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).
Coordination of Benefits with Medicare (PDF)
2023 NALC Health Benefit Plan brochure
2022 NALC Health Benefit Plan brochure
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 |
20% after deductible is met |
50% after deductible is met* |
Mental Health/Substance Abuse Room & Board Other Services and Supplies |
|
|
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* |
Telehealth professional services for minor acute conditions |
10% after deductible is met |
All charges |
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 |
||
Office visit |
20% after deductible is met |
50% after deductible is met* |
Outpatient telemental or virtual visits |
10% 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 |
Network |
Non-Network |
Retail Pharmacy |
1st and 2nd fill: 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 |
Mail Order Program |
90-day supply: $20 generic/$90 Formulary brand/$125 Non-Formulary brand (after deductible is met) |
|
Specialty drugs (requires prior approval) |
|
|
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 Out-of-Network providers/facilities out-of-pocket maximum: Per person: $12,000 |
|
*In addition, you are responsible for the difference, if any, between the Plan allowance and the billed amount. |
Coordination of Benefits with Medicare (PDF)
2023 NALC Health Benefit Plan brochure