2027 Open Enrollment Information: Active Members
2027 Open Enrollment Information: Active Members
The State Health Plan (Plan) continues to offer two Preferred Provider Organization (PPO) plans for 2027.
- The Standard PPO Plan
- The Plus PPO Plan
All members will be automatically enrolled into the Standard PPO Plan during Open Enrollment, which takes place Oct. 12-30, 2026. If members want to enroll in the Plus PPO Plan or make changes to dependents, members will need to take action during Open Enrollment.
2027 Benefit Information Resources (More Coming Soon)
Important Notes About Your 2027 Benefits
- SALARY-BASED PREMIUMS only apply to the subscriber-only rate and is based on the subscriber's current salary. This amount does not include any bonus pay, longevity pay, or overtime pay and is placed in the system by your employer. Your premium will remain the same for 2027 regardless of future salary adjustments.
- Beginning Jan. 1, 2027, the State Health Plan will introduce a four-tiered provider network. Your costs will depend on the tier of the provider.
Providers will be grouped into tiers: Preferred, Access, Non-Preferred and Out-of-Network. You will pay the least when you see a Preferred Provider. - The following office visit copays are NOT IMPACTED by provider tier placement and will have the same copay as 2026: Behavioral Health, Speech, Occupational, Chiropractor, Physical Therapy and Urgent Care.
- Preferred and non-preferred insulin continues to have a $0 copay for a 30-day supply.
- Preventive services and medications remain covered at 100% – no copay or deductible – on either plan.
- If you would like to change your selected Primary Care Provider (PCP) to a Preferred Provider, you will need to wait until after Jan. 1, 2027, to make that change. If your selected PCP is already noted as a Preferred Provider, you do not need to take any action. As a reminder, PCPs can be changed anytime, and ID cards typically arrive 7-10 days after the change is made.
- The Lantern Surgical Benefit remains available to eligible members, which partners members with top-quality surgeons for more than 1,500 planned, non-emergency procedures. Members who use a Lantern provider pay $0 for the surgery—no deductible, copay, or coinsurance. Click here for more information on Lantern.
- The formulary (drug list), which determines what medications are covered and what tier they fall under, changes on a quarterly basis, so there is a possibility that you will have changes in your prescription coverage in 2027.
Pharmacy Resources (Coming Soon)
CVS Caremark is the State Health Plan’s Pharmacy Benefit Manager.
The State Health Plan utilizes a custom, closed formulary (drug list). The formulary indicates which drugs are excluded from the formulary and not covered by the Plan. All other drugs that are on the formulary are grouped into tiers. Your medication’s tier determines your portion of the drug cost.
These documents and tools include information based on the 2026 formulary and are subject to change prior to January 1, 2027.
Frequently Asked Questions
Tab/Accordion Items
- Health care costs continue to rise faster than the funding available to the Plan. Without changes, the Plan would have faced significantly higher costs that would have required a 21% premium increase and benefit reductions for all members.
- Instead of asking every member to pay more, the Plan is changing how it purchases health care. Hospitals and health systems had the opportunity to compete to become Preferred Providers by offering high-quality care at a better overall value for Plan members.
- Members can still receive care from any provider in the network, but those who choose Preferred Providers will generally pay less out of pocket .
- By focusing on value rather than simply increasing premiums across the board, the Plan can better manage rising health care costs while continuing to provide members with access to quality care.
- The tiered network impacts members on the Standard and Plus PPO plans as well as Medicare retirees on the 70/30 Plan. This does not impact members on the Humana Medicare Advantage Plans or members in the High Deductible Health Plan.
- The goal of the Preferred Provider Program was to use competition to help lower health care costs while maintaining access to high-quality care.
- In parts of the state where multiple health systems compete for patients, the Plan invited providers who have proven to have high quality care to compete to become Preferred Providers. Those providers agreed to offer the Plan a better overall value. In return, members who choose those Preferred Providers will generally pay less out of pocket.
- In some areas of the state, there is little or no competition because one health system serves most of the community. In those areas, providers have less incentive to offer additional discounts or pricing arrangements because they already care for the majority of patients in that region. As a result, many of those providers are classified as Access Providers rather than Preferred Providers.
- For example, ECU Health provides excellent care and is the primary health system for much of eastern North Carolina. Because there are few competing hospital systems in that region, the same competitive pricing opportunities that exist in other parts of the state simply aren't available in Eastern North Carolina, which is why most providers in that area of the state are Access Providers (which is the same benefit you have today).
- There will not be any other health systems added as a Preferred Provider. The State Health Plan will continue to add Independent providers when possible as Preferred.
- UNC Health, Novant Health and Iredell Health are in addition to the already existing Preferred Providers in place today. To find Preferred Providers, click here. The Find a Doctor tool will be updated in September for 2027.
- Both systems are working hard now to increase capacity on all fronts and are excited to welcome new patients in the new year.
- If you are already seeing a Preferred Provider then you don’t have to do anything.
- If you are seeing an Access provider, which is most providers, you can continue to see them at the current benefit level with a lower specialist copay.
- If you’re seeing a Non-Preferred Specialist, you will have to pay more to continue seeing that provider and may want to consider moving your care.
- For those members out of state, all out of state providers are considered in the Access tier.
- Beginning Jan. 1, 2027, if you’re seeing a Non-Preferred Provider you will have to pay more if you choose to continue seeing that provider.
- As a reminder, Behavioral Health, Therapies, and Emergency Room copays are not impacted by the tiered network, copays remain the same.
- If you are going through cancer treatments, having a transplant, pregnant, or have a child in the NICU you will not have to switch and will receive care at the Access tier level. You will be receiving information in the mail regarding that process and will need to complete a Transition of Care form.
- Members with certain complex conditions that are seeing Non-Preferred providers will be able to request an exception for the Access tier benefit. Members in this situation will be communicated to directly via mail.
- This is why there are Access Providers, these providers are available to ensure access to care and are available with the same benefit you have today and in many cases your specialist copay will be lower.
- Most providers in North Carolina are access providers.
- All out of state providers are in the Access tier.
- In-network Deductibles and OOP limits will accumulate across all tiers simultaneously. For example, if a member on the Plus Plan hits their OOP max at a preferred provider ($3,000) and then goes to an access provider, they could spend up to an additional $2,000 in the access tier to reach their access OOP max ($5,000).