note: "Domestic Pharmacy" includes onsite pharmacies, inhouse pharmacies, and client owned pharmacies. |
A. Rx plan design corresponding to experience data (2025):
| GROUP/PLAN NAME: | Group Insurance Commission Rx Plan | |
| Who is/are the current medical carriers for this plan? | Harvard Pilgrim, MGB, Unicare/Wellpoint/Health New England/Medicare Holding Plan | |
| Number of employees/retirees currently enrolled in this specific plan design: | 146,654 | |
| Number of total members (includes covered dependents) currently enrolled in this specific plan design: | 308,769 | Note: Enrollment could possibly grow starting 1/1/2027. Expecting an additional 3,000-5,000 subscribers. |
| Above enrollment is as of what date? | 7/1/26 |
| Individual | Family | ||
| Annual deductible, if any | $100.00 | $200.00 | Per claim, if applicable |
| Member out-of-pocket maximum or "stop loss", if applicable | $5,000.00 | $10,000.00 | $ |
| Are the above amounts for Rx only or combined medical/Rx? | Not Applicable |
| Tier-1 | Tier-2 | Tier-3 | Tier-4 | Days supply limit | |
| Select from the drop down menus to describe the plan's copay/coinsurance tiers | Generic | Preferred Brand | Non-Formulary Brand | Specialty (if applicable) | |
| Copay ($) or coinsurance (%) – please include any minimum or maximum copays, if applicable | |||||
| • Retail-30 | 10 | 30 | 65 | 10/30/65 | 30 |
| • Retail-90 | 25 | 75 | 165 | N/A | 90 |
| • Mail order | 25 | 75 | 165 | N/A | 90 |
| • Domestic Pharmacies (30 day), if applicable | N/A | N/A | N/A | N/A | N/A |
| • Domestic Pharmacies (90 day), if applicable | N/A | N/A | N/A | N/A | N/A |
| After how many | |||||
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | Generic | Preferred Brand | Non-Formulary Brand | Specialty (if applicable) | retail fills? |
| Describe the Retail-30 network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s) - please provide) | CVS Caremark National Network |
| Describe the Retail-90 network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s) - please provide) | Maintenance Choice Network & Mail Order Pharmacies |
| Does client use your "Mail at Retail" network (e.g., mail order pricing for 90 day supply at certain retail pharmacies)? | Yes |
| If so, which pharmacy chains, are included in the Mail at Retail network (mail order pricing for 90 day supply at certain retail pharmacies)? | Maintenance Medications at CVS and Affiliated M. Choice Pharmacies |
| Are all generic drugs on Tier-1? | No. Some subject to Brand over Generic brand product takes tier 1 copay |
| Is there mandatory mail order OR retail refill limits/penalties for non-specialty drugs? | neither |
| How are specialty drugs covered? (Open = no restrictions; Refill Limit = must use specialty pharmacy after specified # of fills at retail; Exclusive = only covered at PBM's specialty pharmacy) | Refill Limit |
| For specialty drugs, how many grace fills are allowed at retail, if any? | 1 |
| What days' supply (DS) is allowed for Specialty Pharmacy claims (30 DS limit, 90 DS limit, clinical DS is used, other please specify) | 30 |
| What is the name of the formulary drug list? | Standard Control Formulary with ACSF |
| Does the formulary have drug exclusions? | Yes |
| If the formulary has exclusions, are these hard edits or is there a PA process for drugs on the "excluded drug list"? | Hard edits, with Medical Necessity pathway to coverage |
| Are products used to treat diabetic conditions excluded from the formulary? | No |
| Are GLP-1 weight loss products excluded from the formulary? | No, GLP-1 weight loss products are NOT excluded for this time frame. |
| Has PBM's standard formulary been customized for Client? If so, how? (e.g., moved a drug from formulary to non-formulary status, eliminated coverage for certain non-formulary products)? | No, not during this time frame; changes for 7/1/2026. |
| Is the above formulary also used at Domestic Pharmacies? | Yes |
| Is this a HDHP? with HRA? or HSA? | No, no HDHP |
| Does the plan use the PBM’s standard HDHP Preventive Drug List or a custom HDHP Preventive Drug List? | N/A |
| Does Client's HDHP Preventive Drug List include brand and generics OR only generics? | n/a |
| Do drugs on Client's HDHP Preventive Drug List: (a) bypass the deductible and subject to the standard cost-share; or (b) bypass the deductible and have a $0 copay? | n/a |
| Does Client's HDHP Preventive Drug List include diabetes testing supplies? | n/a |
| Does Client's HDHP Preventive Drug List include GLP-1 weight loss products? | n/a |
| Does Client's pharmacy benefit plan cover Vaccines? | plan covers both ingredient cost and administration fee |
| Does Client currently have a copay maximizer program in place for this plan design? | No, not during this time frame; changes for 7/1/2026. |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties,etc.) | |
| Rx & Medical Deductibles are Separate, OOPs are combined. Hinge Health added 7/1/2025; Drug Savings Review added 1/1/2026; Vida Weight Management Program added 1/1/2026 |
