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 Preventive: MCHCP Pays 100% Notes: Diabetic Drugs have reduced copayments (5%/10%/20%)		PPO Plans Preventive: MCHCP Pays 100% Specialty: $100 through Accredo Notes: Diabetic Drugs have reduced copayments ($7.50/$25/$60)
Specialty (Up to a 31-day Supply)	HSA Plans --		PPO Plans $100 through Accredo

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 Coninsurance - 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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