Exhibit_6_Current_Plan_Designs.xlsx

XLSX spreadsheet 61 KB Posted Aug 12, 2026

Attached to: RFP for Pharmacy Benefit Manager
Solicitation number: EV00000953
Issued by: Oklahoma

About this file

Written by GovTribe AI · Aug 14, 2026

This document is a plan design exhibit for the State of Oklahoma's 2026 commercial health insurance offerings managed through the Employees Group Insurance Division (EGID), which operates under the Oklahoma Health Care Authority. The State of Oklahoma is requesting Pharmacy Benefit Manager (PBM) services to administer pharmacy claims adjudication, customer service, reporting, and related services across multiple health plan options. The current plan portfolio encompasses six distinct plan designs—High, High Alt, Basic, Basic Alt, HDHP, and Low Plan (No Part D)—with a combined membership of 158,464 lives as of the file date, plus additional EGWP (Employer Group Waiver Plan) membership of 27,989 lives under High and Low Options with a January 1, 2026 go-live date. The plans are subject to the Affordable Care Act and administered under State/Local laws applicable to ERISA clients.

All plans utilize a tiered copay structure for retail, mail order, and specialty pharmacy services, with generic drugs (Tier 1) ranging from $10-$25, formulary brands (Tier 2) from $45-$90, and non-formulary brands (Tier 3) from $75-$150 depending on supply day limits and delivery method. Individual deductibles vary by plan type from $100 to $1,750, with out-of-pocket maximums between $1,067.50 and $12,000, and all plans include mandatory generic requirements with DAW (Dispense as Written) penalties applied both at and after out-of-pocket maximum thresholds. Supply limits are standardized at 30 days for retail acute fills, 90 days for retail maintenance and mail order, and 90 days for specialty drugs through open networks. All plans incorporate custom generic preventive drug lists and apply standard copay structures post-deductible, with no maximum allowable benefits or copay assistance programs currently enrolled, and no participation in copay maximizer programs at this time.

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High, High Alt, High 30

State of Oklahoma (Commercial)

2026 Plan Design

Client Information

Client Legal Name	State of Oklahoma
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:
•	Membership in plan	84,781

Member Cost Share

Retail Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)	$10.00	N/A	N/A	N/A
•	Formulary Brand (Tier 2)	$45.00	N/A	N/A	N/A
•	Non-Formulary Brand (Tier 3)	$75.00	N/A	N/A	N/A

Retail-90 Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)	$25	N/A	N/A	N/A
•	Formulary Brand (Tier 2)	$90	N/A	N/A	N/A
•	Non-Formulary Brand (Tier 3)	$150	N/A	N/A	N/A

Mail Order Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)	$25	N/A	N/A	N/A
•	Formulary Brand (Tier 2)	$90	N/A	N/A	N/A
•	Non-Formulary Brand (Tier 3)	$150	N/A	N/A	N/A
		1-30 DS		31-60 DS	61-90 DS
Specialty Copay/Coinsurance		(Copay)	(Coinsurance %)	Copay	Copay
•	Generic drugs (Tier 1)	$10	N/A	$25	$25
•	Formulary Brand (Tier 2)	$100	N/A	$200	$300
•	Non-Formulary Brand (Tier 3)	$200	N/A	$400	$600

Annual deductible/Out of Pocket Max, if any		Deductible	Out of Pocket Max
•	Individual	$100	$2,500
•	Family	$300	$4,000
•	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	Yes	Yes
•	What copay does the participant pay?	Brand	Brand
•	Do the penalties apply to the OOP max?	No	No
•	Do the penalties apply after OOP max is met?	Yes	Yes
•	Does an ancillary charge apply to brand "DAW 2" claims	Yes	Yes
•	What copay does the participant pay?	Brand	Brand
•	Do the penalties apply to the OOP max?	No	No
•	Do the penalties apply after OOP max is met?	Yes	Yes

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	NA open network 90
•	Birth control (90-day contraceptives)	90