B. Were any Rx plan design changes made for 2026? Yes Please complete section C below.
C. 2026 Rx plan design (only need to complete if different from 2025)
| GROUP/PLAN NAME: |
| Who is/are the current medical carriers for this plan? |
| Number of employees/retirees currently enrolled in this specific plan design: |
| Number of total members (includes covered dependents) currently enrolled in this specific plan design: |
| Above enrollment is as of what date? |
| Individual | Family | ||
| Annual deductible, if any | $ | $ | Per claim, if applicable |
| Member out-of-pocket maximum or "stop loss", if applicable | $ | $ | $ |
| Are the above amounts for Rx only or combined medical/Rx? | ? |
| Tier-1 | Tier-2 | Tier-3 | Tier-4 | Days supply limit | |
| Select from the drop down menus to describe the plan's copay/coinsurance tiers | ? | ? | ? | Specialty (if applicable) | |
| Copay ($) or coinsurance (%) – please include any minimum or maximum copays, if applicable | |||||
| • Retail-30 | |||||
| • Retail-90 | |||||
| • Mail order | |||||
| • Domestic Pharmacies (30 day), if applicable | |||||
| • Domestic Pharmacies (90 day), if applicable | |||||
| After how many | |||||
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | ? | ? | ? | Specialty (if applicable) | retail fills? |
| Describe the Retail-30 network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s) - please provide) | |
| Describe the Retail-90 network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s) - please provide) | |
| Does client use your "Mail at Retail" network (e.g., mail order pricing for 90 day supply at certain retail pharmacies)? | |
| If so, which pharmacy chains, are included in the Mail at Retail network (mail order pricing for 90 day supply at certain retail pharmacies)? | |
| Are all generic drugs on Tier-1? | |
| Is there mandatory mail order OR retail refill limits/penalties for non-specialty drugs? | ? |
| How are specialty drugs covered? (Open = no restrictions; Refill Limit = must use specialty pharmacy after specified # of fills at retail; Exclusive = only covered at PBM's specialty pharmacy) | Retail Lockout |
| For specialty drugs, how many grace fills are allowed at retail, if any? | None |
| What days' supply (DS) is allowed for Specialty Pharmacy claims (30 DS limit, 90 DS limit, clinical DS is used, other please specify) | 30 |
| What is the name of the formulary drug list? | |
| Does the formulary have drug exclusions? | |
| If the formulary has exclusions, are these hard edits or is there a PA process for drugs on the "excluded drug list"? | |
| Are products used to treat diabetic conditions excluded from the formulary? | |
| Are GLP-1 weight loss products excluded from the formulary? | Yes, Effective 7/1/2026 |
| Has PBM's standard formulary been customized for Client? If so, how? (e.g., moved a drug from formulary to non-formulary status, eliminated coverage for certain non-formulary products)? | Yes, GLP-1 drugs excluded for Weight Loss, eff. 7/1/2026 |
| Is the above formulary also used at Domestic Pharmacies? | Yes |
| Is this a HDHP? with HRA? or HSA? | |
| Does the plan use the PBM’s standard HDHP Preventive Drug List or a custom HDHP Preventive Drug List? | |
