Pharmacy Plan

State Non-Medicare Retirees

All medical coverage includes MCHCP’s prescription drug benefits, administered by Express Scripts. Express Scripts provides a nationwide retail pharmacy network, as well as its specialty pharmacy, Accredo. Express Scripts offers home delivery for maintenance medications that can help save you time and money. You may have to pay more if you get a brand name drug when a generic is available. Express Scripts’ preferred formulary list is available on myMCHCP or by calling Express Scripts.

Benefit Description	HSA Plans		PPO Plans
	Network	Non-Network	Network	Non-Network
Prescription Out-of-Pocket Maximum	HSA Plans Combined with Medical		PPO Plans Network $4,150/individual $8,300/family	PPO Plans Non-Network No Maximum
Prescription Drugs Reduced costs for certain drugs and supplies.	HSA Plans Diabetes Support Services Diabetic drugs - 50% of the applicable coinsurance after deductible is met. Diabetic supplies - preferred glucometer (one per year) and prescribed preferred test strips and lancets covered at 100% when received through a network pharmacy. Preventive Drugs MCHCP Pays 100% at network pharmacies.		PPO Plans Diabetes Support Services Diabetic drugs - 50% of the applicable generic, preferred or non-preferred copayment. Diabetic supplies - preferred glucometer (one per year) and prescribed preferred test strips and lancets covered at 100% when received through a network pharmacy. Preventive Drugs MCHCP Pays 100% at network pharmacies.
Specialty (Up to a 31-day Supply)	HSA Plans Applicable generic, preferred or non-preferred drug coinsurance applies after deductible is met. Specialty drugs must be filled through Accredo specialty pharmacy.		PPO Plans $100 for up to a 31-day supply. Specialty drugs must be filled through Accredo specialty pharmacy.

Plan	Type	Retail Network one-month (31-day supply)	Retail Network two-month (60-day supply)	Retail Network three-month (90-day supply)	Home Delivery three-month (90-day supply)	Retail Non-Network one-month (31-day supply)
HSA Plan Coinsurance - after deductible is met	Generic	Retail Network one-month (31-day supply) 10% up to $50	Retail Network two-month (60-day supply) 10% up to $100	Retail Network three-month (90-day supply) 10% up to $150	Home Delivery three-month (90-day supply) 10% up to $150	Retail Non-Network one-month (31-day supply) 40%
	Preferred	Retail Network one-month (31-day supply) 20% up to $100	Retail Network two-month (60-day supply) 20% up to $200	Retail Network three-month (90-day supply) 20% up to $300	Home Delivery three-month (90-day supply) 20% up to $300	Retail Non-Network one-month (31-day supply) 40%
	Non-Preferred	Retail Network one-month (31-day supply) 40% up to $200	Retail Network two-month (60-day supply) 40% up to $400	Retail Network three-month (90-day supply) 40% up to $600	Home Delivery three-month (90-day supply) 40% up to $600	Retail Non-Network one-month (31-day supply) 50%
PPO Plans Copayment	Generic	Retail Network one-month (31-day supply) $15	Retail Network two-month (60-day supply) $30	Retail Network three-month (90-day supply) $45	Home Delivery three-month (90-day supply) $37.50	Retail Non-Network one-month (31-day supply)
	Preferred	Retail Network one-month (31-day supply) $50	Retail Network two-month (60-day supply) $100	Retail Network three-month (90-day supply) $250	Home Delivery three-month (90-day supply) $125	Retail Non-Network one-month (31-day supply)
	Non-Preferred	Retail Network one-month (31-day supply) $120	Retail Network two-month (60-day supply) $240	Retail Network three-month (90-day supply) $360	Home Delivery three-month (90-day supply) $300	Retail Non-Network one-month (31-day supply)

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