Understanding the Value of Your State Health Plan Coverage
The State Health Plan offers two health plan options: The Enhanced PPO Plan (80/20) and the Base PPO Plan (70/30).
Both the Enhanced PPO Plan (80/20) and the Base PPO Plan (70/30) are administered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC) but benefits are paid by the state, not Blue Cross NC. You can seek care from providers in the NC State Health Plan Network or go out-of-network. However, if you stay in-network, your deductibles, copays and coinsurance will be lower. Both plans cover the same medical and pharmacy services. However, the member cost share varies by each plan
CVS Caremark is the Plan’s pharmacy manager. Members should note that this does NOT mean members will have to go to a CVS pharmacy location for their prescriptions.
The State Health Plan utilizes a custom, closed formulary or drug list. Under a custom, closed formulary, certain drugs are not covered. If you find that your prescription is not covered, speak to your provider about possible alternatives. There is an exception process available to providers who believe that, based on medical necessity, it is in the member’s best interest to remain on a non-covered drug.
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