| Does Client's HDHP Preventive Drug List include brand and generics OR only generics? | ? |
| Do drugs on Client's HDHP Preventive Drug List: (a) bypass the deductible and subject to the standard cost-share; or (b) bypass the deductible and have a $0 copay? | ? |
| Does Client's HDHP Preventive Drug List include diabetes testing supplies? | |
| Does Client's HDHP Preventive Drug List include GLP-1 weight loss products? | |
| Does Client's pharmacy benefit plan cover Vaccines? | ? |
| Does Client currently have a copay maximizer program in place for this plan design? | Yes, PrudentRx, effective 7/1/2026 |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties,etc.) | |
| Drug Savings Review program added 1/1/2026; Vida Weight Management program added 1/1/2026, and discontinued effective 12/31/2026 |
Clinical Programs Client: Massachusetts GIC - Commercial CVS Caremark
Current Clinical Programs
| Program Name | Description | In place during 2025? | In place during 2026? | ||||
| Channel Management Programs | |||||||
| Mail Order Programs/90 Day Retail/Exclusive Specialty | Maintenance Choice | ||||||
| Mandatory Opt-Out | 84+ ds allowed at CVS and select pharmacies | Yes | Yes | ||||
| Narrow Network | National Network | National Network | Yes | Yes | |||
| Site of Care Redirection | Site of Care and Drug Benefit Alignment | Applies to GIC's WellPoint population only. Redirects to lower cost site of care or distrubtion channel. | Yes | Yes | |||
| Self-Administered/Infused Drug Exclusions | N/A | Included as part of the formulary design | Yes | Yes | |||
| Medical Channel Management | N/A | ||||||
| (Have CVS standard Medical Benefit Only Drug List) | MBO drugs are blocked from pharmacy coverage | Yes | Yes | ||||
| GLP-1 Management | |||||||
| Weight Loss GLP-1 Management Program (WL GLP-1 Program) |
Provide a description in column F, including the following:
- Administered by point solution vendor or PBM?
- Mandatory or Voluntary?
| - Any unique member cost sharing? | Vida | Vida is administered as a point solution vendor. It is mandatory for WL GLP-1 coverage through 6/30/26. Effective 7/1/2026, WL coverage will be removed and WL GLP-1s are only covered for supplemental indications. Starting 7/1/26, members can continue to access their Vida RDs/coaches, medical nutrition therapy and the Vida app to support lifestyle modifications and achieving weight loss through YE 2026. | No | Yes | ||||
| Does the WL GLP-1 Program have BMI requirements that are more stringent than the FDA guidelines? If so, what are they? | No | N/A | N/A | |||||
| Does the WL GLP-1 Program have step therapy requirements? If so, what are they? | N/A | N/A | N/A | |||||
| Does the WL GLP-1 Program limit providers that can prescribe GLP-1s? If so, detail the limitations. | WL GLP-1s are covered as long as Vida prescribes through 6/30/2026. | |||||||
| Effective 7/1/2026, Vida is no longer able to prescribe WL GLP-1s. Members will transition back to their PCP without prescriber limitations. Effective 7/1/2026, WL GLP-1s are only covered for supplemental indications. | No | Yes, through 6/30/2026 | ||||||
| Diabetes GLP-1 Management Program (D GLP-1 Program) |
Provide a description in column F, including the following:
- Administered by point solution vendor or PBM?
- Mandatory or Voluntary?
