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2025 CDHP
| Commonwealth of Kentucky |
| Rx Plan Designs |
| 2025 |
Client Information
| Client Legal Name | Commonwealth of Kentucky |
| Is this plan subject to ACA/HCR? | Yes |
| Is this an ERISA client or do State/Local laws apply? | State/Local laws apply |
| Does the client align to standard ACA coverage? | Yes |
| Plan name: | | LivingWell CDHP | |
| • | Membership in plan | 168,456 | As of 1/15/2025 |
| • | # of claims | 101,109 | As of 1/14/2025 |
| • | Plan Type | CDH | |
| • | Medical Carrier | Anthem | |
Plan Design
| • | Number of Cost Sharing Tiers | 2 |
| • | Formulary | Exclusions-based |
| • | Mail/Maintenance Drug Incentives | Voluntary (None) |
| • | Specialty | Open |
Retail Network and Formulary
| What Retail 30 Network is currently in place? | | Broadest |
| • | Network name? | National |
| • | How many pharmacies are included in this network? | 66,219 |
| • | What specific chains are excluded from your network? | None |
| • | How many grace fills are allowed? | None |
| What Retail 90 Network is currently in place? | | Broadest |
| • | Network name? | National |
| • | How many pharmacies are included in this network? | 64855 |
| • | What specific chains are excluded from your network? | None |
| • | If Mail at Retail is selected, what specific chains are members required to use? | N/A |
| • | How many grace fills are allowed? | None |
| What Vaccination Network is currently in place? | | Broad (All Pharmacies) |
| • | If Narrow is selected, which pharmacies are in-network? | N/A |
| What Formulary is currently in place? | | Exclusions-based Formulary |
| • | Formulary Name | Value Formulary |
| • | How many products are excluded from this formulary? | 650 Brands Covered |
| • | Does this formulary exclude certain products to maximize rebates? | No |
Specialty Pharmacy Network
| What Specialty Network is currently in place? | | Open |
| • | An open network implies specialty pharmacy prescriptions can be filled at any network pharmacy | |
| • | A closed network requires specialty pharmacy prescriptions to be filled at specific locations | |
| If a Closed Specialty Network is in place today: | | | | |
| • | Is there a retail grace fill allowance? | | (Please Select From Drop Down) | N/A |
| - | If so, how many grace fills are allowed? | | |
| • | Are retail pharmacies included as part of your closed network? | | (Please Select From Drop Down) | |
| • | Is your mail service pharmacy included as part of the closed network? | | (Please Select From Drop Down) | |
Member Cost Share
| Retail Copay/Coinsurance (Non-Specialty) | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Generic drugs (Tier 1) | | DED then 20% | | |
| • | Formulary Brand (Tier 2) | | DED then 20% | | |
| • | Non-Formulary Brand (Tier 3) | | N/A - no Tier 3 | | |
| Retail-90 Copay/Coinsurance (Non-Specialty) | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Generic drugs (Tier 1) | | DED then 20% | | |
| • | Formulary Brand (Tier 2) | | DED then 20% | | |
| • | Non-Formulary Brand (Tier 3) | | N/A - no Tier 3 | | |
| Mail Order Copay/Coinsurance (Non-Specialty) | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Generic drugs (Tier 1) | | DED then 20% | | |
| • | Formulary Brand (Tier 2) | | DED then 20% | | |
| • | Non-Formulary Brand (Tier 3) | | N/A - no Tier 3 | | |
| Specialty Copay/Coinsurance | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Retail | | DED then 20% | | |
| • | Mail Order | | DED then 20% | | |
| Annual deductible/Out of Pocket Max, if any | | Deductible | Out of Pocket Max |
| • | Individual | $1,500 | $3,000 |
| • | Family | $2,750 | $5,750 |
| • | Integrated for medical and Rx OR Rx only | Integrated with Medical | Integrated with Medical |
| Mandatory Generic (DAW Penalties) | | Retail | Mail |
| • | Does an ancillary charge apply to brand "DAW 1" claims | No | No |
| • | What copay does the participant pay? | Other | Other |
| • | Do the penalties apply to the OOP max? | No | No |
| • | Do the penalties apply after OOP max is met? | No | No |
| • | Does an ancillary charge apply to brand "DAW 2" claims | No | No |
| • | What copay does the participant pay? | Other | Other |
| • | Do the penalties apply to the OOP max? | No | No |
| • | Do the penalties apply after OOP max is met? | No | No |
| Supply limit (in Days) | | |
| • | Traditional prescription drugs filled at Retail Acute Network | 30 |
| • | Traditional prescription drugs filled at Retail Maintenance Network | 90 |
| • | Traditional prescription drugs filled at Mail Order | 90 |
| • | Specialty Drugs filled through your Preferred Specialty Pharmacy Network | 30 |
| • | Birth control (90-day contraceptives) | 90 |
| Preventive Drug List | | | |
| • | Does the Plan use a Preventative Drug List? | Yes-CDHP | |
| • | Does the Plan use PBM standard list? (Yes/No) | No | |
