New Cost Structure for Specialty Drugs Coming in 2023

In 2023, there will be a new tiered cost structure for specialty drugs for participants in non-high-deductible health plans (non-HDHPs or “PPO” plans).

The new cost structure was designed after a thorough review of options to help manage pharmacy costs in the NRECA Medical Plan. Specialty drugs represent the top rising cost to the plan.

In 2021, only 1.2% of all prescriptions were specialty drugs, but these drugs represented 53% of the overall prescription drug spend.

This trend has been especially pronounced in the non-HDHP, or PPO plans, compounded by the fact that specialty drug cost share by PPO participants has been decreasing over the past several years; last year it was 2.5% – 3.1% below the industry average. NRECA expects the trends in specialty pharmacy costs to continue, as 66% of medications in the pipeline for upcoming FDA approval are specialty drugs.

The table below compares costs for specialty drugs under current non-HDHP (PPO) plans, versus under the new structure effective January 1, 2023:

Drug Tier	CURRENT Copay	NEW (2023) Coinsurance
Generic	$0	30% ($100 max)
Preferred Brand	$100	30% ($300 max)
Non-Preferred Brand	$100	30% ($500 max)

Assistance for participants
Participants can contact CVS Specialty at 800.237.2767 to find out if copay assistance is available for their specialty drug. Participants can also choose to receive copay assistance when filling their prescription.

Union Plans
If your co-op requires an exception to this benefit change due to a union contract currently in effect, please contact your NRECA field representative as soon as possible.

Participant Notification
Later this year, NRECA will be directly notifying those participants who will be affected by this cost change.

If you have any questions on this new cost structure, reach out to your NRECA field representative.