- Any unique member cost sharing?
| - Is step therapy required? If so, please detail. | N/A | N/A | N/A | N/A | |||
| Safety Edits: | |||||||
| • | Concurrent DUR | POS Safety Messaging | Point of sale message that flags potential medication safety concerns at point of sale based upon the member's demographic and claims history. | Yes | Yes | ||
| • | Retrospective DUR | Retrospective DUR | Safety & Monitoring: Reviews claims within 72 hours of adjudication to identify potential medication safety concerns | Yes | Yes | ||
| • | Fraud, Waste and Abuse Management | Core Pharmacy Audit | Daily review of all prescription claims (including specialty claims) to identify and address pharmacy-related FWA. Select network pharmacies chosen for onsite audit. | Yes | Yes | ||
| • | Controlled Substance Management Programs | Opioid Utilization Management | CDC aligned utilization management criteria that includes rigorous parameters for the use of prescription opioids- MME based quantity limits, step therapy (IR before ER), opioid naïve 3 & 7 day supply limits, post-limit prior authorization, prior authorization | Yes | Yes | ||
| • | Safety Programs | Safety & Monitoring | Safety & Monitoring in addition to UM. | Yes | Yes | ||
| Clinical Rules | |||||||
| Quantity limitation system edits and support (list all classes below): | |||||||
| • | Insomnia Products | Quantity Limits specific to GIC's plan on insomnia products (e.g., brand/generic Ambien, Lunesta, etc.) | Yes | Yes | |||
| • | Analgesics Opioid Agonists | Quantity Limit with Post-Limit PA on opioid containing cough and cold products | Yes | Yes | |||
| • | Analgesics Opioids | Quantity Limit on methadone products, immediate-release combination products, buprenorphine, buprenorphine-naloxone products, and opioid antagonists. | Yes | Yes | |||
| • | Analgesics Opioids | Quantity Limit with Post-Limit PA on brands/generics for STADOL (butorphanol nasal spray), extended-release opioids, and immediate release products. | Yes | Yes | |||
| • | Analgesics Anti-Inflammatory | Quantity Limit on brands/generics for KETOROLAC and PENNSAID | Yes | Yes | |||
| • | Anti-anxiety | Quantity Limit on brands/generics anti-anxiety agents, anticonvulsants. | Yes | Yes | |||
| • | Anti-asthmatic and Bronchodilator Agents | Quantity Limit on brands/generics corticosteroid oral inhalers, pulmicort products, long acting beta2-agonist inhalers, mast cell stabilizer/anticholinergic inhalers, and short acting beta2 agonist inhalers. | Yes | Yes | |||
| • | Anti-infectives, Antivirals, and Antiparasitic | Quantity Limit on brand/generic ALINIA, vancomycin oral products, molnupiravir, PAXLOVID, XIFAXAN 200mg, ALBENZA, BILTRICIDE, EMVERM, influenza products (e.g., TAMIFLU), and PREVYMIS | Yes | Yes | |||
| • | Contraceptives | Quantity Limit on emergency contraceptive ELLA and levonorgestrel. Quantity Limit with Post Limit PA on female and male condoms. | Yes | Yes | |||
| • | Dermatologicals | Quantity Limit on brands/generics for FLECTOR, LICART, topical corticosteroids, voltaren gel, gentamicin topical products, metronidazole topical products, clindamycin topical products, erythromycin topical products, mupirocin topical products, and topical antifungals | Yes | Yes | |||
| • | Impotence Agents | Quantity Limit on erectile dysfunction medications | Yes | Yes | |||
| • | Continuous Glucose Monitors | Quantity Limit on CGM sensors | Yes | Yes | |||
| • | Migraine | Quantity Limit on MIGRANAL NASAL SPRAY and QL with Post Limit PA on 5HT1 agonists (triptan medications) | Yes | Yes | |||
| • | Musculoskeletal Therapy Agents | Quantity limit on SOMA and carisprodol/ASA/codeine products | Yes | Yes | |||
