As we officially approach the holiday season, we want to share important information for you and your employees. 

Holiday Hours

We wish you and your families a happy Thanksgiving holiday, and would like to take this time to express our heartfelt gratitude for your partnership. As a reminder, our offices will be closing at 3:00 p.m. on Wednesday, November 27th and closed on Thursday, November 28th for the holiday. There will be no Coverage Connection weekly newsletter  next week. 

Copay Accumulators for Specialty Medications

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 percent 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 are sending an informational letter to any of our members who filled a specialty medication in 2024. The member letter is available for review here.  

Members can still use manufacturer coupons or copay assistance for specialty medications, and they can track their progress 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. 

Open Enrollment Period Reminders

HealthEquity Renewals:

Groups who have flexible benefits through our vendor, HealthEquity, must submit open enrollment templates by December 6th, 2024 in order to be entered and loaded to employee accounts by January 1st, 2025. Please reach out to your account manager with any questions.

834 Enrollment Files:

Reminder, Open Enrollment 834 files need to be submitted to Sanford Health Plan no earlier than Nov. 25, 2024 and no later than Dec. 6, 2024. This will ensure ID cards arrive before January 1, 2024 for all policyholders. You should have received an 834 communication from your Account Manager with information as well. Please reach out to your Account Manager with any questions.