| • | If No, please list the therapeutic classes with customizations | | All standard classes included EXCEPT Anti-Obesity |
| • | What is the member cost structure after bypassing the deductible | Standard Copay/Coins | |
| Maximum Allowable Benefits (ie. Infertility) (Yes/No) | | No |
| • | If Yes, please list the classes and the coverage limit applied | N/A |
| Copay Assistance/Copay Maximizer Programs | | |
| • | Is the plan currently enrolled in a copay assistance/copay maximizer program? | No |
| • | When did the plan implement the program? | |
| • | What is the member's cost share? | |
| • | Does the program include HIV and Transplant drugs? | (Please Select From Drop Down) |
| • | Is there a penalty if members do not enroll? If so, please explain. | |
Appeals
| Indicate what level of appeals are currently supported for this client. | | |
| • | First level | Support provided |
| • | Second level | Support provided |
| • | External review | Support provided |
Clinical Programs
| Please indicate if the following clinical programs are in place today | | |
| • | Adherence Programs | Yes |
| • | Connected Blood Glucose Meter Strategies (i.e. Livongo, Biotelcare) | Yes |
| • | Compound Drug Management Strategy | Yes |
| • | Fraud Waste & Abuse | Yes |
| • | Gaps in Care | Yes |
| • | Opioid Mangement Strategy | Yes |
| • | Retrospective Drug Utilization Review (RDUR) | Yes |
| • | Specialty Copay Card Programs - True Accumulators? | No |
| • | Specialty Copay Card Programs - Copay Card Maximization? | No |
| • | Specialty Copay Card Programs - 3rd Party Patient Assistance Program? | No |
| Other Clinical Programs (List All) | | Weight Management (coverage of Anti-Obesity medications as long as member participates in program) |
| • | List all other programs not identified above, separated by commas | |
Utilization Management
Confirm utilization management document included as a separate attachment Yes
| Is step therapy in place today? | | Yes |
| • | List therapeutic classes, separated by commas | anti-pruritic/skin, chelating agents, dermatological, diabetes amylin analog, diabetes dipeptidyl peptidase-4 inhibitors, diabetes dipeptidyl peptidase-4 inhibitor combinations, diabetes insulin mimetic agents, diabetes sodium-glucose co-transporter 2 inhibitors, diabetes sodium-glucose co-transporter 2 inhibitor/biguanide combination, diabetes long-acting insulin/glp-1 agonist, Migraine, oral calcitonin gene-related peptide receptor antagonists |
| Are quantity limits in place today? | | Yes |
| • | List therapeutic classes, separated by commas | Anti-Anxiety, Anti-Convulsant, anti-infective influenza agents, anti-infective miscellaneous, anti-pruritic/skin, asthma steroid inhalants, asthma/COPD long-acting beta2-adrenergic agonists/corticosteroid, asthma/COPD long-acting beta2-adrenergic agonists/anticholinergic/corticosteroid, attention deficit hyperactivity disorder, COPD long-acting beta2-adrenertic agonists, COPD anticholinergic/beta agonist combinations, COPD anticholinergic combination and mast cell stabilizer oral inhalation, COPD short acting beta2adrenergic agonist oral inhalation, dermatological, dermatology skin inflammation and hives corticosteroids, dermatological topical NSAID, gastrointestinal agents anti-nausea agents, Migraine, narcolepsy, opioid analgesics, opioid analgesics-immediate release, opioid dependence agents, oral/intranasal fentanyl products, pain and inflammation, pain and inflammation butalbital products, pain and inflammation carisoprodol products, pain and inflammation local anesthetics- topical agents, pain and inflammation opioid agents/long-acting, pain and inflammation opioid agents, short-acting pain and inflammation opioid agents, short-acting, sleep agents hypnotics non-benzodiazepines, antiemetics, proton pump inhibitors, diabetic test strips, anthelmintics, ophthalmic antibiotic, otic antibiotic, anti-fungal topical, antibiotic topical |
| Are prior authorization rules in place today? | | Yes |
| • | PA volume, last 12 months: | |
| • | List therapeutic classes, separated by commas | Allergenic Extracts, Anti-Convulsant, Anti-Fungal-Imidazole Related, Anti-hyperlipidemic, anti-infective/antibacterial, anti-infective anti-protozoal, cardiovascular antilipemic, combination products, dermatological topical NSAID, fibromyalgia, gastrointestinal agent irritable bowel disease-diarrhea predominant, narcolepsy, opioid analgesics, opioid dependence agents, pain management, pheochromocytoma agents, seizures, select medical devices Rx only, select artificial saliva medical devices Rx only, Anabolic Steroids, anti-inflammatory oral, anti-obesity, BPH, Constipation, cough suppressant, isotretinoin, muscle relaxant, nutritional errors of inborn metabolism or genetic condition, retinoids, testosterone products |
2025 Basic CDHP
| Commonwealth of Kentucky |
