Pharmacy Benefits for Non-Medicare Retirees 80/20 PPO Plan The 80/20 PPO 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 Caremark. This does NOT mean members will 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 Caremark.com. The 80/20 PPO Plan Pharmacy benefit includes: Federal legend prescription drugs Self-administered injectable medications Insulin Diabetic testing supplies Certain immunizations Preventive Medications List 2021 Comprehensive Formulary 80/20 PPO 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 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 our 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 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. 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 2021 Drug Cost Lookup and Pharmacy Locator Tools Click below to access the Drug Cost Lookup and Pharmacy Locator Tools: 80/20 PPO 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 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. The notice is available by clicking here.