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2014 State Health Plan Pharmacy Benefit Changes

The State Health Plan (SHP) pharmacy benefits for active members and non-Medicare retirees in 2014 will continue to have Express Scripts as the pharmacy benefit manager for the following SHP plans:

  • Enhanced 80/20 Plan
  • Traditional 70/30 Plan
  • Consumer-Directed Health Plan (CDHP) 

The Enhanced 80/20 plan and the CDHP will include coverage for the Affordable Care Act (ACA) preventive medications at no cost to members.  In addition, the CDHP will include a preventive medication list, which includes those preventive medications covered for 15 percent coinsurance without the member first having to meet the deductible. All preventive medication lists are available on the SHP’s website.

The 80/20 and 70/30 plans’ preferred drug list will have five pharmacy copayment/coinsurance tiers. In general, the pharmacy copayments and preferred-drug list will stay the same for these plans except for some high-cost generics in Tier 2, and the addition of nonpreferred specialty medications in Tier 5. The preferred drug list is available on the SHP’s website.

The CDHP does not have a preferred drug list since medications are subject to a deductible or coinsurance only.

2014 State Health Plan/Express Scripts Prescription Drug Coverage Comparisons


Traditional 70/30 Plan

(Express Scripts)

Enhanced 80/20 Plan

(Express Scripts)

Consumer-Directed Health Plan (Express Scripts)


Active, Early Retirees, & Medicare Primary Retirees

Active & Early Retirees Only

Active & Early Retirees Only


30-day supply

30-day supply

30-day supply

Tier 1

$12 copayment

$12 copayment

15% coinsurance after deductible for in-network and 35% coinsurance after deductible for out-of-network

Tier 2

$40 copayment

$40 copayment

Tier 3

$64 copayment

$64 copayment

Tier 4

25% coinsurance

($100 max)

25% coinsurance ($100 max)

Tier 5

25% coinsurance

($150 max)

25% coinsurance ($150 max)

ACA Preventive Medications




CDHP Preventive Medications



15% coinsurance, no deductible


  • Tier 1 – Includes mostly generics
  • Tier 2 – Preferred brands, high-cost generics and compound medications
  • Tier 3 – Nonpreferred brands
  • Tier 4Preferred specialty medications – 25% coinsurance up to $100 max. per 30-day supply
  • Tier 5 – Nonpreferred specialty medications – 25% coinsurance up to $150 max. per 30-day supply (new tier for 2014)

Please note that Tier 5 will be added January 1, 2014.  Some specialty medications will be moved to Tier 5.  Affected members were notified in late November 2013.

A list of the SHP’s specialty medications can be found on their website.  The Tier 5 (nonpreferred specialty) medications will be avaiable on this list as of January 1, 2014.

Tier 5 (nonpreferred specialty) is reserved for those specialty medications that have preferred alternatives as determined by the SHP’s Pharmacy and Therapeutics committee, or where there are available specialty generics or biosimilars.  The majority of specialty medications will be in Tier 4.  As new specialty generics or biosimilars become available, additional medications may be added to Tier 5. 

Providers are encouraged to use an SHP-preferred specialty medication whenever appropriate. 

The following are the new Tier 5 (nonpreferred specialty) medications as of January 1, 2014:

Nonpreferred Specialty Medications

Preferred Specialty Alternatives


Follistim® AQ



Nutropin® AQ, Saizen®, Zorbtive®

Genotropin®, Humatrope®, Norditropin®

Cimzia®, Simponi®, Xeljanz®

Enbrel®, Humira®


Generic Fondaparinux sodium


Generic Enoxaparin sodium


Generic Sildenafil


Generic Temozolomide


Updates for Medicare Primary Members

State Health Medicare-eligible retirees will have pharmacy benefits administered by Humana, UnitedHealthcare, or Express Scripts and will include the following plans:

  • Humana Group Medicare Advantage (PPO) Base Plan
  • Humana Group Medicare Advantage (PPO) Enhanced Plan
  • UnitedHealthcare Group Medicare Advantage (PPO) Base Plan
  • UnitedHealthcare Group Medicare Advantage (PPO) Enhanced Plan
  • Traditional 70/30 Plan (pharmacy benefits administered by Express Scripts)

Please note that the preferred drug lists and medications requiring prior authorization are different for the various SHP insurers.  You may visit the State Health Plan’s website. or call the following insurers if you have any questions:

  • Express Scripts           800-417-1764
  • Humana                      800-865-8715
  • UnitedHealthcare        877-842-3210


Pharmacy Prior Authorization Changes Effective January 1, 2014

On January 1, 2014, prescription medications Lovaza® (omega-3- acid ethyl esters) and Vascepa® (icosapent ethyl) will require prior authorization for initial and continued use for the Enhanced 80/20 Plan, Traditional 70/30 Plan, and the Consumer-Directed Health Plan.  Lovaza and Vascepa are Omega 3 fatty acids used in conjunction with diet to reduce triglyceride levels in adult patients with severely high triglycerides. 

Also effective January 1, 2014, the following specialty medications will require prior approval for initial use: Ilaris® (canakinumab), Chenodal™ (chenodiol), Promacta® (eltrombopag), Korlym® (mifepristone), Arcalyst® (rilonacept), Kuvan® (sapropterin), and Xenazine® (tetrabenazine).  All current users will be grandfathered into the program in order to continue therapy.   These medications are used to treat complex medical conditions and in non-acute situations, they must be obtained through Accredo Specialty Pharmacy.  Visit the SHP’s website to view the specialty medications list.

To request a coverage review, providers may call Express Scripts toll-free at 800-417-1764, from 8 a.m. to 9 p.m. Eastern Time, Monday through Friday.  For more information visit the SHP’s website.