High Option Plan

Plan Brochure

The Official NALC Health Benefit Plan brochure (RI 71-009)

Certain deductibles, copayments and coinsurance amounts do not apply if Medicare is your primary coverage for medical services (pays first).

Coordination of Benefits with Medicare

Prescription Drug Benefit (PDF)

2019 NALC Health Benefit Plan brochure

2018 NALC Health Benefit Plan brochure

The Summary of Benefits and Coverage (High Option SBC)

BENEFIT DESCRIPTION

YOU PAY

PPO

Non-PPO

Preventive Care

Annual Routine Physical Exam (age 3 or older)

Nothing

30% after $300 deductible*

Adult Routine Immunizations & Tests

Nothing

30% after $300 deductible*

Well Child Care (through age 2)

Nothing

30% after $300 deductible*

Routine Immunizations (through age 21)

Nothing

30% after $300 deductible*

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/surgical

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 dedctible*

Chiropractic Care

Initial office visit / Office visit on day of manipulation

$20 coapyment per visit

30% after $300 deductible*

Manipulations (24 per calendar year)

15% after $300 deductible

30% after $300 deductible*

One set of spinal x-rays annually

15% after $300 deductible

30% after $300 deductible*

Physician Care

Office visits

$20 copayment

30% after $300 deductible*

X-rays, other diagnostic services

15% after $300 deductible

30% after $300 deductible*

Laboratory Services

 

 

   LabCorp or Quest Diagnostics

Nothing

 

   Other lab facility 15% after $300 deductible 30% after $300 deductible*

Maternity Care (complete)

Nothing

30% after $300 deductible*

Accidental Injury

Nothing within 72 hours

Any amount over the Plan allowance within 72 hours

Surgery

15%

30% after $300 deductible*

Mental Health and Substance
Abuse Care:

   Office visit

$20 copayment per visit

30% after $300 deductible*

   Other diagnostic services

15% after $300 deductible

30% after $300 deductible*

   LabCorp or Quest Diagnostics

Nothing

 

   Other lab facility

15% after $300 deductible

30% after $300 deductible*

Dental

   

Accidental dental injury (to a sound natural tooth)

15% within 72 hours 30% after $300 deductible within 72 hours*

 

Prescription Drugs
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a brand name.Certain drugs require prior approval.

Network

Non-Network

Retail Pharmacy

There is a 30-day plus one refill limit at local retail.

1st and 2nd fill:
20% of generic cost 
(10% of cost for asthma, diabetes, & hypertension)
30% of Formulary brand cost
45% of Non-Formulary brand cost

Note: You may purchase up to a 90-day supply (84-day minimum) of covered drugs and supplies at a CVS/Caremark Pharmacy or Longs Drugs through our Maintenance Choice Program. You will pay the applicable mail order copayment for each prescription purchased.

Full cost at time of purchase - 45%*

Mail Order Program

60-day supply: $8 generic / $43 Formulary brand / $58 Non-Formulary brand
90-day supply: $ 5 NALC Select generic / $7.99 NALCPreferred generic / $12 generic / $65 Formulary brand / $80 Non-Formulary brand ($8 generic / $50 Formulary brand / $70 Non-formulary brand for asthma, diabetes & hypertension)

Specialty drugs (requires prior approval)

We use the NALC's Advanced Control Specialty formulary

Caremark Specialty Pharmacy Mail Order:
  • 30-day supply: $150
  • 60-day supply: $250
  • 90-day supply: $350

Catastrophic Limits

Medical/Surgical/Mental health and substance abuse care

You pay nothing after coinsurance expenses total:

  • $3,500 per person or $5,000 family for services of PPO providers/facilities.
  • $7,000 per person or family for services of PPO/Non-PPO providers/facilities combined

Prescription

After coinsurance amounts for prescription drugs purchased at a network retail pharmacy and mail order copayment amounts total $3,100 per person or $4,000 family, network retail coinsurance amounts and specialty drug mail order copayment amounts are waived for the remainder of the calendar year.

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

This is a summary of some of the features of the NALC Health Benefit Plan High Option.  Detailed information on the benefits for the 2019 NALC Health Benefit Plan can be found in the official brochure (RI 71-009). All benefits are subject to the definitions, limitations, and exclusions set forth in the official brochure.

Coordination of Benefits with Medicare

Prescription Drug Benefit (PDF)

2019 NALC Health Benefit Plan brochure

2018 NALC Health Benefit Plan brochure

The Summary of Benefits and Coverage (High Option SBC)