Suppose a patient has a health insurance plan with a $30 copay to visit a primary care physician, a $50 copay to see a specialist, and a $10 copay for generic drugs. The patient pays these fixed. Copays for an in-network specialist on her plan are $50, which she must pay, while her insurer will cover the rest of the neurologist’s fee. Total out-of-pocket costs: $100 for the ER copay.
- A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. How it works: Your plan determines what your copay is for different types of services, and when you have one. You may have a copay before you’ve finished paying toward your deductible.
- You see the specialist and refill both of your prescriptions. Your February copayments are $60 + $25 + $45 = $130. But the endocrinologist also orders a series of tests and labs, which aren't covered by the specialist office visit copay, since they're instead counted towards your deductible. You end up paying $240 for the tests, and that counts.
The Clear Pricing Project
Learn more about how you can save money in 2021 by visiting a Clear Pricing Project Provider!
The State Health Plan’s Clear Pricing Project (CPP) was developed to secure the Plan’s financial future and to promote quality, accessible health care. The goal is to ensure that members have this valuable benefit for years to come, while bringing transparency to health care expenses and addressing the rising health costs that you and your family face every day.
This effort resulted in more than 26,000 providers partnering with the Plan for transparent and affordable health care. These provider partners are included in the North Carolina State Health Plan Network, which is made up of providers who signed up for the Plan's Clear Pricing Project, and Blue Cross NC's Blue Options network.
Starting January 1, 2021, in an effort to help members control their health costs and to support our CPP providers, members will be able to enjoy the following copay waivers and reductions in 2021.
- If you select a Clear Pricing Project provider as your Primary Care Provider listed on your ID card, your visits are free!
- If you visit a Clear Pricing Project specialist, 80/20 Plan members will pay only $40 for a CPP specialist ($80 for a non-CPP specialist), and 70/30 Plan members will pay $47 for a CPP specialist ($94 for a non-CPP specialist).
Compare the difference and check out the savings!
CLEAR PRICING PROJECT PROVIDER COPAY COMPARISON CHART | ||
Provider | 80/20 Plan | 70/30 Plan |
Primary Care Provider (PCP) | $0 for Clear Pricing Project (CPP) PCP on ID card; $10 for non-CPP PCP on ID card; $25 for any other PCP | $0 for Clear Pricing Project (CPP) PCP on ID card; $30 for non-CPP PCP on ID card; $45 for any other PCP |
Specialist | $40 for CPP Specialist; $80 for other Specialists | $47 for CPP Specialist; $94 for other Specialists |
Speech, Occupational, Chiropractor and Physical Therapy | $26 for CPP Providers; $52 for other Providers | $36 for CPP Providers; $72 for other Providers |
Specialist Copay United Healthcare
Please note the following:
- The Clear Pricing Project does not affect members on Medicare Advantage plans.
- The NC State Health Plan Network is composed of CPP providers and Blue Options providers. There is an indicator in the Find A Doctor tool that identifies CPP providers. That CPP designation DOES need to be noted in the Find a Doctor tool for the provider to be a CPP Primary Care Provider (PCP).
- Providers joined the CPP at the practice level, so members should be able to see any provider in that listed CPP practice. However, a lot of providers practice at multiple locations and different practices. If members see their CPP PCP at a NON-CPP practice, the member will not receive the $0 copay. Members are encouraged to check with their provider on their CPP status.
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Frequently Asked Questions
What is the State Health Plan’s Clear Pricing Project?What is the State Health Plan’s Clear Pricing Project?
As a State Health Plan member in 2021, you will have access to the North Carolina State Health Plan Network, which is made up of providers who signed up for the Plan’s Clear Pricing Project (CPP), and Blue Cross NC’s Blue Options network. CPP providers have agreed to get rid of secret contracts, making health care more affordable and transparent. In an effort to lower health care costs for members and to support CPP providers, the Plan will be offering significant copay reductions for members who visit a CPP provider in 2021. The CPP is applicable to members on the 70/30 Plan and 80/20 Plan.
What does this mean for Medicare-eligible members?What does this mean for Medicare-eligible members?
This does not impact members on the Medicare Advantage plans. This would only be applicable to Medicare-eligible members on the 70/30 Plan.
Specialist Copay Bcbs
What geographical area does the Clear Pricing Project cover?What geographical area does the Clear Pricing Project cover?
The CPP is only applicable to North Carolina providers, including Primary Care Provider (PCP) offices, specialist offices, participating hospitals and urgent care facilities. Outside of North Carolina, you would still have access to in-network providers in the Blue Options network.
Can I just go to any Clear Pricing Project provider to get a copay reduction?Can I just go to any Clear Pricing Project provider to get a copay reduction?