Preventive Drug List
•	Does the Plan use a Preventative Drug List?	Yes-ACA
•	Does the Plan use PBM standard list? (Yes/No)	No
•	If No, please list the therapeutic classes with customizations	Custom Generic Preventive
•	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

Copay Assistance/Copay Maximizer Programs
•	Is the plan currently enrolled in a copay assistance/copay maximizer program?	No

Basic, Basic Alt

State of Oklahoma (Commercial)

2026 Plan Design

Client Information

Client Legal Name	State of Oklahoma
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:
•	Membership in plan	47,600

Member Cost Share

Retail Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)	$10.00	N/A	N/A	N/A
•	Formulary Brand (Tier 2)	$45.00	N/A	N/A	N/A
•	Non-Formulary Brand (Tier 3)	$75.00	N/A	N/A	N/A

Retail-90 Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)	$25.00	N/A	N/A	N/A
•	Formulary Brand (Tier 2)	$90.00	N/A	N/A	N/A
•	Non-Formulary Brand (Tier 3)	$150.00	N/A	N/A	N/A

Mail Order Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)	$25.00	N/A	N/A	N/A
•	Formulary Brand (Tier 2)	$90.00	N/A	N/A	N/A
•	Non-Formulary Brand (Tier 3)	$150.00	N/A	N/A	N/A
		(Copay)		31-60 DS	61-90 DS
Specialty Copay/Coinsurance		1-30 DS	(Coinsurance %)	(Copay)	(Copay)
•	Generic drugs (Tier 1)	$10.00	N/A	$25.00	$25.00
•	Formulary Brand (Tier 2)	$100.00	N/A	$200.00	$300.00
•	Non-Formulary Brand (Tier 3)	$200.00	N/A	$400.00	$600.00

Annual deductible/Out of Pocket Max, if any		Deductible	Out of Pocket Max
•	Individual	$100	$2,500
•	Family	$300	$4,000
•	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	Yes	Yes
•	What copay does the participant pay?	Brand	Brand
•	Do the penalties apply to the OOP max?	No	No
•	Do the penalties apply after OOP max is met?	Yes	Yes
•	Does an ancillary charge apply to brand "DAW 2" claims	Yes	Yes
•	What copay does the participant pay?	Brand	Brand
•	Do the penalties apply to the OOP max?	No	No
•	Do the penalties apply after OOP max is met?	Yes	Yes

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	NA open network 90
•	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	Custom Generic Preventative DL: Multiple Sclerosis/Weight Loss/Antimalarial drugs not included
•	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

Copay Assistance/Copay Maximizer Programs
•	Is the plan currently enrolled in a copay assistance/copay maximizer program?	No

HDHP

State of Oklahoma (Commercial)

2026 Plan Design

Client Information

Client Legal Name	State of Oklahoma
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:
•	Membership in plan	25,807

Member Cost Share

Retail Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)	$10.00	N/A	N/A	N/A
•	Formulary Brand (Tier 2)	$45.00	N/A	N/A	N/A
•	Non-Formulary Brand (Tier 3)	$75.00	N/A	N/A	N/A

Retail-90 Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)	$25.00	N/A	N/A	N/A
•	Formulary Brand (Tier 2)	$90.00	N/A	N/A	N/A
•	Non-Formulary Brand (Tier 3)	$150.00	N/A	N/A	N/A

Mail Order Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)	$25.00	N/A	N/A	N/A
•	Formulary Brand (Tier 2)	$90.00	N/A	N/A	N/A
•	Non-Formulary Brand (Tier 3)	$150.00	N/A	N/A	N/A
		(Copay)		31-60 DS	61-90 DS
Specialty Copay/Coinsurance		1-30 DS	(Coinsurance %)	(Copay)	(Copay)
•	Generic drugs (Tier 1)	$10.00	N/A	$25.00	$25.00
•	Formulary Brand (Tier 2)	$100.00	N/A	$200.00	$300.00
•	Non-Formulary Brand (Tier 3)	$200.00	N/A	$400.00	$600.00

