My Pharmacy Benefits

Additional Information on PPO Plans

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. For behavioral health and prescription policies see the list below. All other medical policies can be found here on the Blue Cross Blue Shield website*. Please check both areas for more information.

Behavioral Health Policies

Medical Policy Name Policy Number
IN0560
IN0300
AD0420
IN0450
AD0430
ME0650
ME0495
IN0550
AH0725
IN0510
IN0520

* If any of the State Health Plan medical policies conflict with the Blue Cross and Blue Shield of North Carolina medical policies, the State Health Plan medical policies will prevail.

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