Base PPO Plan (70/30) for Non-Medicare Retirees Base PPO Plan (70/30) Overview The Base PPO Plan (70/30) 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 and lower out-of-pocket costs (copay only for most in-network office visits) 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) 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 2022 by visiting a CPP provider! Base PPO Plan (70/30) Important Documents 2022 70/30 PPO Benefits Booklet 2022 Plan Comparison Chart 2022 Uniform Summary of Coverage 2022 Preventive Services Summary 2022 Comprehensive Formulary Drug List 2022 Preferred Drug List 2022 Preventive Medications List Base PPO Plan (70/30) Rate Sheets 70/30 PPO Plan for Non-Medicare Subscribers 70/30 PPO Plan for 50% Contributory Non-Medicare Primary Subscribers 70/30 PPO Plan for 100% Contributory Non-Medicare Primary 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.