| Rx Plan Designs |
| 2025 |
Client Information
| Client Legal Name | Commonwealth of Kentucky |
| Is this plan subject to ACA/HCR? | Yes |
| Is this an ERISA client or do State/Local laws apply? | State/Local laws apply |
| Does the client align to standard ACA coverage? | Yes |
| Plan name: | | LivingWell Basic CDHP | |
| • | Membership in plan | 18,299 | As of 1/15/2025 |
| • | # of claims | 7,078 | As of 1/14/2025 |
| • | Plan Type | CDH | |
| • | Medical Carrier | Anthem | |
Plan Design
| • | Number of Cost Sharing Tiers | 2 |
| • | Formulary | Exclusions-based |
| • | Mail/Maintenance Drug Incentives | Voluntary (None) |
| • | Specialty | Open |
Retail Network and Formulary
| What Retail 30 Network is currently in place? | | Broadest |
| • | Network name? | National |
| • | How many pharmacies are included in this network? | 66,219 |
| • | What specific chains are excluded from your network? | None |
| • | How many grace fills are allowed? | None |
| What Retail 90 Network is currently in place? | | Broadest |
| • | Network name? | National |
| • | How many pharmacies are included in this network? | 64855 |
| • | What specific chains are excluded from your network? | None |
| • | If Mail at Retail is selected, what specific chains are members required to use? | N/A |
| • | How many grace fills are allowed? | None |
| What Vaccination Network is currently in place? | | Broad (All Pharmacies) |
| • | If Narrow is selected, which pharmacies are in-network? | N/A |
| What Formulary is currently in place? | | Exclusions-based Formulary |
| • | Formulary Name | Value Formulary |
| • | How many products are excluded from this formulary? | 650 Brands Covered |
| • | Does this formulary exclude certain products to maximize rebates? | No |
Specialty Pharmacy Network
| What Specialty Network is currently in place? | | Open |
| • | An open network implies specialty pharmacy prescriptions can be filled at any network pharmacy | |
| • | A closed network requires specialty pharmacy prescriptions to be filled at specific locations | |
| If a Closed Specialty Network is in place today: | | | | |
| • | Is there a retail grace fill allowance? | | (Please Select From Drop Down) | N/A |
| - | If so, how many grace fills are allowed? | | |
| • | Are retail pharmacies included as part of your closed network? | | (Please Select From Drop Down) | |
| • | Is your mail service pharmacy included as part of the closed network? | | (Please Select From Drop Down) | |
Member Cost Share
| Retail Copay/Coinsurance (Non-Specialty) | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Generic drugs (Tier 1) | | DED then 30% | | |
| • | Formulary Brand (Tier 2) | | DED then 30% | | |
| • | Non-Formulary Brand (Tier 3) | | N/A - no Tier 3 | | |
| Retail-90 Copay/Coinsurance (Non-Specialty) | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Generic drugs (Tier 1) | | DED then 30% | | |
| • | Formulary Brand (Tier 2) | | DED then 30% | | |
| • | Non-Formulary Brand (Tier 3) | | N/A - no Tier 3 | | |
| Mail Order Copay/Coinsurance (Non-Specialty) | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Generic drugs (Tier 1) | | DED then 30% | | |
| • | Formulary Brand (Tier 2) | | DED then 30% | | |
| • | Non-Formulary Brand (Tier 3) | | N/A - no Tier 3 | | |
| Specialty Copay/Coinsurance | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Retail | | DED then 30% | | |
| • | Mail Order | | DED then 30% | | |
| Annual deductible/Out of Pocket Max, if any | | Deductible | Out of Pocket Max |
| • | Individual | $2,000 | $4,000 |
| • | Family | $3,750 | $7,750 |
| • | Integrated for medical and Rx OR Rx only | Integrated with Medical | Integrated with Medical |
| Mandatory Generic (DAW Penalties) | | Retail | Mail |
| • | Does an ancillary charge apply to brand "DAW 1" claims | No | No |
| • | What copay does the participant pay? | Other | Other |
| • | Do the penalties apply to the OOP max? | No | No |
| • | Do the penalties apply after OOP max is met? | No | No |
| • | Does an ancillary charge apply to brand "DAW 2" claims | No | No |
| • | What copay does the participant pay? | Other | Other |
| • | Do the penalties apply to the OOP max? | No | No |
| • | Do the penalties apply after OOP max is met? | No | No |
| Supply limit (in Days) | | |
| • | Traditional prescription drugs filled at Retail Acute Network | 30 |
| • | Traditional prescription drugs filled at Retail Maintenance Network | 90 |
| • | Traditional prescription drugs filled at Mail Order | 90 |
| • | Specialty Drugs filled through your Preferred Specialty Pharmacy Network | 30 |
| • | Birth control (90-day contraceptives) | 90 |
| Preventive Drug List | | | |
| • | Does the Plan use a Preventative Drug List? | Yes-CDHP | |
| • | Does the Plan use PBM standard list? (Yes/No) | No | |
| • | If No, please list the therapeutic classes with customizations | | All standard classes included EXCEPT Anti-Obesity |
