Traditional Pharmacy Benefits

Traditional Pharmacy Plan

*Traditional 70/30 Plan and Enhanced 80/20 Plan.

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

The Traditional 70/30 and Enhanced 80/20 prescription benefits cover:

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

Members that have elected the Enhanced 80/20 Plan receive ACA Preventive Medications at no charge with a prescription.

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.

  Up to 30-day Supply 31-60 day Supply 61-90 day Supply
Tier 1 $12 $24 $36
Tier 2 $40 $80 $120
Tier 3 $64 $128 $192
Tier 4 25% coinsurance up to $100 for each 30-day supply 25% coinsurance up to $200 for each 60-day supply 25% coinsurance up to $300 for each 90-day supply
Tier 5 25% coinsurance up to $125 for each 30-day supply 25% coinsurance up to $250 for each 60-day supply 25% coinsurance up to $375 for each 90-day supply
Brand name drug with a generic equivalent Tier 1 copay plus the difference in the cost to the Plan between the generic and brand name drug, not to exceed $100 per 30-day supply of the brand name medication.
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 204 test strips and non-insulin dependent members will receive 102 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 Traditional Pharmacy prescription benefit plans, please call Express Scripts Customer Service at 800-336-5933, or visit Express Scripts.

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