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Pharmacy Benefits
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Consumer-Directed Health Plan (CDHP) for Active Employees
Consumer-Directed Health Plan (CDHP) Pharmacy Benefits

The CDHP 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.

The CDHP is an "integrated" plan which means that your pharmacy and medical deductibles and out-of-pocket costs are shared. Your prescription medications count towards your annual deductible and out-of-pocket maximums.

Instead of copays, members will have to meet a deductible. After meeting the deductible, the member pays a 15% coinsurance on all in-network medical and pharmacy benefits and 35% coinsurance on all out-of-network medical and pharmacy benefits.

Your HRA has been set up by the State Health Plan to help you meet the deductible and coinsurance. The money in your HRA is used to pay for eligible medical expenses and prescription medications. 

Detailed information regarding your benefits is available below and is also available in your benefits booklet.

 

 The CDHP Pharmacy benefit includes:

  • Federal legend prescription drugs

  • Self-administered injectable medications

  • Insulin

  • Diabetic testing supplies

  • Certain immunizations

Medication Types Coinsurance
Prescription Medications​​​​

​15% coinsurance after deductible for in-network pharmacy
35% coinsurance after deductible for out-of-network pharmacy
ACA Preventive Medications
​$0 (If meet specified criteria and have written prescription)
​CDHP Preventive Medications
​ 15% coinsurance, no deductible

How the CDHP with HRA Works at the Pharmacy

  • Step 1 – Present Member ID card to pharmacy at time of service. If deductible is not met, member pays for prescription (non-preventive medication) in full (100% of Plan's covered expenses). If deductible is met, member pays 15% coinsurance for in network pharmacy and 35% for out of network pharmacy.

  • Step 2 – Pharmacy claims are submitted by the pharmacy benefit manager to the HRA system for adjudication every two weeks.

  • Step 3 – Pharmacy claim processes in the HRA system and if funds are available, a check is issued to the member.

  • Monitor HRA balances and claim payments through Blue Connect​, which is accessible on the Plan's website. 

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 Process
Formulary Exclusion Exception Provider Form

2017 Drug Cost Lookup and Pharmacy Locator Tools

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.”

CDHP (85/15) Drug Cost Lookup Tool 
 
2017 Pharmacy Locator Tool 

Notice of Creditable Coverage

​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​​​.