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In some situations, people on specialty medications could end up paying an additional $9,450 (individual) to $18,900 (family) out of pocket in 2024

If you’re a Select Health customer through a small employer or individual plan, there are important changes to Select Health’s RxCore five-tier formulary that you should be aware of. Beginning January 1, 2024, when Select Health members fill specialty medications at in-network specialty pharmacies, payments made using manufacturer copay assistance programs will no longer count towards their accumulators. This is set to affect Select Health customers in all states.

What this means is that if you use a drug manufacturer’s copay assistance card to help cover the cost of your medication, and you usually reach your out-of-pocket maximum early in the year, that will likely change. You will also likely end up paying more out of your own pocket for your medications. That’s because like several other health insurance companies that do not count manufacturer copay assistance towards your deductible and out-of-pocket maximum for prescriptions, Select Health is now following suit.

Even if you don’t see your medication on the list above, if you use are using a copay assistance card to help cover a portion of the cost of the your medication, we recommend contacting the provider of your copay assistance program to determine how changes to the Select Health RxCore five-tier formulary (the list of a plan’s covered drugs) will affect you.

Select Health says this change is being implemented to help manage the high cost of health care. In a recent agent alert, Select Health noted:

As we manage health care costs for all our members, we sometimes have to make difficult decisions about the drugs we cover and how we cover them. These changes are guided by evidence-based assessments and receive approval from our Pharmacy & Therapeutics Committee.

”This could have a major impact on the affordability and access to certain medications” according to Rebecca Yates, CEO and Founder of Ark Insurance Solutions. “Even if your copay assistance program card has covered the majority of the expense for your specialty medicines in the past, this will likely change in 2024. Worst case scenario, it could mean paying an additional $9,450 (individual) to $18,900 (family) out of pocket in 2024.”

Since the amount of out-of-pocket expense could increase by thousands of dollars in 2024, Select Health customers should be proactive in reaching out to the drug company’s copay assistance program to determine the amount of the annual assistance maximum. During the past 4 years, all other Utah health insurance carriers have implemented a copay accumulator or copay maximizer program.

Helpful Resources:

Your drug manufacturer copay assistance program:
Contact the program (the phone number is often listed on your copay assistance card) for specifics on how this change will affect you. Specifically, you’ll need to ask what your annual assistance maximum (or cap) is.

Select Health:
For additional information, please visit selecthealth.org/rxfaq. To review the 2024 RxCore five-tier drug list for each state, visit selecthealth.org/pharmacy/pharmacy-coverage-2024