Attachment 15b-GIC Plan Design and Clinical Programs-EGWP.xlsx

This document is a plan design and clinical programs specification sheet for the Massachusetts Group Insurance Commission's Employer Group Waiver Plan (EGWP) pharmacy benefit, currently administered by CVS Caremark as the incumbent vendor. The SSI GIC EGWP plan covers approximately 124,278 members as of July 1, 2026, with potential enrollment growth of 3,000-5,000 subscribers beginning January 1, 2027. The plan features a zero annual deductible with a $2,100 out-of-pocket maximum for pharmacy benefits only, utilizing a four-tier copay structure with retail-30 day ($10/$30/$65), retail-90 day ($30/$90/$195), and mail order ($25/$75/$165) options. The plan employs a closed formulary (3T Copper Commercial) with no drug exclusions, though GLP-1 weight loss products are excluded from 2027 coverage despite being covered in 2026. The medical carriers for this plan include HNE, Point32, and Wellpoint. Specialty drugs are covered on an open basis with 90-day supply limits at the specialty pharmacy, and the plan utilizes CVS's Mail at Retail network for 90-day supplies at select retail locations.

The plan incorporates comprehensive safety edits including concurrent and retrospective drug utilization review, fraud and waste management, and controlled substance management programs, all included within the EGWP fee structure for both 2025 and 2026. CVS Caremark did not provide substantive responses regarding quantity limitation system edits, prior authorization protocols, step therapy requirements, duration of therapy limits, dose optimization programs, or other clinical management strategies, instead indicating these features are not applicable to EGWP arrangements. The plan does not qualify as a high-deductible health plan with health reimbursement or savings accounts, and most specialized clinical programs—including disease management, medication therapy management, genetic testing, specialty pharmacy programs, and care engine initiatives—are marked as not applicable to EGWP coverage. No changes to the pharmacy plan design occurred between 2025 and 2026, and no copay maximizer program is currently in place.