2025 Benefit Information: Medicare Members

2025 Benefit Information: Medicare Members

Starting Jan. 1, 2025, the State Health Plan is transitioning Third-Party Administrator (TPA) services from Blue Cross NC to Aetna. While this does not affect Humana Medicare Advantage Plan members, it does impact members and dependents on the Base PPO Plan (70/30), which is currently administered by Blue Cross NC.

As a Medicare-eligible member, you will continue to have three plan options in 2025:

  • The Humana® Group Medicare Advantage (PPO) Base Plan (90/10)*
  • The Humana® Group Medicare Advantage (PPO) Enhanced Plan (90/10)*
  • The Base PPO Plan (70/30), administered by Aetna

Open Enrollment Informational Video

For the 2025 benefit year, members in the Humana Medicare Advantage Base and Enhanced plans will remain in that plan unless you took action during Open Enrollment, which was held Sept. 30-Oct. 25, 2024.

Medicare members enrolled in the Base PPO Plan (70/30) were moved to the Humana Base Plan unless they enrolled in the Base PPO Plan (70/30) during Open Enrollment.

If you have non-Medicare Primary dependents on your plan, they have different options: the Enhanced PPO Plan (80/20) and the Base PPO Plan (70/30). If they are currently enrolled in the Enhanced PPO Plan (80/20), they were moved to the Base PPO Plan (70/30) for the 2025 benefit year. Action should have been taken during Open Enrollment if your non-Medicare Primary dependents want to be enrolled in the Enhanced PPO Plan (80/20) for the 2025 benefit year.

ID CARD UPDATE: No matter what action members take during Open Enrollment, all members will receive a new State Health Plan ID card for 2025, from either Humana or Aetna, depending on the plan in which you enroll. Your current card will not work after Dec. 31, 2024.

*The Humana Group Medicare Advantage Plans have a benefit value equivalent to a 90/10 plan.

2025 Medicare Primary Monthly Rates

2025 Group Medicare Advantage Plan (90/10) Resources

2025 Humana Medicare Advantage Plans Highlights

  • Eligible subscriber premiums for the Humana Base Medicare Advantage Plans will remain the SAME; however, the dependent premiums have changed. Adding a spouse will be $37 for the Base Plan and $167 for the Enhanced Plan (for subscriber and spouse). 
  • There are NO major benefit changes with the Humana Medicare Advantage Plans. 
  • Member cost share of the Humana plan’s covered insulin products covered under Part B and Part D is no more than $35 for every one-month (up to a 30-day) supply. 
  • Pharmacy out-of-pocket maximum will be lowered from $2,500 to $2,000. 
  • Members who reach the Catastrophic Coverage Stage for prescriptions will pay nothing for covered Part D drugs. 
  • There may be changes to the Humana Medicare Advantage Plan formulary (drug list).
     

2025 Base PPO Plan (70/30) Highlights

  • Aetna will become the State Health Plan’s new Third-Party Administrator (TPA) on Jan. 1, 2025. Blue Cross NC is the Plan’s current TPA and currently administers the Base PPO Plan (70/30). 
  • Members will be able to enjoy Aetna’s broad national network which includes 99.5% of North Carolina providers including all major hospitals in North Carolina. 
  • There are NO major benefit or premium changes with the Base PPO Plan (70/30). 
  • The formulary (drug list) for the Base PPO Plan (70/30) is updated on a quarterly basis, so there is always a possibility that your medication could change tier levels or become a non-covered drug.
  • Members who select a Clear Pricing Project Provider as their Primary Care Provider will continue to enjoy a $0 copay on the Base PPO Plan (70/30).
  • Preferred and non-preferred insulin continues to have a $0 copay for a 30-day supply on the Base PPO Plan (70/30). 
  • Members needed to re-select a Primary Care Provider during Open Enrollment to continue to enjoy the lower copays when seeing that provider in 2025.

Aetna Health Concierge (Customer Service) at 833-690-1037 is open! Representatives are available Monday through Friday 8am-5pm. Representatives can assist members with finding a provider or benefit-related questions. Please note that representatives are not able to look up your current claims.

2024 Base PPO Plan (70/30) Resources

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.

CVS Caremark is the State Health Plan’s Pharmacy Benefit Manager.

These documents and tools include information based on the 2024 formulary and are subject to change prior to January 1, 2025.

Find a Doctor

Online resources to help you find a provider, including Clear Pricing Project providers.

Third-Party Administrator Transitions to Aetna

This page serves as the official State Health Plan information source for members seeking details regarding the transition from Blue Cross NC to Aetna on Jan. 1, 2025. Click here to learn more.