State Health Plan coverage includes prescription benefits at no extra cost. Prescription drugs are a major benefit to you and a major part of the cost of our self-insured health plan. Prescription drugs are only covered at network pharmacies. Express Scriptsexternal link, opens in a new tab is the pharmacy benefits manager.
Benefits with the Standard Plan
As a Standard Plan member, you will pay a copayment for prescription drugs, up to $3,000 per year. A copayment is the fixed amount you pay for a covered drug. Once you meet the maximum, the Plan will pay 100% of the cost for your covered drugs for the rest of the year.
|Tier 1 (generic)||$13||$32||$32|
|Tier 2 (brand — preferred)||$46||$115||$115|
|Tier 3 (brand — non-preferred)||$77||$192||$192|
Benefits with the Savings Plan
As a Savings Plan member, you will pay the full allowed amount for prescription drugs until you meet your deductible. Then, you pay your coinsurance.
Coverage with Medicare
If you are enrolled in the State Health Plan as an active employee and you or your covered dependents become eligible for Medicare, PEBA automatically enrolls the Medicare-eligible member in Express Scripts Medicare®, the State Health Plan’s Medicare Part D program.
You can learn more about the Medicare Supplemental Plan and Express Scripts Medicare in the Insurance Coverage for the Medicare-eligible Member handbook.
The formulary is the list of covered drugs, and includes some brand drugs and generics. After review, some safe and effective drugs become preferred (Tier 2) and other alternatives may become non-preferred (Tier 3). Talk to your doctor if you currently use a drug that is not on the formulary. Doing this can save you money, and using generic drugs may save you even more. Log in to your Express Scriptsexternal link, opens in a new tab account to see if a drug is on the formulary.
Sometimes a prescription isn’t enough to determine if the State Health Plan will provide benefits. Express Scripts might need more information to determine coverage. Coverage reviews rely on medical experts and research, and aim to provide drug safety. Reviews also encourage the use of lower-cost alternatives when possible. If the determination is made to cover the medication, you will pay the appropriate copayment. There are three types of coverage reviews:
- Prior authorizations;
- Drug quantity management; and
- Step therapy.
You can log in to your Express Scriptsexternal link, opens in a new tab account to see if a prescription needs a coverage review. To begin a coverage review, call Express Scripts at 855.612.3128.
After your initial enrollment, you will receive two identification cards from Express Scripts. You can also access your digital identification card from the Express Scripts mobile app. If you need to order a replacement card, visit www.express-scripts.comexternal link, opens in a new tab or call Express Scripts at 855.612.3128. You will need your Benefits Identification Number (BIN). If you don’t know your BIN, log in to MyBenefitsexternal link, opens in a new tab and select Get My BIN.