High Option Plan

Benefits at a Glance

2019 Physician Benefits

Refer to the 2019 NALC Health Benefit Plan brochure (RI 71-009) for complete details.

The NALC Health Benefit Plan offers comprehensive coverage for your medical needs whether you need diagnostic and treatment services, maternity care, or well-child care. You can see a provider that is in our network or one that is not, but by choosing physicians and facilities that are in our network of preferred providers, you'll save money and avoid having to file claims.

 

Benefit

You pay at
PPO Provider
You pay at
Non-PPO Provider
Office, outpatient consultation or visits $20 copayment per office visit 30% after $300 deductible*
X-rays, other diagnostic services 15% after $300 deductible 30% after $300 deductible*

Laboratory Services

LabCorp

Quest Diagnostics

Other lab facility

 

Nothing

Nothing


15% after $300 deductible

 

30% after $300 deductible*

Maternity Care (complete) Nothing

30% after $300 deductible*

Accidental Injury (nonsurgical care, simple laceration repair and immobilization of a sprain, strain, or fracture)

Nothing within 72 hours

Any amount over the Plan allowance within 72 hours
Accidental Dental Injury (outpatient care) 15% when treatment incurred within 72 hours of an accidental injury 30% after $300 deductible when treatment incurred within 72 hours of an accidental injury*
Surgery 15%
30% after $300 deductible*

Mental Health and Substance Abuse Care

Office visit

Other diagnostic services

 


$20 copayment

15% after $300 deductible

 


30% after $300 deductible*

Preventive Care

Annual Routine Physical Exam (age 3 or older)

Well Child Care (through age 2)

Routine immunizations (up to age 21)

Adult routine immunizations



Nothing




Nothing


Nothing


Nothing



30% after $300 deductible*



30% after $300 deductible*

30% after $300 deductible*

30% after $300 deductible*

*In addition, you are responsible for the difference, if any, between the Plan allowance and the billed amount.


Cigna HealthCare Shared Administration OAP Network

You have access to more PPO providers and improved discounts, which means less out-of-pocket for you. The NALC Health Benefit Plan offers our members a nationwide PPO provider network with greater discounts through our partnership with the Cigna HealthCare Shared Administration OAP Network. Your identification card displays the Cigna HealthCare Shared Administration OAP Network logo that allows you to receive network discounts.

Cigna HealthCare OAP Network provides you with over 9,157 hospitals and 21,079 facilities and 2,996,285 specialists and primary care physicians nationwide.

OptumHealth(R) Behavioral Solutions

Our network provider for mental health and substance abuse benefits is OptumHealthSM Behavioral Solutions. The network has over 5,300 facilities and 167,000 professionals—specialists recognized for their clinical specialty and quality rating to ensure that each patient receives the most skilled clinician possible.


To receive the maximum benefit for some outpatient services, you must follow a treatment plan authorized by OptumHealthSM Behavioral Solutions. Call 877-468-1016 to locate in-network clinicians and to receive authorization to see a provider. An Intake Counselor will assess your needs and refer you to an appropriate hospital or practitioner. A Care Manager will evaluate the practitioner's clinical assessment and the recommended treatment plan, and will certify the appropriate care.

2019 Hospital Benefits

Refer to the 2019 NALC Health Benefit Plan brochure (RI 71-009) for complete details.

Precertify Your Admission:

You, your representative, your physician or your hospital must call us before you are admitted to the hospital. If you have an emergency admission, you must precertify within 2 days of the admission. Call us at 877-220-6252, unless the admission is related to a mental health or substance abuse condition. In that case, call 877-468-1016. We will reduce benefits if the hospital stay is not precertified.

You do not need to precertify when you are admitted to a hospital outside of the United States or when another group health insurance, such as Medicare Part A, is the primary payor for the hospital stay. If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, you need to precertify by calling 877-220-6252.

More information about the precertification process, follow the benefit chart below. For a complete explanation of Physician Benefits or the precertification process, please view our official brochure.

Benefit
You pay at
PPO Provider
You pay at
Non-PPO Provider
Inpatient Hospital Care (precertification required)
Maternity Nothing

30% after $350 per admission copay*

Medical/Surgery

Room and Board
Other Services and Supplies

 

$200 copayment per admission

 

30% after $350 per admission copay*

Mental Health/Substance Abuse

Room & Board Other Services and Supplies

 


$200 copayment per admission

 


30% after $350 per admission copay*

Outpatient Hospital Care
Medical 15% after $300 deductible 35% after $300 deductible*
Emergency Medical 15% after $300 deductible 15% after $300 deductible*
Observation Room $200 copayment 35% after $300 deductible*
*In addition, you are responsible for the difference, if any, between the Plan allowance and the billed amount.


You have access to more PPO providers and improved discounts, which means less out-of-pocket for you. The NALC Health Benefit Plan offers our members a nationwide PPO provider network with greater discounts through our partnership with the Cigna HealthCare Shared Administration OAP Network. Your identification card displays the Cigna HealthCare Shared Administration OAP Network logo that allows you to receive network discounts.

Cigna HealthCare OAP Network provides you with over 9,157 hospitals and 21,079 facilities and 2,996,285 specialists and primary care physicians nationwide.