2025 Open Enrollment Information: Individual Members
2025 Open Enrollment Information: Individual Members
Starting Jan. 1, 2025, we’re switching State Health Plan Third-Party Administrator (TPA) services from Blue Cross NC to Aetna. We look forward to enhanced benefits that Aetna will offer our members. Aetna stands ready to serve our members and is working hard to make the transition as seamless as possible.
ACTION REQUIRED! All members will be automatically enrolled in the Base PPO Plan (70/30). Members who wish to enroll in the Enhanced PPO Plan (80/20) or who wish to reduce their monthly premium in either the Enhanced PPO Plan (80/20) or the Base PPO Plan (70/30) by completing the tobacco attestation MUST TAKE ACTION during Open Enrollment, which is Sept. 30-Oct. 25, 2024.
During Open Enrollment, all members will need to RE-SELECT a Primary Care Provider (PCP) in order to continue to enjoy lower copays when visiting that provider in 2025. Members will do this during the Open Enrollment online process in eBenefits, the Plan’s enrollment system.
Important Highlights About Your 2025 Benefits
- No premium increases for the 7th year in a row with no increase in copays or deductibles!
- Same plan options [Base PPO Plan (70/30) and Enhanced PPO Plan (80/20)]
- No benefit changes
- New TPA
- New ID Card
- New expanded disease and case management programs
- New 24/7 Nurse Line
- New virtual care services through Teladoc
- New LifeMart discount program
- The formulary (drug list), which determines what medications are covered and what tier they fall under, changes on a quarterly basis, so there is a possibility that you will have changes in your prescription coverage in 2024. Please refer to your Benefit Book for full coverage details.
- Members who select a Clear Pricing Project Provider as their Primary Care Provider will continue to enjoy a $0 copay!
- Members will continue to enjoy a reduced copay when visiting a Clear Pricing Project Specialist!
- Preferred and non-preferred insulin continues to have a $0 copay for a 30-day supply!
- Preventive Services remain covered at 100% – no copay or deductible – on either plan!
2025 Rate Sheets
- 70/30 & 80/20 Plan for COBRA
- 70/30 & 80/20 Plan for Active Subscribers Who Are Medicare Primary Due to Upcoming Retirement
- 80/20 & 70/30 Plan for 12-Month RIF Subscribers
- 70/30 & 80/20 Plan for Active Subscribers Who Are Medicare Primary Due to ESRD
- 70/30 & 80/20 Plan for Active Subscribers Whose Dependent is Medicare Primary Due to ESRD
- 70/30 & 80/20 Plan for Active Subscribers Who Are Medicare Primary Due to ESRD and Have an ESRD Medicare Primary Dependent
- 70/30 & 80/20 Plan for Non-Medicare Subscribers who are in the Direct Bill & Sponsored Dependent Groups
- Medicare Primary Plans 100% Contributory Medicare Primary Subscribers who are in the Direct Bill & Sponsored Dependent Groups
- Medicare Primary Plans 100% Contributory Medicare Primary Subscribers who are in COBRA
2025 OE Resources - More Coming Soon
Tobacco Attestation Premium Credit
|
At Time of Enrollment Subscriber-Only Monthly Premium |
Enhanced PPO Plan (80/20) |
Base PPO Plan (70/30) |
|
$694.96 |
$669.96 |
|
|
*Attest to being a non-tobacco user or agree to visit a provider (by Nov. 30, 2024) for at least one cessation counseling session to earn a monthly premium credit of $60. |
-$60 |
-$60 |
|
Total Monthly Employee-Only Premium (With Credit) |
$634.96 |
$609.96 |
- Tobacco users can attend a tobacco cessation counseling session at a provider's office for FREE to receive a lower premium for 2025! You have until November 30, 2024, to take action. Please Note: The rates are for 100% Contributory Members.
- If you combine your tobacco cessation visit with another service, there may be a copay.
- After you visit a provider for your tobacco cessation session, the provider will submit a claim on your behalf. To ensure you receive credit for your visit, you should upload your office visit summary to the “Document Center” located in eBenefits, the Plan’s enrollment system. Make sure to request a copy of your visit summary during your counseling session.
Pharmacy Resources
CVS Caremark is the State Health Plan’s Pharmacy Benefit Manager.
The State Health Plan utilizes a custom, closed formulary (drug list). The formulary indicates which drugs are excluded from the formulary and not covered by the Plan. All other drugs that are on the formulary are grouped into tiers. Your medication’s tier determines your portion of the drug cost.
These documents and tools include information based on the 2024 formulary and are subject to change prior to January 1, 2025.
Forgot Password for eBenefits?
For members that log in directly to eBenefits (not through an employer portal) you can reset your password yourself and DO NOT need to call the Eligibility and Enrollment Support Center to reset your password.
If you are having issues logging into eBenefits, do not continue to attempt to log in or you will lock your account. Instead you have the option to reset your password. Simply click “Reset your account” on the log-in page, and then click “I can’t remember my password." From there, you will be prompted to a screen that will ask you to enter your username, so a passcode can be sent to the email address you have in eBenefits.