Annual deductible/Out of Pocket Max, if any		Deductible	Out of Pocket Max
•	Individual	$1,750	$6,000
•	Family	$3,500	$12,000
•	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	Yes	Yes
•	What copay does the participant pay?	Brand	Brand
•	Do the penalties apply to the OOP max?	No	No
•	Do the penalties apply after OOP max is met?	Yes	Yes
•	Does an ancillary charge apply to brand "DAW 2" claims	Yes	Yes
•	What copay does the participant pay?	Brand	Brand
•	Do the penalties apply to the OOP max?	No	No
•	Do the penalties apply after OOP max is met?	Yes	Yes

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	NA open network 90
•	Birth control (90-day contraceptives)	90

Preventive Drug List
•	Does the Plan use a Preventative Drug List?	Yes-ACA
•	Does the Plan use PBM standard list? (Yes/No)	No
•	If No, please list the therapeutic classes with customizations	Custom Generic Preventative
•	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

Copay Assistance/Copay Maximizer Programs
•	Is the plan currently enrolled in a copay assistance/copay maximizer program?	No

Low Plan (No Part D)

State of Oklahoma (Commercial)

2026 Plan Design

Client Information

Client Legal Name	State of Oklahoma
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:
•	Membership in plan	10

Member Cost Share

Retail Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)		25%
•	Formulary Brand (Tier 2)		25%
•	Non-Formulary Brand (Tier 3)		25%

Retail-90 Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)		25%
•	Formulary Brand (Tier 2)		25%
•	Non-Formulary Brand (Tier 3)		25%

Mail Order Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)		25%
•	Formulary Brand (Tier 2)		25%
•	Non-Formulary Brand (Tier 3)		25%

Specialty Copay/Coinsurance		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Retail		25%
•	Mail Order		25%

Annual deductible/Out of Pocket Max, if any		Deductible	Out of Pocket Max
•	Individual	$360	$1067.50 per Indv. Coverage gap
•	Individual	NA	$4,850
•	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	Yes	Yes
•	What copay does the participant pay?	Brand	Brand
•	Do the penalties apply to the OOP max?	No	No
•	Do the penalties apply after OOP max is met?	Yes	Yes
•	Does an ancillary charge apply to brand "DAW 2" claims	Yes	Yes
•	What copay does the participant pay?	Brand	Brand
•	Do the penalties apply to the OOP max?	No	No
•	Do the penalties apply after OOP max is met?	Yes	Yes

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	NA open network 90
•	Birth control (90-day contraceptives)	90

Preventive Drug List
•	Does the Plan use a Preventative Drug List?	Yes-ACA
•	Does the Plan use PBM standard list? (Yes/No)	No
•	If No, please list the therapeutic classes with customizations	Custom Generic Preventative
•	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

Copay Assistance/Copay Maximizer Programs
•	Is the plan currently enrolled in a copay assistance/copay maximizer program?	No

High Plan (No Part D)

State of Oklahoma (Commercial)

2026 Plan Design

Client Information

Client Legal Name	State of Oklahoma
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:
•	Membership in plan	656

Member Cost Share

Retail Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)	$10.00	N/A	N/A	N/A
•	Formulary Brand (Tier 2)	$45.00	N/A	N/A	N/A
•	Non-Formulary Brand (Tier 3)	$75.00	N/A	N/A	N/A

Retail-90 Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)	$25.00	N/A	N/A	N/A
•	Formulary Brand (Tier 2)	$90.00	N/A	N/A	N/A
•	Non-Formulary Brand (Tier 3)	$150.00	N/A	N/A	N/A

