The State Health Plan includes prescription drug benefits. Prescription drugs are a major benefit to you and a major part of the cost of our self-insured health plan. Express Scripts is the pharmacy benefits manager. Benefits are paid only for prescriptions filled at network pharmacies or through Express Scripts mail-order pharmacy.
Understanding your prescription benefits
Standard Plan members pay a copayment for prescription drugs. The prescription drug benefit has a separate annual coinsurance maximum of $3,000 per person. Once you meet the maximum, the Plan will pay 100 percent of the cost for your covered drugs for the rest of the year. Below are the copayments.
Savings Plan members pay the full allowed amount. You pay the full allowed amount until you meet your annual deductible. Then, you pay 20 percent of the allowed amount for the drug.
Coverage with Medicare
PEBA automatically enrolls all Medicare-eligible retirees and dependents into Express Scripts Medicare®. This is the State Health Plan’s Medicare Part D prescription drug program. But, you have the option to opt out and continue coverage under the State Health Plan Prescription Drug Program, which covers members who are not eligible for Medicare. There are no changes in an active employee's prescription drug coverage when he or his covered dependents becomes eligible for Medicare. More information about Express Scripts Medicare is available in the Insurance Coverage for the Medicare-eligible Member handbook.
The formulary is the list of covered drugs, including 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 www.Express-Scripts.com 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 may need more information to determine your 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. There are three types of coverage reviews:
Drug quantity management; and
You can log in to your Express Scripts account at www.Express-Scripts.com 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 pharmacy benefits 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.com 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 MyBenefits and select Get My BIN.