| • | What is the member cost structure after bypassing the deductible | Standard Copay/Coins | |
| Maximum Allowable Benefits (ie. Infertility) (Yes/No) | | No |
| • | If Yes, please list the classes and the coverage limit applied | N/A |
| Copay Assistance/Copay Maximizer Programs | | |
| • | Is the plan currently enrolled in a copay assistance/copay maximizer program? | No |
| • | When did the plan implement the program? | |
| • | What is the member's cost share? | |
| • | Does the program include HIV and Transplant drugs? | (Please Select From Drop Down) |
| • | Is there a penalty if members do not enroll? If so, please explain. | |
Appeals
| Indicate what level of appeals are currently supported for this client. | | |
| • | First level | Support provided |
| • | Second level | Support provided |
| • | External review | Support provided |
Clinical Programs
| Please indicate if the following clinical programs are in place today | | |
| • | Adherence Programs | Yes |
| • | Connected Blood Glucose Meter Strategies (i.e. Livongo, Biotelcare) | Yes |
| • | Compound Drug Management Strategy | Yes |
| • | Fraud Waste & Abuse | Yes |
| • | Gaps in Care | Yes |
| • | Opioid Mangement Strategy | Yes |
| • | Retrospective Drug Utilization Review (RDUR) | Yes |
| • | Specialty Copay Card Programs - True Accumulators? | No |
| • | Specialty Copay Card Programs - Copay Card Maximization? | No |
| • | Specialty Copay Card Programs - 3rd Party Patient Assistance Program? | No |
| Other Clinical Programs (List All) | | Weight Management (coverage of Anti-Obesity medications as long as member participates in program) |
| • | List all other programs not identified above, separated by commas | |
Utilization Management
Confirm utilization management document included as a separate attachment Yes
| Is step therapy in place today? | | Yes |
| • | List therapeutic classes, separated by commas | anti-pruritic/skin, chelating agents, dermatological, diabetes amylin analog, diabetes dipeptidyl peptidase-4 inhibitors, diabetes dipeptidyl peptidase-4 inhibitor combinations, diabetes insulin mimetic agents, diabetes sodium-glucose co-transporter 2 inhibitors, diabetes sodium-glucose co-transporter 2 inhibitor/biguanide combination, diabetes long-acting insulin/glp-1 agonist, Migraine, oral calcitonin gene-related peptide receptor antagonists |
| Are quantity limits in place today? | | Yes |
| • | List therapeutic classes, separated by commas | Anti-Anxiety, Anti-Convulsant, anti-infective influenza agents, anti-infective miscellaneous, anti-pruritic/skin, asthma steroid inhalants, asthma/COPD long-acting beta2-adrenergic agonists/corticosteroid, asthma/COPD long-acting beta2-adrenergic agonists/anticholinergic/corticosteroid, attention deficit hyperactivity disorder, COPD long-acting beta2-adrenertic agonists, COPD anticholinergic/beta agonist combinations, COPD anticholinergic combination and mast cell stabilizer oral inhalation, COPD short acting beta2adrenergic agonist oral inhalation, dermatological, dermatology skin inflammation and hives corticosteroids, dermatological topical NSAID, gastrointestinal agents anti-nausea agents, Migraine, narcolepsy, opioid analgesics, opioid analgesics-immediate release, opioid dependence agents, oral/intranasal fentanyl products, pain and inflammation, pain and inflammation butalbital products, pain and inflammation carisoprodol products, pain and inflammation local anesthetics- topical agents, pain and inflammation opioid agents/long-acting, pain and inflammation opioid agents, short-acting pain and inflammation opioid agents, short-acting, sleep agents hypnotics non-benzodiazepines, antiemetics, proton pump inhibitors, diabetic test strips, anthelmintics, ophthalmic antibiotic, otic antibiotic, anti-fungal topical, antibiotic topical |
| Are prior authorization rules in place today? | | Yes |
| • | PA volume, last 12 months: | |
| • | List therapeutic classes, separated by commas | Allergenic Extracts, Anti-Convulsant, Anti-Fungal-Imidazole Related, Anti-hyperlipidemic, anti-infective/antibacterial, anti-infective anti-protozoal, cardiovascular antilipemic, combination products, dermatological topical NSAID, fibromyalgia, gastrointestinal agent irritable bowel disease-diarrhea predominant, narcolepsy, opioid analgesics, opioid dependence agents, pain management, pheochromocytoma agents, seizures, select medical devices Rx only, select artificial saliva medical devices Rx only, Anabolic Steroids, anti-inflammatory oral, anti-obesity, BPH, Constipation, cough suppressant, isotretinoin, muscle relaxant, nutritional errors of inborn metabolism or genetic condition, retinoids, testosterone products |
2025 PPO
| Commonwealth of Kentucky |
| Rx Plan Designs |
| 2025 |
Client Information
| Client Legal Name | Commonwealth of Kentucky |
