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State of North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan

Benefits Changes for 2009-20101

This Benefit Summary is only intended to highlight your North Carolina State Health Plan benefit plan options. A complete list of benefits and what is not covered are in the benefit booklets. You may review the benefit booklets at www.shpnc.org or request a benefit booklet from your Health Benefit Representative.

   Basic Plan (70/30)  Standard Plan (80/20)
Plan Design Feature In-Network Out-of-Network In-Network Out-of-Network
Benefit Year Deductible $800 Individual
$2,400 Family		 $1,600 Individual
$4,800 Family		 $600 Individual
$1,800 Family		 $1,200 Individual
$3,600 Family
Coinsurance Maximum
(does not include deductible)		 $3,250 Individual
$9,750 Family		 $6,500 Individual
$19,500 Family		 $2,750 Individual
$8,250 Family		 $5,500 Individual
$16,500 Family
Primary Care $30 copayment 50% coinsurance after deductible $25 copayment 40% coinsurance after deductible
Specialist $70 copayment 50% coinsurance after deductible $60 copayment 40% coinsurance after deductible
Urgent Care $75 copayment Same as in-network benefit $75 copayment Same as in-network benefit
Inpatient Copay $250 copayment $250 copayment $200 copayment $200 copayment
SHORT TERM THERAPIES
Physical / Occupational / Speech 		$55 copayment
50% coinsurance after deductible $45 copayment
 40% coinsurance after deductible
Chiropractic $55 copayment 50% coinsurance $45 copayment
 40% coinsurance after deductible
Routine Eye Exam2 $30 copayment Not covered $25 copayment Not covered
Office Services
MENTAL HEALTH/ CHEMICAL DEPENDENCY 		$55 copayment 50% coinsurance
 $45 copayment 40% coinsurance
 Generic Rx Copay                     $10                     $10
Brand Rx Copay
(No Generic Equivalent) 		                    $35                     $35
Preferred Rx Copay
(Generic Equivalent)		 This copay tier has been eliminated. Member will be required to pay the difference between the Plan's actual cost of the brand name drug and the amount the Plan would have paid for the generic equivalent in addition to the generic copay.
 This copay tier has been eliminated. Member will be required to pay the difference between the Plan's actual cost of the brand name drug and the amount the Plan would have paid for the generic equivalent in addition to the generic copay.
Non-Preferred Rx Copay                        $55                      $55
Specialty Rx3 Copay 25% coinsurance up to $100 for each 30 day supply           25% coinsurance up to $100 for each 30 day supply         
Diabetic Supplies $10 for preferred brand
$25 for non-preferred brand		 $10 for preferred brand
$25 for non-preferred brand
  1. All benefits are subject to medical necessity; amounts shown reflect what the memeber pays.
  2. Routine eye exams as of January 1, 2010 will no longer be covered. Check with your HBR about your benefit options for vision.
  3. All non-acute specialty drugs, excluding cancer medications must be obtained through the Accredo specialty pharmacy.

 

Please visit the State Health Plan website at http://shpnc.org or contact:
Customer Service at 1-888-234-2416 for a plan booklet