Research shows drug coverage is one of the most important benefits to plan members.

The plan options in our DrugSolutions Program help balance the health needs of your plan members with the cost management goals of your organization.


Enhanced Generic Substitution

Limiting coverage to the cost of generic drugs is a key way to help keep your drug plan affordable without compromising your plan member’s health. They can be significantly cheaper than their brand name equivalent.

Our Enhanced Generic Substitution (EGS) plan option limits coverage to the cost of the lowest-priced generic alternative.

This encourages plan members to use the generic medication over the brand-name drug, which can save plan members money if they pay a portion of the cost of the prescription.

For example, consider a brand-name drug that costs $100 and a generic equivalent that costs $20. Assuming the plan provides 100% coverage, the plan member would be required to pay $80 if the brand-name drug was dispensed, but zero if the generic equivalent was selected.

Prior Authorization

Our prior authorization program is fundamental to a robust drug plan management strategy. We have specialists including physicians, pharmacists and nurses who have the expertise to make decisions about the drugs that should be included in our prior authorization program.

Plan sponsors can be confident that their plan members have access to the medication they need to be healthy and productive, and that claims for specialty drugs are approved when specific criteria are met.

We review our list of prior authorization drugs on a regular basis to ensure medications included make therapeutic sense.

We have approximately 150 drugs on our prior authorization list. As new drugs enter the market, they’re reviewed to determine if they should be included in our list.

Health Case Management

Our Health Case Management (HCM) program is designed to assist plan members who have been prescribed specialty medications to treat complex, chronic conditions like rheumatoid arthritis and Crohn’s disease.

HCM provides support and education to those who are enrolled, addressing one of the primary dilemmas facing many group benefit plans: how to help plan members access vital drug therapies while ensuring the cost of the plan is sustainable.

Plan members who have been prescribed a certain specialty medication will be connected with a health case manager, who is a qualified health care professional. Health case managers work with plan members and their physicians to help identify the most effective and appropriate treatment as well as provide ongoing support and monitoring.

Through our designated pharmacy network, plan members taking certain specialty medications will also benefit from competitive pricing, and work with pharmacists who can provide expertise on those medications.

Therapeutic Class Pricing

Therapeutic Class Pricing is similar to our Enhanced Generic Substitution product feature. While the Enhanced Generic Substitution is based on the cost of the lowest-priced interchangeable medication with the same medicinal ingredient, Therapeutic Class Pricing may include a different medicinal ingredient.

A plan that includes Therapeutic Class Pricing reimburses plan members up to the cost of the reference drug.

Acute/Maintenance/Specialty Formulary

This formulary allows plan sponsors to provide comprehensive coverage to plan members, while helping to maintain the affordability of the benefits plan.

The Acute/Maintenance/Specialty formulary offers variable coverage levels for acute and maintenance medications, and 100% coverage for specialty medications providing financial support where it’s needed most.

Additional plan design options

In addition to our plan design options, we offer a wide variety of cost containment features. By implementing one or more of these plan options, plan sponsors can realize effective cost controls and encourage smart healthcare consumerism among plan members. Examples include:

  • Dispense fee cap
  • Coinsurance options
  • Limit lifestyle drugs
  • Deductible = dispense fee
  • Per prescription deductible
  • Annual deductible

Looking for more information?

We have specialists around the country who can help develop solutions that fit your needs.

Contact us