Medicare-Eligible Pharmacy Benefits

Express Scripts Medicare™ Prescription Drug Plan

Effective Jan. 1, 2013, the Plan implemented a new Medicare Part D Prescription Plan for all Medicare-eligible members called the Express Scripts Medicare™ Prescription Drug Plan. Click here for the benefits booklet. The overall pharmacy benefit is similar to the Traditional Pharmacy Plan.

All Medicare-eligible members are automatically enrolled in this plan. This plan is comparable to the Traditional Pharmacy Plan and offers better coverage than a standard Medicare Part D Plan. This prescription drug coverage is considered Creditable Coverage, which means it is at least as good as the standard Medicare prescription drug coverage. By offering this new plan, the State Health Plan will be eligible for ongoing savings that will in turn benefit our members.

This prescription benefit covers:

  • Federal legend prescription drugs
  • Injectable medications
  • Insulin
  • Diabetic testing supplies
  • Certain over-the-counter medications
  • Certain immunizations

Eligible members will automatically be enrolled, so you do not need to take any action. If you do not wish to be enrolled in this plan you need to call Customer Service at 855-859-0966 to opt out within 21 days of your effective date.

If you opt out, your coverage will remain the same as your current plan; however, you will forfeit the enhanced benefits described below under "Important things to remember." Note: If you have already chosen to opt out, you can re-enroll at any time by calling State Health Plan Customer Service at 888-234-2416.

You will receive a pre-notification letter in the mail with details of this new plan prior to your effective date. Please review and save the letter and the enclosed Benefit Overview, which provides details about your new prescription drug coverage.

Your Welcome Kit will also arrive in the mail prior to your effective date and will include important information as well as your new prescription drug ID card.

Express Scripts Customer Service is able to answer questions on your plan's specific prescription coverage and copay amounts. You may contact Express Scripts Customer Service at 877-680-4882, 24 hours a day, 7 days a week. TTY users should call 800-716-3231, or visit Express Scripts.

The drug tiers listed in the Formulary may not represent the true member cost share. In an effort to continue similar drug coverage to the Traditional Pharmacy Plan, many copays have been reduced (please click here to view the list of medications with reduced copays).

Please refer to the Formulary Drug List(Preferred Drug List). This document is 53 pages

To view a list of participating pharmacies, log in to Express Scripts. Please note: Express Scripts has merged with Medco to become one company.

If a medication was covered previously by the State Health Plan, it will continue to be covered under the Express Scripts Medicare™ Prescription Drug Plan.

Copay
  Up to 31-day Supply 32-60 day Supply 61-90 day Supply
Tier 1 Generics $12 $24 $36
Tier 2 Preferred Brand $40 $80 $120
Tier 3
Non-Preferred Brand		 $64 $128 $192
Tier 4
Specialty Medications

*Specialty medications may be filled at any participating network pharmacy.		 25% coinsurance up to $100 for each 30-day supply
Diabetic Testing Supplies Copay*
  Up to 31-day Supply 32-60 day Supply 61-90 day Supply
Preferred Brand $10 $20 $30
Non-preferred Brand $25 $50 $75

*Insulin dependent members will receive 153 test strips and non-insulin dependent members will receive 51 test strips per 30-day supply. Additional test strips are covered under your medical benefit.

Part D Prescription Drug Plan Frequently Asked Questions

Important things to remember:

  • You will now have two ID cards, one for your medical benefits as well as one for your pharmacy benefits. You will receive your new pharmacy ID card prior to your effective date.
  • Enhanced benefits include:
    • Premium reduction for Medicare-eligible dependents
    • Extra Help for qualified low income members for copays and premium reduction
    • Elimination of member pay the difference on brand name drugs with a generic equivalent
    • Medication Adherence Program (MAP) will expand to additional pharmacies
    • Extra medication counseling provided by Express Scripts pharmacists
    • Availability of specialty medications at any in-network pharmacy
    • $0 copay/31 days for over-the-counter heartburn medications (Prilosec®, Prevacid®, Zegerid®) with a prescription
    • This plan switches your pharmacy benefit to a calendar year, which means members' out-of-pocket maximums do not change, but will start over Jan. 1, 2013. The pharmacy out-of-pocket maximum of $2,500 will be cut in half to $1,250 for the period of July 1, 2012 through December 31, 2012. Refunds will be issued the first quarter of 2013 for the total amount over $1,250.
  • You will now receive an Explanation of Benefits (EOB). This EOB includes details on benefits activity, so please take a moment to review the information.
  • Coverage that remains the same as the Traditional Pharmacy Plan:
    • There is no donut hole or coverage gap with this plan and all copay levels remain the same (except for some specialty medications)
    • Diabetic supplies will remain covered
    • Certain immunizations remain covered

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. All copays, including specialty are applied to the $2,500 maximum.

Medication Adherence Program (MAP) – Members may obtain a 90-day supply of chronic cardiovascular and diabetes medications at participating network pharmacies for 2½ copays.

Some drugs may require prior approval, step therapy, or be subject to quantity limits. It is very important to make sure that prior approval is received before going to the pharmacy.

To comply with pharmacy "best practice" standards and regulatory requirements the State Health Plan follows criteria to determine when a prescription can be refilled. For information about the State Health Plan's refill guidelines, click here.

Specialty medications are used for the treatment of complex diseases, require special dosing or administration, require special handling and are typically prescribed by a specialist provider. Click here to view specialty medications.

Mail order is available for members requiring long-term prescriptions. Enjoy the convenience of having your long-term medications delivered to your home or office by using the Medco Pharmacy, the Plan's mail order pharmacy.

My Rx Choices lets you review and identify potential cost-saving alternatives for your prescriptions and is available at Express Scripts. Savings can come from generics, lower-cost brand name alternatives, over-the-counter medications, or using Medco Pharmacy, the Plan's mail order pharmacy.

Express Scripts Customer Service is able to answer questions on your plan's specific prescription coverage and copay amounts. You may contact Express Scripts Customer Service at 877-680-4882, 24 hours a day, 7 days a week. TTY users should call 800-716-3231, or visit Express Scripts.

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