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Important Forms

80/20 Plan for Active Employees
Important Forms

Below are several forms you may need in communicating with the State Health Plan about your benefits. 

Request Reimbursement

In most cases, health care providers and pharmacies will file your insurance claims for you, and you will pay only your copay out of pocket. However, providers who are not part of the State Health Plan network will ask for full payment directly from you. In those cases, if the services are normally covered by the State Health Plan, you can request that your expenses be reimbursed.

Use the appropriate form below to request reimbursement from the State Health Plan.

  • PPO Plan Medical Claim Form
    Use this form to request reimbursement for health care services, such as a visit to a doctor not in the Blue Options℠ provider network. The Plan will only reimburse you up to the allowable, usual, customary, reasonable amount. Non-participating providers may bill you for the remainder of their charges.

  • Prescription Drug Claim Form
    Use this form to request reimbursement for prescription drugs, such as those not purchased from a pharmacy contracted with the State Health Plan. Your reimbursement will be the Plan's maximum allowable amount, not the charge for the prescription drug.

Subrogation – Third Party Recovery

The State Health Plan (Plan) has the right of subrogation upon its injured members' right to recover from liable third parties. The Plan's objective is to recover medical expenditures incurred by the Plan where a third party is liable for the care.

Please note that in accordance with North Carolina General Statute (N.C.G.S.) § 135-48.37, the Plan is required to inquire about the terms of any third party recovery and disbursement to all lien holders if payment to the Plan is less than 100 percent of its lien. The Plan collects 50 percent of the total damages recovered by members after reasonable costs of collection have been subtracted from the total recovery.

Members should contact Health Management Systems Inc. (HMS), which has been contracted by the Plan to perform subrogation services, at 800-294-2757 to determine whether the Plan is claiming a right to recovery. Members or their duly authorized representatives can also email subrogation requests to

For a complete copy of N.C.G.S. § 135-48.37, which governs the Plan's right of subrogation and right of recovery, please click here.