| Is this plan subject to ACA/HCR? | Yes |
| Is this an ERISA client or do State/Local laws apply? | State/Local laws apply |
| Does the client align to standard ACA coverage? | Yes |
| Plan name: | | LivingWell PPO | |
| • | Membership in plan | 81,935 | As of 1/15/2025 |
| • | # of claims | 73,125 | As of 1/14/2025 |
| • | Plan Type | PPO | |
| • | Medical Carrier | Anthem | |
Plan Design
| • | Number of Cost Sharing Tiers | 2 |
| • | Formulary | Exclusions-based |
| • | Mail/Maintenance Drug Incentives | Voluntary (None) |
| • | Specialty | Open |
Retail Network and Formulary
| What Retail 30 Network is currently in place? | | Broadest |
| • | Network name? | National |
| • | How many pharmacies are included in this network? | 66,219 |
| • | What specific chains are excluded from your network? | None |
| • | How many grace fills are allowed? | None |
| What Retail 90 Network is currently in place? | | Broadest |
| • | Network name? | National |
| • | How many pharmacies are included in this network? | 64855 |
| • | What specific chains are excluded from your network? | None |
| • | If Mail at Retail is selected, what specific chains are members required to use? | N/A |
| • | How many grace fills are allowed? | None |
| What Vaccination Network is currently in place? | | Broad (All Pharmacies) |
| • | If Narrow is selected, which pharmacies are in-network? | N/A |
| What Formulary is currently in place? | | Exclusions-based Formulary |
| • | Formulary Name | Value Formulary |
| • | How many products are excluded from this formulary? | 650 Brands Covered |
| • | Does this formulary exclude certain products to maximize rebates? | No |
Specialty Pharmacy Network
| What Specialty Network is currently in place? | | Open |
| • | An open network implies specialty pharmacy prescriptions can be filled at any network pharmacy | |
| • | A closed network requires specialty pharmacy prescriptions to be filled at specific locations | |
| If a Closed Specialty Network is in place today: | | | | |
| • | Is there a retail grace fill allowance? | | (Please Select From Drop Down) | N/A |
| - | If so, how many grace fills are allowed? | | |
| • | Are retail pharmacies included as part of your closed network? | | (Please Select From Drop Down) | |
| • | Is your mail service pharmacy included as part of the closed network? | | (Please Select From Drop Down) | |
Member Cost Share
| Retail Copay/Coinsurance (Non-Specialty) | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Generic drugs (Tier 1) | $20.00 | | | |
| • | Formulary Brand (Tier 2) | $40.00 | | | |
| • | Non-Formulary Brand (Tier 3) | N/A - no Tier 3 | | | |
| Retail-90 Copay/Coinsurance (Non-Specialty) | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Generic drugs (Tier 1) | $40.00 | | | |
| • | Formulary Brand (Tier 2) | $80.00 | | | |
| • | Non-Formulary Brand (Tier 3) | N/A - no Tier 3 | | | |
| Mail Order Copay/Coinsurance (Non-Specialty) | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Generic drugs (Tier 1) | $40.00 | | | |
| • | Formulary Brand (Tier 2) | $80.00 | | | |
| • | Non-Formulary Brand (Tier 3) | N/A - no Tier 3 | | | |
| Specialty Copay/Coinsurance | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Retail | $40.00 | | | |
| • | Mail Order | $80.00 | | | |
| Annual deductible/Out of Pocket Max, if any | | Deductible | Out of Pocket Max | |
| • | Individual | N/A - no DED on Pharmacy | $2,500 | **Member's medical out-of-pocket maximum is separate from your pharmacy out-of-pocket maximum, and they accumulate separately. |
| • | Family | N/A - no DED on Pharmacy | $5,000 | |
| • | Integrated for medical and Rx OR Rx only | Rx Only | Rx Only | |
| Mandatory Generic (DAW Penalties) | | Retail | Mail |
| • | Does an ancillary charge apply to brand "DAW 1" claims | No | No |
| • | What copay does the participant pay? | Other | Other |
| • | Do the penalties apply to the OOP max? | No | No |
| • | Do the penalties apply after OOP max is met? | No | No |
| • | Does an ancillary charge apply to brand "DAW 2" claims | No | No |
| • | What copay does the participant pay? | Other | Other |
| • | Do the penalties apply to the OOP max? | No | No |
| • | Do the penalties apply after OOP max is met? | No | No |
| Supply limit (in Days) | | |
| • | Traditional prescription drugs filled at Retail Acute Network | 30 |
| • | Traditional prescription drugs filled at Retail Maintenance Network | 90 |
| • | Traditional prescription drugs filled at Mail Order | 90 |
| • | Specialty Drugs filled through your Preferred Specialty Pharmacy Network | 30 |
| • | Birth control (90-day contraceptives) | 90 |
| Preventive Drug List | | | |
| • | Does the Plan use a Preventative Drug List? | No | |
| • | Does the Plan use PBM standard list? (Yes/No) | No | |
| • | If No, please list the therapeutic classes with customizations | | PPO Plan does not include HDHP Preventive Drug List benefit |
