Preferred Provider Organization (PPO)

This program is sponsored by the State Health Plan of North Carolina. The third-party administrator is Blue Cross / Blue Shield of North Carolina.

The State Health Plan's Preferred Provider Organization (PPO) plans offer freedom of choice among in-network providers, lower out-of-pocket costs and a strong emphasis on preventive health. There are two levels of PPO coverage:

• NC SmartChoice Basic
• NC SmartChoice Standard

To receive the maximum coverage under the PPO plan, you must see in-network providers. In-network provider lists are available by clicking here (select "Find a Doctor: PPO Plans"). The PPO can be used as either primary or secondary coverage.

All permanent full-time employees who work 30 or more hours per week are eligible for coverage. The University pays 100 percent of employee-only coverage in either plan. Dependent coverage is also available at group rates. Spouses and legally dependent children up to age 19 (or to age 26 if a full-time student) are eligible.

All permanent part-time employees who work 20-29 hours per week are eligible for coverage, but are not eligible for the University contribution and pay 100 percent of the cost of coverage.

Premiums: Premiums for this plan are paid through a combination of University and employee contributions as a pre-tax payroll deduction. Premiums are paid one month in advance of coverage. For example, premiums withheld in January pay for coverage for the month of February. The monthly premiums for the PPO are:

If you are paid on a monthly basis, the full monthly contribution is deducted from each paycheck. If you are paid on a biweekly basis, half of your monthly contribution is deducted from the first two paychecks of the month.

Deductibles and Co-Pays: The employee is responsible for a plan year deductible per insured. The amount of the deductible varies depending on the plan level you elect and whether you choose in- or out-of-network providers, as shown below:

Employees participating in one of the PPO plans pay a copay for in-network physician office visits and specialists. Co-payments do not count towards your deductible or co-insurance maximums.

Until your deductible is met, you are responsible for the entire amount of the allowable charges (aside from copays for physician office visits). The Plan Year runs from July 1 to June 30.

After your deductible has been met, you pay a coinsurance rate of the eligible expenses, up to the maximum out-of-pocket amount. These coinsurance rates and maximum out-of-pocket amounts vary depending on the plan level you elect, as shown below:

When you reach your maximum out-of-pocket amount, the PPO plan covers 100 percent of the remaining charges.

Prescription drug co-payments are as follows:

You must enroll within 30 days of your hire date, a qualifying family status change or during annual enrollment. You may be subject to certain waiting periods if you are a late enrollee.

PPO coverage includes:

• routine wellness exams and other physician services
• maternity care
• immunizations for prevention of contagious diseases 
• surgery, medical supplies, diagnostic and therapeutic radiological services

All claims must be filed within 18 months from the date of service.

Medical claims should be mailed to State Health Plan, c/o Blue Cross / Blue Shield , PO Box 30087, Durham, NC 27702-3025. BC/BS can be reached at 888-234-2416.

Prescription drug claims should be mailed to Medco, PO Box 14711, Lexington, KY 40512. Medco can also be reached at 800-336-5933 for details.

Appeals must be submitted within 180 days of receiving a denial or benefits decision.

If you have questions about the benefits offered through this plan, please contact your department's Benefit Specialist.

If you have questions about a claim, or have experienced problems in receiving a reimbursement, contact Blue Cross / Blue Shield at the address listed below.

Blue Cross and Blue Shield of North Carolina
Customer Services
PO Box 30085
Durham, NC 27702
Phone: 1-888-234-2416

Benefits Services in the Office of Human Resources is responsible for reviewing and revising as needed the content of this page.

The information contained in this website is not a contract and is subject to change. It should be understood that explanations in this summary cannot alter, modify or otherwise change the controlling legal documents or general statutes in any way, nor can any right accrue by reason of any inclusion or omission of any statement in this presentation. The most current information will always be found at the benefit carrier's home page. The Office of Human Resources designs these pages to be as current as possible; however, the benefit information provided herein is always subject to change.