My Pharmacy Benefits

Additional Information on PPO Plan Benefits

Preventive Benefits

The State Health Plan is committed to providing preventive services to help members lead healthy, happy and productive lives. Preventive care benefits include routine physicals and screening procedures, laboratory tests and immunizations.

Routine Physicals and Screening Procedures

Routine physicals are only available in-network.

The PPO plans provide coverage for one routine physical examination and related diagnostic tests per benefit period for each member age two and over. Your office visit copay will cover all preventive services when provided by an in-network provider in an office.

The following preventive care benefits are available both in– and out-of-network:

  • Gynecological exams
  • Cervical cancer screening
  • Ovarian cancer screening
  • Screening mammograms
  • Colorectal screening
  • Prostate specific antigen tests

Well-Baby and Well-Child Care

Benefits are only available in-network.

The PPO Plans provide coverage for well-baby and well-child care including periodic assessments and immunizations. Benefits are limited to six well-baby visits for members through 12 months old and three well-child visits for members 13 months up to 24 months old. Your office visit copay will cover all well-baby and well-child care when provided by an in-network provider in his or her office.

Immunizations

Benefits are only available in-network.

Coverage is provided in-network for the full series of standard immunizations recommended by the federal Centers for Disease Control and Prevention (CDC).

Routine Mammograms

Beginning at age 35, coverage is provided for one screening mammogram per female member per benefit year, along with a doctor's interpretation of the results. Screening mammograms are covered at 100%.

Routine Hearing Exam

Benefits are only available in-network.

Coverage is provided for one routine hearing exam per benefit period. The copayment amount is dependent on whether you receive care from an in-network primary care provider or an in-network specialist.

NC HealthSmart Healthy Living Services

For Wellness Services, visit the Wellness page.

For Disease and Case Management Services, visit the Disease Management page. You can also visit the Maternity page for maternity services information.

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