Pharmacy Benefits for Active Employees Enhanced PPO Plan (80/20)

The Enhanced PPO Plan (80/20) includes pharmacy benefits. When visiting a participating pharmacy, be sure to present your State Health Plan ID card.

The State Health Plan utilizes a Pharmacy Benefit Manager (PBM), which administers the pharmacy benefit. The current PBM for the State Health Plan is CVS CaremarkThis does NOT mean members have to go to a CVS pharmacy location for their prescriptions. CVS Caremark has a broad pharmacy network.

The State Health Plan utilizes a custom, closed formulary (drug list). The formulary indicates which drugs are excluded from the formulary and not covered by the Plan. All other drugs that are on the formulary are grouped into tiers (as shown below). Your medication’s tier determines your portion of the drug cost.

Detailed information regarding your benefits is available in your Benefits Booklet or you can call CVS Caremark Customer Service at 888-321-3124, or visit

The Enhanced PPO Plan (80/20) Pharmacy Benefit Covers:

Enhanced PPO Plan (80/20) Pharmacy Copays

Tier Up to 30-day Supply 31-60 day Supply 61-90 day Supply
Tier 1
$5 $10 $15
Tier 2 $30 $60 $90
Tier 3 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
Tier 4 $100 $200 $300
Tier 5 $250 $500 $750
Tier 6 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

It is important to note that  Tier 3 and Tier 6 medications do not have a defined copay, but are subject to a deductible/coinsurance. This means that you will have to pay the full cost of the medication until you meet your deductible. Once you meet your deductible, you will be responsible for the 20% coinsurance amount until you reach your out-of-pocket maximum. Medications that are subject to coinsurance in most cases will result in higher out-of-pocket costs to members. You are encouraged to speak with your provider about generic medication options, which save you money!

On the 80/20 Plan, there is a combined medical and pharmacy out-of-pocket maximum of $4,890 individual and $14,670 family for in-network coverage. Once this amount is reached, the State Health Plan pays 100% of allowed charges per benefit period.  

Diabetic Supplies Copays

Brand Up to 30-day Supply 31-60 day Supply 61-90 day Supply
Preferred Brand
$5 $10 $15
Non-preferred Brand 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible

Additional test strips are covered under your medical benefit and are subject to deductible and coinsurance.

Insulin Medication

The copay for preferred and non-preferred insulin has been waived for 30-day supply of insulin. This means regardless of the formulary tier, any covered insulin or insulin approved through the Formulary Exceptions (medical necessity) process will have a $0 copay/coinsurance for you.

Formulary Exclusion Exception Process

A formulary exclusion exception process is available for Plan members who, per their provider, have a medical necessity to remain on an excluded, or non-covered, medication. If a member is approved for the excluded drug, that drug will be placed into Tier 3 or Tier 6.

Formulary Exclusion Exception Process 

2024 Drug Cost Lookup and Pharmacy Locator Tools

Click below to access the Drug Cost Lookup and Pharmacy Locator Tools:

80/20 Plan Drug Cost Lookup & Pharmacy Locator Tool

Please note: If a drug will not be covered by the State Health Plan, the following advisory will appear under Plan Notes: “Not covered: Ask your doctor about alternatives.”

Medication Extended Day Supply Request Form

Plan members who will be traveling outside of the United States 90 days or more may request an extended day supply of medication. Members may request additional refills by completing the Medication Extended Day Supply Request Form, and emailing it to 30 days prior to their scheduled departure date. Please notify your provider of your plans. The policy is available by clicking here.

Notice of Creditable Coverage

The Notice of Creditable Coverage is a required notice that verifies that the State Health Plan provides prescription drug coverage that is expected to pay at least as much as the standard Medicare Part D prescription drug coverage under Centers for Medicare and Medicaid Services (CMS) regulations. This is a required notice and no action is required. The notice is available by clicking here.