| • | Nasal Agents | Quantity Limit on intranasal steroid/antihistamine products | Yes | Yes | |||
| • | Psychotherapeutic & Neurological Agents | Quantity Limit on brands/generics for GRALISE, HORIZANT | Yes | Yes | |||
| • | Antiadrenergic Agents | Quantity Limit with Post Limit PA on brand/generic LUCEMYRA | Yes | Yes | |||
| • | Anticonvulsant | Quantity Limit with Post Limit PA on gabapentin IR capsules and gabapentin solution. | Yes | Yes | |||
| • | Diabetic Test Strips | Quantity Limit with Post Limit PA | Yes | Yes | |||
| • | Gastrointestinal Antiemetics | Quantity Limit with Post Limit PA on brands/generics for AKYNZEO, antiemetic agents (e.g., ZOFRAN), EMEND, CINVANTI, VARUBI, MARINOL and dronabinol products | Yes | Yes | |||
| • | Local Anesthetics Topical | Quantity Limit with Post Limit PA on topical lidocaine and lidocaine combination products | Yes | Yes | |||
| • | Clotrimazole Troches/Lozenges | Quantity Limit with Post Limit PA | Yes | Yes | |||
| • | Methergine tab (methylergonovine) | Quantity Limit with Post Limit PA | Yes | Yes | |||
| • | Vasopressors | Quantity Limit with Post Limit PA on epinephrine auto-injectors and prefilled syringes | Yes | Yes | |||
| • | Mephyton | Quantity Limit with Post Limit PA | Yes | Yes | |||
| • | Analgesics - Non-Narcotic | QL with post-limit PA on JOURNAVX | No | Yes | |||
| • | Specialty Quantity Limits | QL on Specialty medications | Yes | Yes | |||
| Prior authorization (PA) edits and support (list all classes below): | |||||||
| • | Oral Allergenic Extracts | PA | Prior Authorization | Yes | Yes | ||
| • | Analgesics Opioids | PA | Prior Authorization | Yes | Yes | ||
| • | Androgens (Testosterone Products) | PA | Prior Authorization | Yes | Yes | ||
| • | Antidiabetic GLP-1s | PA | Prior Authorization with Limit on GLP-1s approved for diabetes | Yes | Yes | ||
| • | Antifungals (e.g., itrarconazole, voriconazole) | PA | Prior Authorization | Yes | Yes | ||
| • | Antihyperlipidemics | PA | Prior Authorization on brands/generics for NEXLETOL, NEXLIZET, OLVAZA, and VASCEPA | Yes | Yes | ||
| • | Anti-infectives, Antimalarials, Antimycobacterial Agents, and Antivirals | PA | Prior Authorization on brands/generics for SIRTURO, DARAPRIM, PRETOMANID, SITAVIG, VIVJOA, and XEPI | Yes | Yes | ||
| • | Brinsupri | PA | Prior Authorization | No | Yes | ||
| • | Cardiovascular Agents - Misc. | PA | Prior Authorization on brand/generic CORLANOR | Yes | Yes | ||
| • | Chelating Agents | PA | Prior Authorization on brands/generics for CUPRIMINE, DEPEN, and SYPRINE | Yes | Yes | ||
| • | Compounds | Core Compound Strategy | PA for compound > $300 | Yes | Yes | ||
| • | Dermatologicals | PA | Prior Authorization on brands/generics for adapalene, diclofenac sodium gel 3%, FABIOR, LIDODERM, ZTLIDO, Regranex, SANTYL, TAZORAC, tretinoins, OPZELURA, HYFTOR, AKLIEF, ARAZLO, WINLEVI. Select PAs apply only to ages greater than or equal to age 35. | Yes | Yes | ||
| • | Endocrine & Metabolic Agents Misc. | PA | Prior Authorization on brand/generic KERENDIA | Yes | Yes | ||
| • | Genitourinary | PA | Prior Authorization with Limit on brand/generic for ENTADFI | Yes | Yes | ||
| • | Hypoactive Sexual Desire Disorder | PA | Prior Authorization with Limit on brands/generics for VYLEESI and ADDYI | Yes | Yes | ||
| • | Migraine | PA | Prior Authorization with Limit on brand/generic ELYXYB | Yes | Yes | ||
| • | Neuromuscular Agents | PA | Prior Authorization on brands/generics for EXSERVAN, TIGLUTIK | Yes | Yes | ||
| • | Nutritional Supplements | PA | Prior Authorization on infant formula, malabsorption, renal dysfunction, and tube feeding products. | Yes | Yes | ||