Mail Order Copay/Coinsurance (Non-Specialty)		(Copay)	(Coinsurance %)	(Min)	(Max)
•	Generic drugs (Tier 1)	$25.00	N/A	N/A	N/A
•	Formulary Brand (Tier 2)	$90.00	N/A	N/A	N/A
•	Non-Formulary Brand (Tier 3)	$150.00	N/A	N/A	N/A
		(Copay)		31-60 DS	61-90 DS
Specialty Copay/Coinsurance		1-30 DS	(Coinsurance %)	(Copay)	(Copay)
•	Generic drugs (Tier 1)	$10.00	N/A	$25.00	$25.00
•	Formulary Brand (Tier 2)	$100.00	N/A	$200.00	$300.00
•	Non-Formulary Brand (Tier 3)	$200.00	N/A	$400.00	$600.00

Annual deductible/Out of Pocket Max, if any		Deductible	Out of Pocket Max
•	Individual	NA	$4,850
•	Family	NA	NA
•	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	Yes	Yes
•	What copay does the participant pay?	Brand	Brand
•	Do the penalties apply to the OOP max?	No	No
•	Do the penalties apply after OOP max is met?	Yes	Yes
•	Does an ancillary charge apply to brand "DAW 2" claims	Yes	Yes
•	What copay does the participant pay?	Brand	Brand
•	Do the penalties apply to the OOP max?	No	No
•	Do the penalties apply after OOP max is met?	Yes	Yes

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	NA open network 90
•	Birth control (90-day contraceptives)	90

Preventive Drug List
•	Does the Plan use a Preventative Drug List?	Yes-ACA
•	Does the Plan use PBM standard list? (Yes/No)	No
•	If No, please list the therapeutic classes with customizations	Custom Generic Preventative
•	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

Copay Assistance/Copay Maximizer Programs
•	Is the plan currently enrolled in a copay assistance/copay maximizer program?	No

EGWP

CLIENT INFO
PLANS		High Option	Low Option
CLIENT NAME		State of Oklahoma	State of Oklahoma
TOTAL LIVES	27,989	24,620	3,369
GO LIVE DATE	1/1/26

RETAIL
MEMBER COPAYMENTS	DAY SUPPLY	COPAY
GENERIC (TIER 1)	1-30	$10	25%
PREFERRED BRAND (TIER 2)	1-30	$45	25%
NON PREFERRED BRAND (TIER 3)	1-30	$75	25%
HIGH COST	1-30	$100	25%
GENERIC (TIER 1)	31-90	$25	25%
PREFERRED BRAND (TIER 2)	31-90	$90	25%
NON PREFERRED BRAND (TIER 3)	31-90	$150	25%
HIGH COST	31-90	N/A	N/A
MAIL
MEMBER COPAYMENTS	DAY SUPPLY	COPAY
GENERIC (TIER 1)	1-30	$10	25%
PREFERRED BRAND (TIER 2)	1-30	$45	25%
NON PREFERRED BRAND (TIER 3)	1-30	$75	25%
HIGH COST (max DS)	1-30	$100	25%
GENERIC (TIER 1)	31-90	$25	25%
PREFERRED BRAND (TIER 2)	31-90	$90	25%
NON PREFERRED BRAND (TIER 3)	31-90	$150	25%
HIGH COST	31-90	N/A	N/A
SPECIALTY
MEMBER COPAYMENTS	DAY SUPPLY	COPAY
GENERIC (TIER 1)	1-30	$100	25%
PREFERRED BRAND (TIER 2)	1-30	$100	25%
NON PREFERRED BRAND (TIER 3)	1-30	$100	25%
HIGH COST	1-30	$100	25%
ACCUMULATIONS
DEDUCTIBLE		Yes	Yes
MOOP		Yes	Yes
MAB		No	No
DEDUCTIBLE
INDIVIDUAL		$100	$615
FAMILY (OHI)		N/A	N/A
MAXIMUM OUT OF POCKET (MOOP)
INDIVIDUAL		$2,100	$2,100
FAMILY (OHI)		N/A	N/A
ADDITIONAL PROGRAM OFFERINGS
FOLLOW ME LOGIC		Yes	Yes
VACCINATION PROGRAM		Yes	Yes
DISASTER/EMERGENCY OVERRIDES		Yes	Yes

File details come from the government source that posted it. Updated Aug 14, 2026.