The Enhanced 80/20 Plan is a Preferred Provider Organization (PPO) plan administered by Blue Cross and Blue Shield of North Carolina (BCBSNC). A PPO plan offers freedom of choice among in-network providers, lower out-of-pocket costs (copay only for most in-network office visits) and a strong emphasis on preventive health. Additionally, members in this plan have the ability to lower the employee-only monthly premium by completing wellness activities.
Affordable Care Act (ACA) Preventive Services performed by an in-network provider are covered at 100% in this plan, which means there is no charge to you.
Enhanced 80/20 Important Documents
Enhanced 80/20 Plan Rate Sheets (2017)
Members indicated as 50% or 100% contributory notes the percentage of the premium for which they are responsible.
Medical Policies
Although your Benefits Booklet provides a good overview of what services and products are available to you under the PPO plans, the medical policies provide detailed information around the circumstances under which certain services and products are and are not covered. Medical policies can be found here on the Blue Cross and Blue Shield website.* If any of the State Health Plan medical policies conflict with the Blue Cross and Blue Shield of North Carolina medical policies, the State Health Plan medical policies will prevail.
Formulary Exclusion Exception Process
Formulary Exclusion Exception Process
Formulary Exclusion Exception Provider Form
2017 Drug Cost Lookup and Pharmacy Locator Tools
CVS/caremark will be the new Pharmacy Benefit Manager effective January 1, 2017. Click below to access the Drug Cost Lookup and Pharmacy Locator Tools.
Please note: If a drug will not be covered by the State Health Plan effective January 1, 2017, the following advisory will appear under Plan Notes: “Not covered: Ask your doctor about alternatives.”
Prior Authorization
Certain services require prior review and certification before they can be covered by your health insurance plan. Click here for more information.
Appeals
If you disagree with the way a claim has been handled, you can request an appeal or grievance review. For the complete appeals process, please click here.