Retiree Medical & Prescription Drug

The State offers three medical plan options so that retirees can select the plan that best meets their needs as well as access providers in their geographic area. Each medical plan provides comprehensive coverage, with different levels of out-of-pocket expenses and premium contribution rates. Prescription Drug Coverage is included with medical plan enrollment. Retiree plans do not include Vision or EAP benefits or dental coverage. Deductibles and benefits for all plans are provided on a fiscal year, from July 1 through June 30.

Review the new plan year Summaries of Benefits and Coverage (SBC) – Starting July 1, 2023

FY24 PPO SBC

FY24 Traditional SBC

FY24 High Deductible Health Plan (Single Coverage) SBC

FY24 High Deductible Health Plan (Family Coverage) SBC

Benefit Highlights:

Retiree Medical Plan Comparison & Plan Contract

Feature Name	PPO In-Network	PPO Out-of-Network	Traditional	High Deductible
FY23 Plan Contracts	Retiree PPO	Retiree PPO	Retiree Traditional	Retiree HDHP
FY23 Plan Summary	Retiree PPO SBC	Retiree PPO SBC	Retiree Traditional SBC	Retiree HDHP Single SBC Retiree Family HDHP SBC
Deductible - Individual	$350	$600	$450	$2,000
Deductible - Family	$950	$1,700	$1,250	$4,000
Out-of-Pocket Limit - Individual	$3,250	$6,500	$4,300	$5,000
Out-of-Pocket Limit - Family	$6,750	$13,500	$8,600	$10,000
Plan Payment (% of allowable charges after deductible)	$20 copay / 85%	70%	80%	70%
Wellness/Preventive Care	No-copay for listed services	70%	100%	100%
Telehealth/MDLive	No copay (Covered 100% during the Federal State of Emergency)	N/A	No copay (Covered 100% during the Federal State of Emergency)	100% after deductible (Covered 100% during the Federal State of Emergency)

For details about premiums, please see Retiree Premium Rates.

Please keep in mind that deductibles and benefit payments are based on allowable charges. Details about the medical plans, exclusions and waiting periods, can be found in each medical plan document and Summary of Benefits & Coverage (SBC).

Prescription Drug Coverage

Prescription Drug Formulary

Tier	Copay
Tier 1 - Generic	$10
Tier 2 - Preferred Brand	$30
Tier 3 - Non-preferred Brand	$60
Tier 4 - Specialty	$100
Mail Order Prescriptions	90 days for 2 copays

ATTENTION HDHP MEMBERS: The costs for all prescriptions not listed on the HDHP Preventive List are subject to the HDHP deductible. Benefits will not begin until the deductible is met on the HDHP plan.

For a covered Prescription Drug dispensed by a Physician or a Licensed Pharmacist who is not a Participating Pharmacist, the Insured is responsible for paying for the Prescription Drug at the time of purchase and must submit a claim to BCI or one (1) of its designated claims processing vendors. The amount of payment for a covered Prescription Drug is the balance remaining after subtracting the Prescription Drug Copayment and/or Coinsurance from the lower of the Allowed Charge or the Usual Charge for the Prescription Drug.