2010 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 2010 NALC Health Benefit Plan brochure (RI 71-009) for complete details. 2009 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	30% 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	30% after $300 deductible
Inpatient Hospital Care (precertification required)
Maternity	Nothing	30% after $300 per admission copay
Medical/Surgery Room and Board Other Services and Supplies	$200 copayment per admission	30% after $300 per admission copay
Mental Health/Substance Abuse Room & Board Other Services and Supplies	$200 copayment per admission	30% after $300 per admission copay
Outpatient Hospital Care
Medical	15% after $300 deductible	30% after $300 deductible
Emergency (auto accident, acute myocardial infarction & concussion)	15% after $300 deductible	15% after $300 deductible
Chiropractic Care
Initial office visit	$15 copayment	30% after $300 deductible
Initial set of spinal x-rays	15% after $300 deductible	30% after $300 deductible
Spinal manipulations (12 per calendar year)	15% after $300 deductible	30% after $300 deductible
Physician Care
Office visits	$15 copayment per office visit	30% after $300 deductible
X-rays, other diagnostic services	15% after $300 deductible	30% after $300 deductible
Laboratory Services Lab Corp or Quest Diagnostics Other lab facility	Nothing 15% after $300 deductible	30% after $300 deductible
Maternity Care (complete)	Nothing	30% 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)	15% when treatment incurred within 72 hours of an accidental injury	30% after $300 deductible
Surgery	15%	30% after $300 deductible
Mental Health and Substance Abuse Care Office visit Other diagnostic services	$15 copayment 15% after $300 deductible	30% after $300 deductible

Prescription Drugs This is a mandatory generic program	Network	Non-Network
Retail Pharmacy	1st and 2nd fill Generic: 20% of cost Brand name: 30% 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 45% No deductible
Mail Order Program	60-day supply: $8 generic/$43 brand name 90-day supply: $5 NALCSelect generic 90-day supply: $12 generic/$65 brand name
Specialty drugs	Caremark Specialty Pharmacy Mail Order $150 for up to a 30-day supply $350 for greater
Catastrophic Limits
Medical/Surgical	You pay nothing after coinsurance expenses total: $5,000 per person or family for services of PPO/providers/facilities. $7,000 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: $5,000 per person or family for services of network mental health and substance abuse providers/facilities. $7,000 per person for services of out-of-network mental health and substance abuse providers/facilities.
Coinsurance notices for prescription drugs dispensed by an NALC CareSelect Network Pharmacy count toward a $4,000 annual retail prescription out-of-pocket maximum.