Traditional Pharmacy Benefits

Traditional Pharmacy Plan

Detailed information regarding your benefits is available below and is also available in your benefits booklet.

All members not eligible for Medicare are enrolled in this plan. This prescription benefit covers:

  • Federal legend prescription drugs
  • Self-administered injectable medications
  • Insulin
  • Diabetic testing supplies
  • Certain over-the-counter medications
  • Certain immunizations

When visiting a participating pharmacy, be sure to present your State Health Plan ID card to the pharmacist. You will be required to pay the appropriate copay or coinsurance in accordance with State Health Plan benefits.

To view a list of participating pharmacies, log in to Express Scripts. Please note: Express Scripts has merged with Medco to become one company.

Copay
  Up to 30-day Supply 31-60 day Supply 61-90 day Supply
Tier 1 Generics $12 $24 $36
Tier 2 Preferred Brand $40 $80 $120
Tier 3
Non-Preferred Brand		 $64 $128 $192
Brand name drug with a generic equivalent Generic copay + the difference between the Plan's cost of the brand name drug and the Plan's cost of the generic drug not to exceed $100 per a 30-day supply of the brand medication.
Specialty Medications 25% coinsurance up to $100 for each 30-day supply
Diabetic Testing Supplies Copay*
  Up to 30-day Supply 31-60 day Supply 61-90 day Supply
Preferred Brand $10 $20 $30
Non-preferred Brand $25 $50 $75

*Insulin dependent members will receive 153 test strips and non-insulin dependent members will receive 51 test strips per 30-day supply. Additional test strips are covered under your medical benefit.

Prescription drug copayments are limited to $2,500 per person per benefit period. After the $2,500 maximum is reached, the State Health Plan pays 100 percent of allowed prescription drug charges per benefit period. All copays including specialty and any cost difference paid for brand drugs when a generic equivalent is available are applied to the $2,500 maximum.

The State Health Plan provides a preferred drug list to promote clinically appropriate utilization of pharmaceuticals in a cost-effective manner. The list is developed by the Plan's Pharmacy and Therapeutics Committee, is based on safety, effectiveness and clinical outcomes and is updated quarterly.

To comply with pharmacy "best practice" standards and regulatory requirements the State Health Plan follows criteria to determine when a prescription can be refilled. For information about the State Health Plan's refill guidelines, click here.

Some drugs may require prior approval, step therapy, or be subject to quantity limits (see Prior Authorization Page). It is very important to make sure that prior approval is received before going to the Pharmacy.

Specialty medications are used for the treatment of complex diseases, require special dosing or administration, require special handling and are typically prescribed by a specialist provider. In order to obtain non-acute, specialty medications covered under the pharmacy benefit, excluding cancer medications, members must use the Plan's contracted specialty vendor. Click here to view specialty medications.

Mail order is available for members requiring long-term prescriptions. Enjoy the convenience of having your long-term medications delivered to your home or office by using the Medco Pharmacy, the Plan's mail order pharmacy.

My Rx Choices lets you review and identify potential cost-saving alternatives for your prescriptions and is available at Express Scripts. Savings can come from generics, lower-cost brand name alternatives, over-the-counter medications, or using Medco Pharmacy, the Plan's mail order pharmacy.

For questions regarding your prescription benefit, please call Express Scripts Customer Service at 800-336-5933, or visit Express Scripts.
Find a Doctor