| • | What is the member cost structure after bypassing the deductible | No | N/A |
| Maximum Allowable Benefits (ie. Infertility) (Yes/No) | | No |
| • | If Yes, please list the classes and the coverage limit applied | N/A |
| Copay Assistance/Copay Maximizer Programs | | |
| • | Is the plan currently enrolled in a copay assistance/copay maximizer program? | No |
| • | When did the plan implement the program? | |
| • | What is the member's cost share? | |
| • | Does the program include HIV and Transplant drugs? | (Please Select From Drop Down) |
| • | Is there a penalty if members do not enroll? If so, please explain. | |
Appeals
| Indicate what level of appeals are currently supported for this client. | | |
| • | First level | Support provided |
| • | Second level | Support provided |
| • | External review | Support provided |
Clinical Programs
| Please indicate if the following clinical programs are in place today | | |
| • | Adherence Programs | Yes |
| • | Connected Blood Glucose Meter Strategies (i.e. Livongo, Biotelcare) | Yes |
| • | Compound Drug Management Strategy | Yes |
| • | Fraud Waste & Abuse | Yes |
| • | Gaps in Care | Yes |
| • | Opioid Mangement Strategy | Yes |
| • | Retrospective Drug Utilization Review (RDUR) | Yes |
| • | Specialty Copay Card Programs - True Accumulators? | No |
| • | Specialty Copay Card Programs - Copay Card Maximization? | No |
| • | Specialty Copay Card Programs - 3rd Party Patient Assistance Program? | No |
| Other Clinical Programs (List All) | | Weight Management (coverage of Anti-Obesity medications as long as member participates in program) |
| • | List all other programs not identified above, separated by commas | |
Utilization Management
Confirm utilization management document included as a separate attachment Yes
| Is step therapy in place today? | | Yes |
| • | List therapeutic classes, separated by commas | anti-pruritic/skin, chelating agents, dermatological, diabetes amylin analog, diabetes dipeptidyl peptidase-4 inhibitors, diabetes dipeptidyl peptidase-4 inhibitor combinations, diabetes insulin mimetic agents, diabetes sodium-glucose co-transporter 2 inhibitors, diabetes sodium-glucose co-transporter 2 inhibitor/biguanide combination, diabetes long-acting insulin/glp-1 agonist, Migraine, oral calcitonin gene-related peptide receptor antagonists |
| Are quantity limits in place today? | | Yes |
| • | List therapeutic classes, separated by commas | Anti-Anxiety, Anti-Convulsant, anti-infective influenza agents, anti-infective miscellaneous, anti-pruritic/skin, asthma steroid inhalants, asthma/COPD long-acting beta2-adrenergic agonists/corticosteroid, asthma/COPD long-acting beta2-adrenergic agonists/anticholinergic/corticosteroid, attention deficit hyperactivity disorder, COPD long-acting beta2-adrenertic agonists, COPD anticholinergic/beta agonist combinations, COPD anticholinergic combination and mast cell stabilizer oral inhalation, COPD short acting beta2adrenergic agonist oral inhalation, dermatological, dermatology skin inflammation and hives corticosteroids, dermatological topical NSAID, gastrointestinal agents anti-nausea agents, Migraine, narcolepsy, opioid analgesics, opioid analgesics-immediate release, opioid dependence agents, oral/intranasal fentanyl products, pain and inflammation, pain and inflammation butalbital products, pain and inflammation carisoprodol products, pain and inflammation local anesthetics- topical agents, pain and inflammation opioid agents/long-acting, pain and inflammation opioid agents, short-acting pain and inflammation opioid agents, short-acting, sleep agents hypnotics non-benzodiazepines, antiemetics, proton pump inhibitors, diabetic test strips, anthelmintics, ophthalmic antibiotic, otic antibiotic, anti-fungal topical, antibiotic topical |
| Are prior authorization rules in place today? | | Yes |
| • | PA volume, last 12 months: | |
| • | List therapeutic classes, separated by commas | Allergenic Extracts, Anti-Convulsant, Anti-Fungal-Imidazole Related, Anti-hyperlipidemic, anti-infective/antibacterial, anti-infective anti-protozoal, cardiovascular antilipemic, combination products, dermatological topical NSAID, fibromyalgia, gastrointestinal agent irritable bowel disease-diarrhea predominant, narcolepsy, opioid analgesics, opioid dependence agents, pain management, pheochromocytoma agents, seizures, select medical devices Rx only, select artificial saliva medical devices Rx only, Anabolic Steroids, anti-inflammatory oral, anti-obesity, BPH, Constipation, cough suppressant, isotretinoin, muscle relaxant, nutritional errors of inborn metabolism or genetic condition, retinoids, testosterone products |
2025 HDHP
| Commonwealth of Kentucky |
| Rx Plan Designs |
| 2025 |
Client Information
| Client Legal Name | Commonwealth of Kentucky |
| Is this plan subject to ACA/HCR? | Yes |
