Base PPO Plan (70/30) for Medicare Retirees
Base PPO Plan (70/30) for Medicare Retirees Overview
The Base PPO Plan (70/30) is a Preferred Provider Organization (PPO) plan administered by Aetna.
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)
For Medicare retirees, the 70/30 PPO Plan serves as secondary coverage to Medicare.
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 2025 by visiting a CPP provider!
Base PPO Plan (70/30) Important Documents
- 2025 70/30 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.
Medicare Primary Plan Rate Sheets
- Medicare Subscribers
- 50% Contributory Medicare Primary Subscribers
- 100% Contributory Medicare Primary Subscribers
- 100% Contributory Medicare Primary Subscribers (COBRA)
- 100% Contributory Medicare Primary Subscribers who are in Direct Bill & Sponsored Dependent Groups
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 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.