80/20 PPO Plan for Non-Medicare Retirees 80/20 PPO Plan Overview The 80/20 PPO Plan is a Preferred Provider Organization (PPO) plan administered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC). A PPO plan offers: freedom of choice among in-network providers lower out-of-pocket costs (copay only for most in-network office visits) a strong emphasis on preventive health preventive services and medications covered at 100% on this plan ability to lower your copay by selecting and visiting the Primary Care Provider (PCP) listed on your ID card or another provider in the same practice (you can find instructions on updating your PCP here) Additionally, members in this plan have the ability to lower the employee-only monthly premium by completing a tobacco attestation. The State Health Plan’s Clear Pricing Project (CPP) helps members control health care costs and protects the Plan’s financial future. Learn how you can save money in 2021 by visiting a CPP provider! 80/20 PPO Plan Important Documents 2021 80/20 PPO Benefits Booklet 2021 Plan Comparison Chart 2021 Preventive Services Summary 2021 Preventive Medications List 2021 Uniform Summary of Coverage 2021 Comprehensive Formulary Drug List 2021 Preferred Drug List For more information regarding these benefits and what is covered, please call Customer Service at 888-234-2416. 80/20 PPO Plan Rate Sheets 80/20 PPO Plan for Non-Medicare Subscribers 80/20 PPO Plan for 50% Contributory Non-Medicare Subscribers 80/20 PPO Plan for 100% Contributory Non-Medicare Subscribers Members indicated as 50% or 100% contributory notes the percentage of the premium for which they are responsible. Formulary Exclusion Exception Process A formulary exclusion exception process is available for Plan members who, per their provider, have a medical necessity to remain on an excluded, or non-covered, medication. If a member is approved for the excluded drug, that drug will be placed into Tier 3 or Tier 6. Formulary Exclusion Exception Process 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. 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. Blue Connect Visit the eBenefits page to access Blue Connect. From there, you will log into eBenefits, the Plan's enrollment system, through the appropriate portal. Once you're logged into eEnroll, you will see a Blue Connect Quick Link on the left side of your screen. Blue Connect is your online resource that can help you manage costs, make more informed health decisions and reach personal health goals anytime.