| Is this an ERISA client or do State/Local laws apply? | State/Local laws apply |
| Does the client align to standard ACA coverage? | Yes |
| Plan name: | | LivingWell HDHP | |
| • | Membership in plan | 298 | As of 1/15/2025 |
| • | # of claims | 118 | As of 1/14/2025 |
| • | Plan Type | CDH | |
| • | Medical Carrier | Anthem | |
Plan Design
| • | Number of Cost Sharing Tiers | 2 |
| • | Formulary | Exclusions-based |
| • | Mail/Maintenance Drug Incentives | Voluntary (None) |
| • | Specialty | Open |
Retail Network and Formulary
| What Retail 30 Network is currently in place? | | Broadest |
| • | Network name? | National |
| • | How many pharmacies are included in this network? | 66,219 |
| • | What specific chains are excluded from your network? | None |
| • | How many grace fills are allowed? | None |
| What Retail 90 Network is currently in place? | | Broadest |
| • | Network name? | National |
| • | How many pharmacies are included in this network? | 64855 |
| • | What specific chains are excluded from your network? | None |
| • | If Mail at Retail is selected, what specific chains are members required to use? | N/A |
| • | How many grace fills are allowed? | None |
| What Vaccination Network is currently in place? | | Broad (All Pharmacies) |
| • | If Narrow is selected, which pharmacies are in-network? | N/A |
| What Formulary is currently in place? | | Exclusions-based Formulary |
| • | Formulary Name | Value Formulary |
| • | How many products are excluded from this formulary? | 650 Brands Covered |
| • | Does this formulary exclude certain products to maximize rebates? | No |
Specialty Pharmacy Network
| What Specialty Network is currently in place? | | Open |
| • | An open network implies specialty pharmacy prescriptions can be filled at any network pharmacy | |
| • | A closed network requires specialty pharmacy prescriptions to be filled at specific locations | |
| If a Closed Specialty Network is in place today: | | | | |
| • | Is there a retail grace fill allowance? | | (Please Select From Drop Down) | N/A |
| - | If so, how many grace fills are allowed? | | |
| • | Are retail pharmacies included as part of your closed network? | | (Please Select From Drop Down) | |
| • | Is your mail service pharmacy included as part of the closed network? | | (Please Select From Drop Down) | |
Member Cost Share
| Retail Copay/Coinsurance (Non-Specialty) | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Generic drugs (Tier 1) | | DED then 30% | | |
| • | Formulary Brand (Tier 2) | | DED then 30% | | |
| • | Non-Formulary Brand (Tier 3) | | N/A - no Tier 3 | | |
| Retail-90 Copay/Coinsurance (Non-Specialty) | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Generic drugs (Tier 1) | | DED then 30% | | |
| • | Formulary Brand (Tier 2) | | DED then 30% | | |
| • | Non-Formulary Brand (Tier 3) | | N/A - no Tier 3 | | |
| Mail Order Copay/Coinsurance (Non-Specialty) | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Generic drugs (Tier 1) | | DED then 30% | | |
| • | Formulary Brand (Tier 2) | | DED then 30% | | |
| • | Non-Formulary Brand (Tier 3) | | N/A - no Tier 3 | | |
| Specialty Copay/Coinsurance | | (Copay) | (Coinsurance %) | (Min) | (Max) |
| • | Retail | | DED then 30% | | |
| • | Mail Order | | DED then 30% | | |
| Annual deductible/Out of Pocket Max, if any | | Deductible | Out of Pocket Max |
| • | Individual | $2,000 | $8,050 |
| • | Family | $4,000 | $16,100 |
| • | Integrated for medical and Rx OR Rx only | Integrated with Medical | Integrated with Medical |
| Mandatory Generic (DAW Penalties) | | Retail | Mail |
| • | Does an ancillary charge apply to brand "DAW 1" claims | No | No |
| • | What copay does the participant pay? | Other | Other |
| • | Do the penalties apply to the OOP max? | No | No |
| • | Do the penalties apply after OOP max is met? | No | No |
| • | Does an ancillary charge apply to brand "DAW 2" claims | No | No |
| • | What copay does the participant pay? | Other | Other |
| • | Do the penalties apply to the OOP max? | No | No |
| • | Do the penalties apply after OOP max is met? | No | No |
| Supply limit (in Days) | | |
| • | Traditional prescription drugs filled at Retail Acute Network | 30 |
| • | Traditional prescription drugs filled at Retail Maintenance Network | 90 |
| • | Traditional prescription drugs filled at Mail Order | 90 |
| • | Specialty Drugs filled through your Preferred Specialty Pharmacy Network | 30 |
| • | Birth control (90-day contraceptives) | 90 |
| Preventive Drug List | | | |
| • | Does the Plan use a Preventative Drug List? | Yes-CDHP | |
| • | Does the Plan use PBM standard list? (Yes/No) | No | |
| • | If No, please list the therapeutic classes with customizations | | All standard classes included EXCEPT Anti-Obesity; Plan has modular set-up for select classes (Diabetes, COPD, Asthma, Hypertension), where these classes have a lower coinsurance (25%) and bypass the deductible. All other covered Preventive Drug Classes bypass the deductible and take the standard coinsurance (30%). |