| • | Ophthalmic Products | PA | Prior Authorization with Limit (e.g., XIIDRA, RESTASIS, XDEMVY) | Yes | Yes | ||
| • | Rezdiffra | PA | Prior Authorization | Yes | Yes | ||
| • | Rhapsido | PA | Prior Authorization with Limit | No | Yes | ||
| • | Tetracyclines | PA | Prior Authorization with Limit on brand/generic NUZYRA | Yes | Yes | ||
| • | Vasopressin | PA | Prior Authorization on oral and nasal desmopressin products | Yes | Yes | ||
| • | Weight Management UM Bundle | PA | PA with Limit on WL GLP-1s | Yes | Yes until 7/1/26, then replacing with supplemental indications criteria on WL GLP-1s. PAs on WL NON-GLP-1s will remain in place. | ||
| • | Specialty Guideline Management | SGM | PA on specialty medications | Yes | Yes | ||
| Drug exclusions (not as a result of formulary exclusions): | |||||||
| • | Rx Probiotics | Yes | Yes | ||||
| • | Homeopathic Products | Yes | Yes | ||||
| • | OTCs | Rx w/ OTC equivalents | Proton Pump Inhibitors, Non-sedating Anthistamines, OTC Naloxone | Yes | Yes | ||
| • | Injectable Allergy Serums | Yes | Yes | ||||
| • | Arestin (Periodontal) and Topical Fluoride Dental | Yes | Yes | ||||
| • | Cosmetic Drugs | Hair Loss, Anti-Wrinkle, Hair Removal Cream, Other Rx | Yes | Yes | |||
| • | Respiratory Therapy Supplies | Nebulizers and Peak Flow Meters | Yes | Yes | |||
| • | Vitamins: Multiple-Rx Required | Yes | Yes | ||||
| • | Insulin Pumps | Referring to traditional insulin pumps and accessories/supplies recommended for medical coverage | Yes | Yes | |||
| Step therapy: generic first (list all drugs/classes below): | |||||||
| • | Dermatologicals | ST with Limit on EUCRISA | Yes | Yes | |||
| • | Dermatologicals | ST with Limit on Topical Vitamin D Analogs | Yes | Yes | |||
| • | Dermatologicals | ST with Limit on VTAMA | Yes | Yes | |||
| • | Dermatologicals | ST with Limit on ZORYVE | Yes | Yes | |||
| • | Dermatologicals | ST with Limit on ANZUPGO | No | Yes | |||
| • | Migraine | Injectable CGRP Antagonists | Yes | Yes | |||
| • | Migraine | Oral/Intranasal CGRP Antagonists | Yes | Yes | |||
| • | Migraine | REYVOW | Yes | Yes | |||
| Step therapy: generic or preferred brand first (list all drugs/classes below): | |||||||
| • | Anticholinergic | ST with QL on QBREXZA and SOFDRA | Yes | Yes | |||
| • | Dermatologicals | ST with Limit on PRUDOXIN & ZONALON | Yes | Yes | |||
| • | |||||||
| • | |||||||
| Step therapy: preferred brand first (list all drugs/classes below): | |||||||
| • | N/A | ||||||
| • | |||||||
| • | |||||||
| • | |||||||
| Duration of Therapy Limits (including programs targeting medications billed through pharmacy or through medical) | |||||||
| • | N/A | ||||||
| • | |||||||
| • | |||||||
| Dose Optimization (including programs targeting medications billed through pharmacy or through medical | |||||||
| • | CMK Standard Dose Optimization Program | Point of Service Utilization Management- Dose Optimization | Dose Optimization identifies opportunities to reduce the number of medication doses a member takes by offering the choice of switching to a single daily dose at a higher strength. Point of sale notification-The pharmacist is notified that once daily dosing is available for a prescription. | Yes | Yes | ||
| • | |||||||
| • | |||||||
| • | |||||||
| Split-Fill Programs | |||||||
| Compound Management Strategies | |||||||
| Core Compound Strategy | PA for compound > $300 | Yes | Yes | ||||
| Clinical Programs | |||||||
| Formulary Options | Standard Control Formulary with Advanced Control Specialty Formulary | Opt-in formulary with exclusions that have medical necessity PA. Generics first with brands covered if there is no generic available. | Yes | Yes | |||
