Enhanced PPO Plan (80/20) for Employees
Enhanced PPO Plan (80/20) Overview
The Enhanced PPO Plan (80/20) is a Preferred Provider Organization (PPO) plan administered by Aetna. 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 by visiting a CPP provider!
Effective January 1, 2025, you will have a new member ID on your Aetna ID card. Your old ID card is no longer valid and can be discarded. Your new Aetna ID card is the gateway to your State Health Plan benefits, and you will need to show it when you visit any of your medical providers, such as doctors, specialists, hospitals, and pharmacies. Your medical providers will need to update your records to be able to file claims using your new Aetna member ID going forward. Please note that your new member ID is a 12-character ID, consisting of letters and numbers and begins with the letter ‘N’ (for example, NCHG90744201). Your previous member ID was 10 characters in length. The sample below shows the location of your new member ID on the Aetna ID card. If you have questions, please call Aetna Health Concierge at 833-690-1037 (TTY: 711), Monday through Friday, 8 AM to 5 PM ET.
Enhanced PPO Plan (80/20) Important Documents
- 2025 80/20 PPO Benefits Booklet
- 2025 Plan Comparison Chart
- 2025 Uniform Summary of Coverage
- 2025 Preventive Services Summary
- 2025 Comprehensive Formulary Drug List
- 2025 Preferred Drug List
- 2025 Preventive Medications List
For more information regarding these benefits and what is covered, please call Aetna Health Concierge at 833-690-1037.
2025 Enhanced PPO Plan (80/20) & Base PPO Plan (70/30) Rate Sheets
- Active Subscribers
- Active Subscribers Who Are Medicare Primary Due to Upcoming Retirement
- 12-Month RIF Subscribers
- Active Subscribers Who Are Medicare Primary Due to ESRD
- Active Subscribers Whose Dependent is Medicare Primary Due to ESRD
- Active Subscribers Who Are Medicare Primary Due to ESRD and Have an ESRD Medicare Primary Dependent
- Active Employees, Eligible Part-Time, Job Share and Leave of Absence Subscribers
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 Aetna website*.
If any of the State Health Plan medical policies conflict with the Aetna 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 plan. Providers are responsible for submitting the required documentation. Providers can visit the links below 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.
State Health Plan Policies
State Health Plan Policies and Procedures