Pharmacy Benefits for Medicare Retirees Base PPO Plan (70/30)
The Base PPO Plan (70/30) 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 Base PPO Plan (70/30) prescription benefits cover:
- Federal legend prescription drugs
- Self-administered injectable medications
- Insulin
- Diabetic testing supplies
- Certain immunizations
- 2024 Comprehensive Formulary Drug List
- 2024 Preventive Medications List
Base PPO Plan (70/30) 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 | 30% coinsurance after deductible | 30% coinsurance after deductible | 30% coinsurance after deductible |
| Tier 4 | $200 | $400 | $600 |
| Tier 5 | $350 | $700 | $600 |
| Tier 6 | 30% coinsurance after deductible | 30% coinsurance after deductible | 30% 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 30% 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!
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 | 30% coinsurance after deductible | 30% coinsurance after deductible | 30% 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.
2024 Drug Cost Lookup and Pharmacy Locator Tools
Click below to access the Drug Cost Lookup and Pharmacy Locator Tools:
Base PPO Plan (70/30) 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.”
Copay Assistance Cards and How They Affect Your Deductible
Prescription copay cards are offered by drug manufacturers and processed through CVS Specialty Pharmacy to help prescription users meet medication costs. The State Health Plan does not offer nor manage copay cards, but we do allow members to take part in these programs to assist with the high cost of medication.
Please note: Only the amount you actually pay for the prescriptions will be applied towards your deductible or out-of-pocket maximum, when using a third party or manufacturer copay card program or coupon. For example, if a member’s copay is $2,000 and the copay card paid $1,995, you paid $5 and the $5 paid would apply to the deductible or out-of-pocket maximum. In many circumstances the copay card pays all of the costs, resulting in no cost to the member. In this situation nothing would apply to the member’s accumulations because they did not pay anything out-of-pocket.
Overall, your deductible and out-of-pocket maximum include the amounts you actually pay out of pocket. Using a copay card lowers your out-of-pocket expenses, assisting with the expense of the medication, but does not affect your deductible or out-of-pocket maximum.
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 .