Value 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).

***2019 Benefits are now available.***

Coordination of Benefits with Medicare (PDF)

Prescription Drug Benefit (PDF)

2018 NALC Health Benefit Plan brochure (PDF)

2017 NALC Health Benefit Plan brochure (PDF)

The CDHP Summary of Benefits and Coverage (SBC)

The Value Option Summary of Benefits and Coverage (SBC)


BENEFIT DESCRIPTION

YOU PAY

In-Network

Out-of-Network

Preventive Care

Annual Routine Physical Exam (age 3 or older)

Nothing

50% after deductible is met*

Adult Routine Immunizations & Tests

Nothing

50% after deductible is met*

Well Child Care (through age 2)

Nothing

50% after deductible is met*

Routine Immunizations (through age 21)

Nothing

50% after deductible is met*

Inpatient Hospital Care (precertification required)

Maternity

20% after deductible is met

50% after deductible is met*

Medical/Surgery

Room and Board 
Other Services and Supplies

 

20% after deductible is met

 

50% after deductible is met*

Mental Health/Substance Abuse

Room & Board Other Services and Supplies

 


20% after deductible is met

 


50% after deductible is met*

Outpatient Hospital Care

Medical/surgical

20% after deductible is met

50% after deductible is met*

Emergency Medical

20% after deductible is met

20% after deductible is met*

Chiropractic Care

Initial office visit and 12 office visits per calendar year when rendered on the same day as covered manipulations

20% after deductible is met

50% after deductible is met*

Manipulations (12 per calendar year)

20% after deductible is met

50% after deductible is met*

Physician Care

Office visits

20% after deductible is met

50% after deductible is met*

X-rays, other diagnostic services

20% after deductible is met

50% after deductible is met*

Laboratory Services

 20% after deductible is met

 50% after deductible is met*

Maternity Care (complete)

20% after deductible is met

50% after deductible is met*

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

20% after deductible is met

50% after deductible is met*

Surgery

20% after deductible is met

50% after deductible is met*

Mental Health and Substance 
Abuse Care:

   Office visit

20% after deductible is met

50% after deductible is met*

   Other diagnostic services

20% after deductible is met

50% after deductible is met*

   Laboratory Services

20% after deductible is met

 50% after deductible is met*

 

Prescription Drugs
This is a mandatory generic program

Network

Non-Network

Retail Pharmacy

1st and 2nd fill:
$10 of generic cost (after deductible is met)
$40 of Formulary brand cost (after deductible is met)
$60 of Non-Formulary brand cost (after deductible is met)

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
50% after deductible is met*

Mail Order Program

90-day supply: $20 generic/$80 Formulary brand/$120 Non-Formulary brand (after deductible is met)

Specialty drugs (requires prior approval)

  • Caremark Specialty Pharmacy Mail Order:
  • 30-day supply: $200 (after deductible is met)
  • 90-day supply: $400 (after deductible is met)

Catastrophic Limits

Medical/Surgical/Mental health and substance abuse care

In-Network providers/facilities, preferred network pharmacies or mail order pharmacy out-of-pocket maximum:

Per person: $6,600
Per family: $13,200

Out-of-Network providers/facilities out-of-pocket maximum:

Per person: $12,000
Per family: $24,000 

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

Coordination of Benefits with Medicare (PDF)

Prescription Drug Benefit (PDF)

2018 NALC Health Benefit Plan brochure (PDF)

2017 NALC Health Benefit Plan brochure (PDF)

The CDHP Summary of Benefits and Coverage (SBC)

The Value Option Summary of Benefits and Coverage (SBC)