You can go to any CPP Specialist, Chiropractor, Speech or Occupational Therapist to receive a copay reduction. To qualify for the $0 CPP PCP copay, you must have selected a CPP PCP which appears on your State Health Plan ID card and then see that PCP for your office visit. You will need to select a CPP PCP during the Open Enrollment or initial enrollment process for your 2021 benefits. Here's how to select or update your Primary Care Provider!
Specialist Copay Physical Therapy
How do I get a CPP provider listed on my ID card?How do I get a CPP provider listed on my ID card?
You are able to select a CPP provider during the online Open Enrollment or initial enrollment process. You will receive a new ID card prior to January 1, 2021. If you desire a CPP provider for a dependent, make sure you enter a CPP provider for that dependent during the Open Enrollment or initial enrollment process. Beginning January 1, 2021, you will be able select a new provider any time during the year – CPP or non-CPP – by using eBenefits, the Plan’s enrollment system. Here's how to select or update your Primary Care Provider!
How can I locate a Clear Pricing Project provider?How can I locate a Clear Pricing Project provider?
There are two ways to locate a CPP Provider:
1. Find a Doctor tool
Specialist Copay For Medicare
- Visit www.shpnc.org. Click the Find a Doctor link at the top of the home page.
- Scroll down to select your health plan to access your Find a Doctor Tool.
- The Find a Doctor Tool opens. Select the plan type by clicking the Individuals, Families, & Groups button.
- Choose North Carolina State Health Plan in the drop-down box and click Submit.
- Click the Find a Doctor or Facility button.
- From there, you can search by Category or by Name.
- CPP providers will say “Clear Pricing Project Provider” next to their name. Note: You cannot specifically search for a CPP provider by that designation.
2. Clear Pricing Project Provider Search Tool
- Visit www.shpnc.org. Find the Clear Pricing Project page and click on the green CPP provider search tool box.
- Click on the box for the region in which you wish to search for providers: Mountain, Piedmont or Coastal Plains.
- A large list of providers for the selected region will appear in a table.
- You may narrow the search results by typing in the search box. The table will automatically filter your results.
What if you select a CPP provider and then find that they are not taking new patients?
You can change your provider anytime throughout the benefit year (2021), so you will be able to select another provider. You can also research a new provider by using the Find a Doctor tool or contacting the provider’s office to see if they are accepting new patients.
What if my CPP provider or specialist has multiple locations?What if my CPP provider or specialist has multiple locations?
CPP providers and specialists within a practice joined the CPP via the practice level. This means you can see any provider within that practice and still have the copay reduction. Please note that the address is very important. When selecting your provider, make sure you intend to see the provider at the address reflected for that provider. Not all practices that your provider may be affiliated with joined the CPP.
When do the CPP copay reductions start?When do the CPP copay reductions start?
Copay reductions begin January 1, 2021, the start of the new benefit year.
What does this mean for my prescriptions?What does this mean for my prescriptions?
This does not impact your pharmacy benefits with the State Health Plan.
Can multiple CPP providers be listed on my ID card?Can multiple CPP providers be listed on my ID card?
No. There can only be one provider reflected on your ID card as your PCP.
If a provider or hospital is not a part of the CPP, will that provider be considered out of network?If a provider or hospital is not a part of the CPP, will that provider be considered out of network?
No. As long as the provider is part of the Blue Options network, provider will not be considered out-of-network. You will have the normal copayment applied. For emergency situations, service at the nearest hospital would be processed at an in-network benefit.
What if my provider didn't sign on to the CPP?What if my provider didn't sign on to the CPP?
If your provider didn’t sign on to the Clear Pricing Project, they are still considered in-network for 2021, if they are currently in the Blue Options network, but the CPP copay reductions would not apply.
How does the CPP affect my out-of-pocket maximum and deductible?How does the CPP affect my out-of-pocket maximum and deductible?
Using a CPP provider will lower your out-of-pocket amount for your copayment, which is applied to your out-of-pocket maximum, but it does not impact your deductible.
Costs
Find your TRICARE costs, including copayments,enrollment fees, and payment options.
- Most costs are for calendar year 2021 unless noted separately.
- For US Family Health Plan and TRICARE Prime Remote costs, choose 'TRICARE Prime' from the pull-down menu
- Visit the Cost Terms page for definitions to help you better understand TRICARE costs.
- If you're an unremarried former spouse, for the Continued Health Care Benefit Program (CHCBP), chose 'Retired' regardless of your sponsor's status
- Looking for dental costs? Visit the TRICARE Dental Costs section.
Help With Insurance Copays
Specialist Copay Blue Cross Blue Shield
Copayments will be waived retroactively to March 18 for certain testing and office visits related to the testing. The test must be one approved, cleared, or authorized by the Food and Drug Administration to detect SARS-CoV-2 or diagnose COVID-19. If you paid any copayments for testing related to COVID-19 and the resulting office visits with a network or non- network provider, you may file a claim for reimbursement. For more information related to the coronavirus, visit the FAQ page.