Fall Edition 2025 | Living Power Magazine
By Tom Friedman, NC State Health Plan Executive Administrator
Change is never easy—but sometimes it is necessary. That is where we found ourselves in the State Health Plan when the new administration started in January.
The Board of Trustees had multiple votes throughout the year on design changes for the Plan, with the last one being in August when premiums were finalized. Here is a look at the issues most closely associated to folks who may be reading this:
Medicare Members
Medicare-eligible members continue to have three plan options to choose from for 2026:
- Humana Medicare Advantage PPO & Prescription Drug Base Plan
- Humana Medicare Advantage PPO & Prescription Drug Enhanced Plan
- The 70/30 Plan, administered by Aetna
For the 2026 benefit year, all Medicare-eligible members will remain in the plan in which you are currently enrolled UNLESS you would like to enroll in a different plan during Open Enrollment. You need to TAKE ACTION during Open Enrollment if you want to be enrolled in a different plan or need to make any changes regarding your dependents.
Important News for Medicare Members for 2026
Humana Medicare Advantage Plans
- The Centers for Medicaid & Medicare Services (CMS) made policy changes for 2026 that impact Medicare Advantage Plans. These changes allow Humana to administer the medical and pharmacy benefits separately. Splitting the medical and pharmacy benefit is managed completely by Humana, with members not experiencing a lot of change or noticeable differences.
- Splitting the medical and pharmacy benefit allows for significant savings to the State Health Plan.
- There is one slight change to the pharmacy benefit under BOTH Humana Medicare Prescription Drug Plans in 2026. The change is required by CMS to the Pharmacy Out-of-Pocket maximum from $2,000 to $2,100
- You’ll receive two new ID cards—one for medical, one for pharmacy. These cards will arrive separately in the mail. Starting Jan. 1, 2026, provide your new medical plan ID card to your medical providers and your new prescription plan ID card to your pharmacy.
- You’ll receive two confirmations of enrollment—one for medical, one for pharmacy, and some other duplicated CMS required notices.
- There may be changes to the Humana Medicare Prescription Drug Plan formulary (drug list), so members are encouraged to review that information when it becomes available.
The 70/30 Plan Administered by Aetna
- There are INCREASES to the deductible, copays, and maximum out-of-pocket limit in this plan for 2026.
- The Clear Pricing Project is ending and will not be available for 2026; however, the Plan will continue to offer lower copays for certain Preferred Providers.
- Members will receive a new Aetna ID card in December and will need to start using that card as of Jan. 1, 2026.
- The formulary (drug list) for the 70/30 Plan is updated quarterly, so there is always a possibility that your medication could change tier levels or become a non-covered drug.
- Preferred and non-preferred insulin will continue to have a $0 copay for a 30-day supply.
Non-Medicare Members
For 2026, the Plan will continue to offer two Preferred Provider Organization (PPO) plans administered by Aetna. The Standard PPO Plan (formerly named Base PPO Plan 70/30), and the Plus PPO Plan (formerly named Enhanced PPO Plan 80/20).
All members will be automatically enrolled into the Standard PPO Plan. If members would like to enroll in the Plus PPO Plan or would like to make a change to any dependents, you will need to TAKE ACTION during Open Enrollment.
Important News for Medicare Members for 2026
- There are INCREASES to the deductible, copays, and maximum out-of-pocket limit in these plans for 2026.
- The Clear Pricing Project is ending and will not be available for 2026; however, the Plan will continue to offer lower copays for certain Preferred Providers.
- Members will receive a new Aetna ID card in December and will need to start using that card as of Jan. 1, 2026.
- The formulary (drug list) for the Standard PPO Plan and the Plus PPO Plan is updated quarterly, so there is always a possibility that your medication could change tier levels or become a non-covered drug.
- Preferred and non-preferred insulin will continue to have a $0 copay for a 30- day supply.
2026 State Health Plan Open Enrollment: Oct. 13–31, 2025
Open Enrollment is the time to evaluate your State Health Plan (Plan) coverage and make any necessary changes. The choices members make during Open Enrollment are for benefits that will be effective January 1, 2026, through December 31, 2026.
Open Enrollment Medicare Outreach Events
The State Health Plan will be offering a variety of outreach events for Medicare members to learn more about 2026 benefits. These will include in-person events, webinars, and telephone town halls! Visit the Plan’s website at SHPNC.gov to learn more!
Premiums and more information regarding Open Enrollment is located on the Plan’s website at SHPNC.gov. For assistance during Open Enrollment call the Plan’s Eligibility and Enrollment Support Center at 855-859-0966, Monday–Friday, 8 am–10 pm, Saturdays, 8 am–5 pm (ET).
Enrollment Tips
The fall is a busy time for Medicare enrollment, which means you will likely receive several solicitations in the mail, calls from insurance agents, or notice more TV commercials about different plans. Be sure to look for the State Health Plan blue apple logo to ensure that you are reading materials sent by the Plan.
BEFORE you enroll in anything other than the State Health Plan, please call the Eligibility and Enrollment Support Center for information regarding its impact to your State Health Plan coverage. Remember, you cannot be enrolled in multiple Medicare Health Plans at the same time.