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Pharmacy Benefits for Non-Medicare Retirees 70/30 Plan

The 70/30 Plan 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 will have to go to a CVS pharmacy location for their prescriptions. CVS Caremark has a broad pharmacy network, which can be found using the Pharmacy Locator Tool.

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 Caremark.com.

The 70/30 prescription benefits cover:

  • Federal legend prescription drugs

  • Self-administered injectable medications

  • Insulin

  • Diabetic testing supplies

  • Certain immunizations

  • 2018 Comprehensive Formulary (Drug List)

70/30 Plan Pharmacy Copays

Tier Up to 30-day Supply 31-60 day Supply 61-90 day Supply
Tier 1
 
$16 $32 $48
Tier 2 $47 $94 $141
Tier 3 $74 $148 $222
Tier 4 10% coinsurance up to $100 for each 30 day supply 10% coinsurance up to $200 for each 60 day supply 10% coinsurance up to $300 for each 90-day supply
Tier 5 25% coinsurance up to $103 for each 30-day supply 25% coinsurance up to $206 for each 60-day supply 25% coinsurance up to $309 for each 90-day supply
Tier 6 25% coinsurance up to $133 for each 30-day supply 25% coinsurance up to $266 for each 60-day supply 25% coinsurance up to $399 for each 90-day supply

Prescription drug copayments are limited to $3,360 per person per benefit period. After the $3,360 maximum is reached, the State Health Plan pays 100% of allowed prescription drug charges per benefit period.

Diabetic Supplies Copay

Brand Up to 30-day Supply 31-60 day Supply 61-90 day Supply
Preferred Brand
 
$10 $20 $30
Non-preferred Brand $74 $148 $222

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

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

2018 Drug Cost Lookup and Pharmacy Locator Tools

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

70/30 Plan Drug Cost Lookup Tool

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.”

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. The notice is available by clicking here.