My Pharmacy Benefits

My Pharmacy Benefits

Welcome to the State Health Plan's online resource for Pharmacy benefits. The State Health Plan offers the following health plan options for 2015: the Enhanced 80/20 Plan, the Consumer-Directed Health Plan and Medicare Advantage Prescription Drug Plans, in addition to the Traditional 70/30 Plan.

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

2015 Prescription Drug Plans:

Traditional Pharmacy Benefit Plan

The Traditional Pharmacy Benefit Plan includes prescription drug coverage for the Traditional 70/30 Plan and the Enhanced 80/20 Plan. The State Health Plan utilizes a Pharmacy Benefit Manager (PBM), which administers the Traditional 70/30, Enhanced 80/20, and the new Consumer-Directed Health Plan (CDHP) prescription drug benefits. The current PBM for the State Health Plan is Express Scripts. For questions regarding your Traditional Pharmacy Benefit Plan, please call Express Scripts Customer Service at 800-336-5933, or visit Express Scripts.

Traditional 70/30 Plan

The Traditional 70/30 Plan is available to Active Members, Non-Medicare Retirees and Medicare Primary Retirees. This plan does not cover Affordable Care Act (ACA) medications.

Enhanced 80/20 Plan

The Enhanced 80/20 Plan is available to Active Members and Non-Medicare Retirees. Members who elect this plan receive Affordable Care Act (ACA) medications covered at no charge with a prescription. For $0 coverage of Primary Prevention of Breast Cancer, members must meet authorization criteria.

Consumer-Directed Health Plan

The Consumer-Directed Health Plan (CDHP) is available to Active Members and Non-Medicare Retirees. This plan is also administered by Express Scripts. The CDHP is made up of two components: a high deductible health plan and a Health Reimbursement Account (HRA).

Members who elect the CDHP receive ACA preventive medications at no charge with a prescription. For $0 coverage of Primary Prevention of Breast Cancer, members must meet authorization criteria.CDHP preventive medications require a 15% coinsurance with no deductible.

Medicare Advantage Prescription Drug Plans

All Medicare-eligible members are automatically enrolled into one of the two Medicare Advantage Base Plans: Humana Group Medicare Advantage Preferred Provider Organization (PPO) Plan or UnitedHealthcare Group Medicare Advantage PPO Plan, which both include prescription drug coverage. In addition to each PPO Medicare Advantage Base Plan, each carrier offers an Enhanced Plan.

**Attention Express Scripts Medicare Part D Members: If you were enrolled under the Express Scripts Medicare™ Prescription Drug Plan January 1, 2013, through December 31, 2013, and have questions regarding coverage while under the Express Scripts Medicare Prescription Drug Plan, you may contact Express Scripts Customer Service at 877-680-4882. TTY users should call

High Deductible Health Plan (HDHP) for Newly Eligibles

The North Carolina General Assembly recently approved legislation to create a new health benefit to comply with the federal Affordable Care Act (ACA). The HDHP benefit option is available only to employees eligible for coverage under G.S. §135 48.40(e) and includes a different Pharmacy Benefit than the information located on this page.

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