Important: The information on this page is for current (2017) plan members enrolled in the 80/20 Plan for Active Members. To view information on 2018 plans including rates and what’s new for Active Members, please click the Learn More button.
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 Caremark. Members should also note that this change 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.
Detailed information regarding your benefits is available below and is also available in your benefits booklet.
The 80/20 Plan Pharmacy benefit includes:
Federal legend prescription drugs
Self-administered injectable medications
Diabetic testing supplies
ACA Preventive Medications
Additional test strips are covered under your medical benefit and are subject to deductible and coinsurance.
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 percent of allowed prescription drug charges per benefit period.
For questions regarding your Pharmacy benefit, please call CVS/caremark Customer Service at 888-321-3124, or visit Caremark.com.
Formulary Exclusion Exception Process
Formulary Exclusion Exception Provider Form
Click below to access the Drug Cost Lookup and Pharmacy Locator Tools.
Please note: If a drug will not be covered by the State Health Plan effective January 1, 2017, the following advisory will appear under Plan Notes: “Not covered: Ask your doctor about alternatives.”
The Notice of Creditable Coverage 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.