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Pharmacy Benefits for Non-Medicare Retirees 80/20 Plan

The 80/20 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 80/20 Plan Pharmacy benefit includes:

80/20 Plan Pharmacy Copay

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

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% 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
 
$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.

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:

80/20 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.