OptumRx, the pharmacy benefit manager for Sanford Health Plan, is enhancing its systems as of January 1, 2025, to ensure members’ deductible and out-of-pocket costs no longer reflect drug company coupons or copay cards for specialty medication. 

This process change will affect North Dakota and South Dakota individual and family plans, North Dakota small group plans and large group commercial plans. This enhancement ensures that deductible and out-of-pocket costs reflect what members actually pay to the pharmacy for their specialty medication. Many insurers have already adopted this approach as best practice to keep premiums stable and maintain coverage options for their members.

This change will affect less than 1% of our entire member population.

Current State: If a member’s specialty medication costs $1,000 per month and the drug company coupon or copay card covers $800, $200 is the true member cost-share responsibility at the pharmacy. However, the full $1,000 is sent to SHP from the pharmacy and accumulated toward the member’s deductible or maximum out-of-pocket costs. 

Future State: If a member’s specialty medication costs $1,000 per month and the drug company coupon or copay card covers $800, $200 is the true member cost-share responsibility at the pharmacy. This is also the amount accumulated toward their deductible and maximum out-of-pocket costs. 

Next Steps:
We will notify clients early next week and will then be sending and informational letter to any of our members within these affected lines of business who filled a specialty medication in 2024.  The member letter is available for review here. 

Members can still use manufacturer coupons or copay card assistance for specialty medications, and they can track their cost-share toward their deductible and out-of-pocket maximums on the member portal or by contacting customer service.

Please reach out to your account executive with questions.