| Drug Category Exclusions | See drug exclusion section above | ||||||
| Therapeutic Interchange | Real-Time Prescription Benefit | Comprehensive solution through EHR (electronic health records) with actionable, up-to-the minute, member specific information available across multiple points of care. Provides greater visibility to member-specific OOP cost and benefit information to help members and their providers make more informed treatment decisions. | Yes | Yes | |||
| Gaps in Care/Adherence | Core Medication Management (Gaps in Care/Adherence to Drug Therapy) | Provides tailored messages to meet the needs of members with chronic conditions at key points in therapy. Promotes optimal adherence, helps close gaps in medication therapy and simplifies refills and renewals. | Yes | Yes | |||
| Care Engines | N/A | N/A | |||||
| Specialty Programs | Specialty Guideline Management (SGM) and Specialty QLs | Program that promotes safe and appropriate utilization of specialty drugs by applying evidence-based guidelines before and throughout the course of therapy. Quantity limits support clinically appropriate utilization of specialty medications by ensuring dosages dispensed do not exceed the upper limit of safe and appropriate thresholds. These thresholds are based on each drug’s FDA approved dosing limits. | Yes | Yes | |||
| Genetic Testing | SGM | Genetic Testing requirements included within the SGM criteria for applicable drugs | Yes | Yes | |||
| Disease Management/ Medication Therapy Management | Accordant | AccordantCare Specialty | Yes | Yes | |||
| Zero Dollar Copay | Zero Dollar Coverage | $0 copay on generic naloxone and oral anti-cancer medications | Yes | Yes | |||
| DAW Intervention | Generic Substitution at Mail | Mail DAW 1 and 2, also known as DAW solutions, is a mail intervention program that encourages use of generic medication rather than multi-source brand medication. This program complements and works hand-in-hand at mail service with DAW penalties. | Yes | Yes | |||
| Preventive Medications for HDHP | N/A | ||||||
| ACA Medication Coverage | ACA | CMK Standard List | Yes | Yes | |||
| Physician Profiling Report Cards | N/A | N/A | |||||
| Oncology Pathway Programs | N/A | N/A | |||||
| Other Clinical Programs | Diabetic Meter Program | Cost-savings program where the manufacturer provides a blood glucose meter at no cost to those indidviduals currently using a meter. | Yes | Yes | |||
| All Other | |||||||
| Clinical program update or change notification to members (please provide timeline of advance communications) | Quarterly Formulary Notifications - 60 day advance notice, Adherence Reminders- 30 day advance notice | ||||||
| Targeted clinical program mailings to members | Ad Hoc Proactive Utilization Management Notification | ||||||
| Please list ALL other programs: | |||||||
| • | Drug Savings Review | Drug Savings Review | Retrospective clinical look at opportunities for discontinued or modified therapy | No | Yes | ||
| • | PrudentRx | PrudentRx | Assist members in obtaining copay assistance from drug manufacturers resulting in $0 OOP cost on eligible specialty medications | No | Yes starting 7/1/26 | ||
| • | Hinge Health | Hinge Health | Musculoskeltal vendor through point solutions management | Yes, started 7/1/25 | Yes | ||
| • |
Vendor comments, if any:
&G
&"Arial,Regular"&10&K000000Data Class: &B&K00853EPublic &B&"Arial,Regular"&12&K000000 &G
&"Arial,Regular"&10&K000000Data Class: &B&K00853EPublic &B&"Arial,Regular"&12&K000000
&"Arial,Regular"&10&K000000Data Class: &B&K00853EPublic &B&"Arial,Regular"&12&K000000 image1.png image2.png
File details come from the government source that posted it. Updated .