2009 Benefits at a Glance

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

Refer to the 2009 NALC Health Benefit Plan brochure (RI 71-009) for complete details. 2008 Benefits at a Glance and Previous brochures are also available.

Benefit Description	YOU PAY
Benefit Description	PPO	Non-PPO
Preventive Care
Routine Annual Physical Exam	$15 copayment	25% after $300 deductible
Well Child Care (through age 2)	Nothing	Any amount over Plan allowance
Routine immunizations (up to age 22)	Nothing	Any amount over Plan allowance
Adult Routine Immunizations	Nothing	25% after $300 deductible
Inpatient Hospital Care (precertification required)
Maternity	Nothing	30% after $100 per admission copay
Medical/Surgery Room and Board Other Services and Supplies	$100 copayment per admission	30% after $100 per admission copay
Mental Health/Substance Abuse Room & Board Other Services and Supplies	$100 copayment per admission	50% after $500 per admission copay; all charges after 50 days
Outpatient Hospital Care
Medical	15% after $250 deductible	30% after $300 deductible
Emergency (auto accident, acute myocardial infarction & concussion)	15% after $250 deductible	15% after $250 deductible
Chiropractic Care
Initial office visit	$15 copayment	25% after $300 deductible
Initial set of spinal x-rays	10% after $250 deductible	25% after $300 deductible
Spinal manipulations (12 per calendar year)	10% after $250 deductible	25% after $300 deductible
Physician Care
Office visits	$15 copayment per office visit	25% after $300 deductible
X-rays, other diagnostic services	10% after $250 deductible	25% after $300 deductible
Laboratory Services Quest Diagnostics Other lab facility	Nothing 10% after $250 deductible	25% after $300 deductible
Maternity Care (complete)	Nothing	25% 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
Accidental Dental Injury (outpatient care)	10% when treatment incurred within 72 hours of an accidental injury	25% after $300 deductible
Surgery	10%	25% after $300 deductible
Mental Health and Substance Abuse Care Office visit Other diagnostic services	$15 copayment 10% after $250 deductible	50% after $300 deductible All charges after 30 visits

Prescription Drugs This is a mandatory generic program	Network	Non-Network
Retail Pharmacy	1st and 2nd fill 25% of cost Note: You may purchase up to a 90-day supply (84-day minimum) of covered drugs and supplies at a CVS/Caremark Pharmacy 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 $25 deductible
Mail Order Program	60-day supply: $8 generic/$24 name brand 90-day supply: $12 generic/$35 name brand
Catastrophic Limits
Medical/Surgical	You pay nothing after coinsurance expenses total: $4,000 per person or family for services of PPO/providers/facilities. $6,000 per person or family for services of PPO and non-PPO providers/facilities combined.
Mental Health and Substance Abuse	You pay nothing after coinsurance expenses total: $4,000 per person or family for services of network mental health and substance abuse providers/facilities. $8,000 per person for out-of-network mental health and substance abuse inpatient hospital treatment (to a maximum of 50 days).
Coinsurance notices for prescription drugs dispensed by an NALC CareSelect Network Pharmacy count toward a $4000 annual retail prescription out-of-pocket maximum.