| • | What is the member cost structure after bypassing the deductible | Standard Copay/Coins | (With exception of note above) |
| Maximum Allowable Benefits (ie. Infertility) (Yes/No) | | No |
| • | If Yes, please list the classes and the coverage limit applied | N/A |
| Copay Assistance/Copay Maximizer Programs | | |
| • | Is the plan currently enrolled in a copay assistance/copay maximizer program? | No |
| • | When did the plan implement the program? | |
| • | What is the member's cost share? | |
| • | Does the program include HIV and Transplant drugs? | (Please Select From Drop Down) |
| • | Is there a penalty if members do not enroll? If so, please explain. | |
Appeals
| Indicate what level of appeals are currently supported for this client. | | |
| • | First level | Support provided |
| • | Second level | Support provided |
| • | External review | Support provided |
Clinical Programs
| Please indicate if the following clinical programs are in place today | | |
| • | Adherence Programs | Yes |
| • | Connected Blood Glucose Meter Strategies (i.e. Livongo, Biotelcare) | Yes |
| • | Compound Drug Management Strategy | Yes |
| • | Fraud Waste & Abuse | Yes |
| • | Gaps in Care | Yes |
| • | Opioid Mangement Strategy | Yes |
| • | Retrospective Drug Utilization Review (RDUR) | Yes |
| • | Specialty Copay Card Programs - True Accumulators? | No |
| • | Specialty Copay Card Programs - Copay Card Maximization? | No |
| • | Specialty Copay Card Programs - 3rd Party Patient Assistance Program? | No |
| Other Clinical Programs (List All) | | Weight Management (coverage of Anti-Obesity medications as long as member participates in program) |
| • | List all other programs not identified above, separated by commas | |
Utilization Management
Confirm utilization management document included as a separate attachment Yes
| Is step therapy in place today? | | Yes |
| • | List therapeutic classes, separated by commas | anti-pruritic/skin, chelating agents, dermatological, diabetes amylin analog, diabetes dipeptidyl peptidase-4 inhibitors, diabetes dipeptidyl peptidase-4 inhibitor combinations, diabetes insulin mimetic agents, diabetes sodium-glucose co-transporter 2 inhibitors, diabetes sodium-glucose co-transporter 2 inhibitor/biguanide combination, diabetes long-acting insulin/glp-1 agonist, Migraine, oral calcitonin gene-related peptide receptor antagonists |
| Are quantity limits in place today? | | Yes |
| • | List therapeutic classes, separated by commas | Anti-Anxiety, Anti-Convulsant, anti-infective influenza agents, anti-infective miscellaneous, anti-pruritic/skin, asthma steroid inhalants, asthma/COPD long-acting beta2-adrenergic agonists/corticosteroid, asthma/COPD long-acting beta2-adrenergic agonists/anticholinergic/corticosteroid, attention deficit hyperactivity disorder, COPD long-acting beta2-adrenertic agonists, COPD anticholinergic/beta agonist combinations, COPD anticholinergic combination and mast cell stabilizer oral inhalation, COPD short acting beta2adrenergic agonist oral inhalation, dermatological, dermatology skin inflammation and hives corticosteroids, dermatological topical NSAID, gastrointestinal agents anti-nausea agents, Migraine, narcolepsy, opioid analgesics, opioid analgesics-immediate release, opioid dependence agents, oral/intranasal fentanyl products, pain and inflammation, pain and inflammation butalbital products, pain and inflammation carisoprodol products, pain and inflammation local anesthetics- topical agents, pain and inflammation opioid agents/long-acting, pain and inflammation opioid agents, short-acting pain and inflammation opioid agents, short-acting, sleep agents hypnotics non-benzodiazepines, antiemetics, proton pump inhibitors, diabetic test strips, anthelmintics, ophthalmic antibiotic, otic antibiotic, anti-fungal topical, antibiotic topical |
| Are prior authorization rules in place today? | | Yes |
| • | PA volume, last 12 months: | |
| • | List therapeutic classes, separated by commas | Allergenic Extracts, Anti-Convulsant, Anti-Fungal-Imidazole Related, Anti-hyperlipidemic, anti-infective/antibacterial, anti-infective anti-protozoal, cardiovascular antilipemic, combination products, dermatological topical NSAID, fibromyalgia, gastrointestinal agent irritable bowel disease-diarrhea predominant, narcolepsy, opioid analgesics, opioid dependence agents, pain management, pheochromocytoma agents, seizures, select medical devices Rx only, select artificial saliva medical devices Rx only, Anabolic Steroids, anti-inflammatory oral, anti-obesity, BPH, Constipation, cough suppressant, isotretinoin, muscle relaxant, nutritional errors of inborn metabolism or genetic condition, retinoids, testosterone products |