The State Health Plan for Teachers and State Employees Plan Comparisons

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
Plan Coinsurance	30% of eligible expenses after deductible	50% of eligible expenses after deductible and the difference between the allowed amount and the charge	20% of eligible expenses after deductible	40% of eligible expenses after deductible and the difference between the allowed amount and the charge
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
Office Visits	$30¹ copay primary care $70¹ copay specialist	50% coinsurance after deductible	$25¹ copay primary care $60¹ copay specialist	40% coinsurance after deductible
Urgent Care	$75 copayment	Same as in-network benefit	$75 copayment	Same as in-network benefit
Emergency Room	$250 copay plus 30% coinsurance after deductible	Same as in-network benefit	$200 copay plus 20% coinsurance after deductible	Same as in-network benefit
Inpatient	$250 copay plus 30% coinsurance after deductible	$250 copay then 50% coinsurance after deductible	$200 copay plus 20% coinsurance after deductible	$200 copay then 40% coinsurance after deductible
Outpatient Hospital and Ambulatory Surgical Center	30% coinsurance after deductible	50% coinsurance after deductible	20% coinsurance after deductible	40% coinsurance after deductible
Preventative Care	$30¹ copay primary care $70¹ copay specialist	Not covered²	$25¹ copay primary care $60¹ copay specialist	Not covered²
Short-Term Rehabilitative Therapies Evaluation and Management	$30 copay primary care $70 copay specialist	50% after deductible 50% after deductible	$25 copay primary care $60 copay specialist	40% after deductible 40% after deductible
Therapy Services Limited to rehabilitative physical, occupational and speech therapy (PT/OT/ST)	$55 copay	50% after deductible	$45 copay	40% after deductible
Chiropractic (Chiro)	$55¹ copay - 30 visit limit per benefit period	50% coinsurance after deductible	$45¹ copay - 30 visit limit per benefit period	40% coinsurance after deductible
Mental Health/ Substance Abuse (MH/SA) Office Services	$55¹copay	50% coinsurance	$45¹ copay	40% coinsurance
Outpatient Services	30% coinsurance after deductible	50% coinsurance after deductible	20% coinsurance after deductible	40% coinsurance after deductible
Inpatient Services	$250 copay then 30% coinsurance after deductible	$250 copay then 50% coinsurance after deductible	$200 copay then 20% coinsurance after deductible	$200 copay then 40% coinsurance after deductible
	Prior authorization is required after 26-combined in and out-of-network office visits		Prior authorization is required after 26-combined in and out-of-network office visits
Generic Rx	$10 copay for 30 day supply		$10 copay for 30 day supply
Preferred Brand Rx (No Generic Equivalent)	$35 copay for 30 day supply		$35 copay for 30 day supply
Non-Preferred Brand Rx (No Generic Equivalent)	$55 copay for 30 day supply		$55 copay for 30 day supply
	For brand name drugs with an available generic, members will be required to pay the generic copay, plus the difference between the Plan's cost of the brand name drug and the Plan's cost of the generic drug.		For brand name drugs with an available generic, members will be required to pay the generic copay, plus the difference between the Plan's cost of the brand name drug and the Plan's cost of the generic drug.
Specialty Rx³ Copay	25% coinsurance up to $100 for each 30 day supply		25% coinsurance up to $100 for each 30 day supply
Diabetic Supplies⁴	$10 for preferred brand for 30 day supply $25 for non-preferred brand for 30 day supply		$10 for preferred brand for 30 day supply $25 for non-preferred brand for 30 day supply

In-network hospital owned or operated practices may be subject to deductible and coinsurance. Please call your physician or see the Provider Directory to determine if your physician's practice is hospital owned or operated.
The following preventative care benefits are available in both in and out-of-network; gynecological exams, cervical cancer screenings, ovarian cancer screenings, screening mammograms, colorectal screening and prostate specific antigen tests.
Alll non-acute specialty drugs, excluding cancer medications, must be obtained through the Accredo specialty pharmacy.
For a single copay, insulin dependent members will receive 153 test strips and non-insulin dependent members receive 51 test strips per 30 day supply. Additional test strips needed are covered under the medical supply benefit.

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