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 Caremark. This 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.
The Enhanced PPO Plan (80/20) Pharmacy Benefit Covers:
Federal legend prescription drugs
Self-administered injectable medications
Diabetic testing supplies
- 2023 Comprehensive Formulary
Enhanced PPO Plan (80/20) Pharmacy Copays
|Tier||Up to 30-day Supply||31-60 day Supply||61-90 day Supply|
|Tier 3||20% coinsurance after deductible||20% coinsurance after deductible||20% coinsurance after deductible|
|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|
|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.
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.
2023 Drug Cost Lookup and Pharmacy Locator Tools
Click below to access the Drug Cost Lookup and Pharmacy Locator Tools:
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 SHPEDSR@nctreasurer.com 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.