High Option Plan

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

35% after $450 per admission copay*

Medical/Surgery

Room and Board
Other Services and Supplies

$350 copayment per admission

35% after $450 per admission copay*

Mental Health/Substance Abuse

Room & Board Other Services and Supplies

$350 copayment per admission

35% after $450 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

$350 copayment

35% after $300 dedctible*

Chiropractic Care

Initial office visit / Office visit on day of manipulation

$25 copayment per visit

30% after $300 deductible*

Manipulations (24 per calendar year)

$25 copayment per visit

30% after $300 deductible*

One set of spinal x-rays annually

15% after $300 deductible

30% after $300 deductible*

Physician Care

Office visits

$25 copayment per visit

30% after $300 deductible*

Telehealth virtual visit

$10 copayment per visit

30% after $300 deductible*

X-rays, other diagnostic services

15% after $300 deductible

30% after $300 deductible*

Laboratory Services

   LabCorp or Quest Diagnostics

Nothing

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

$25 copayment per visit

30% after $300 deductible*

   Telehealth virtual visit

$10 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

Dental

Accidental dental injury (to a sound natural tooth)

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
50% 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 - 50%*

Mail Order Program

60-day supply: $10 generic / $60 Formulary brand / $84 Non-Formulary brand
90-day supply: $ 5 NALC Select generic / $7.99 NALCPreferred generic / $15 generic / $90 Formulary brand / $125 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

• 30-day supply: $200
• 60-day supply: $300
• 90-day supply: $400

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.