2012 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 2012 NALC Health Benefit Plan brochure (RI 71-009) for complete details. 2011 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	Nothing	30% after $300 deductible*
Well Child Care (through age 2)	Nothing	30% after $300 deductible*
Routine Immunizations (up to age 22)	Nothing	30% after $300 deductible*
Adult Routine Immunizations	Nothing	30% after $300 deductible*
Inpatient Hospital Care (precertification required)
Maternity	Nothing	30% after $350 per admission copay
Medical/Surgery Room and Board Other Services and Supplies	$200 copayment per admission	30% after $350 per admission copay
Mental Health/Substance Abuse Room & Board Other Services and Supplies	$200 copayment per admission	30% after $350 per admission copay
Outpatient Hospital Care
Medical	15% after $300 deductible	35% after $300 deductible*
Emergency Medical	15% after $300 deductible	15% after $300 deductible*
Chiropractic Care
Initial office visit	$20 copayment	30% after $300 deductible*
Initial set of spinal x-rays	15% after $300 deductible	30% after $300 deductible*
Spinal manipulations (20 per calendar year)	15% after $300 deductible	30% after $300 deductible*
Physician Care
Office visits	$20 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 within 72 hours
Accidental Dental Injury (outpatient care)	15% when treatment incurred within 72 hours of an accidental injury	30% after $300 deductible when treatment incurred within 72 hours of an accidental injury*
Surgery	15%	30% after $300 deductible*
Mental Health and Substance Abuse Care Office visit Other diagnostic services	$20 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: $7.99 NALCPreferred generic 90-day supply: $12 generic/$65 brand name
Specialty drugs	Caremark Specialty Pharmacy Mail Order 30-day supply: $150 60-day supply: $250 90-day supply: $350
Catastrophic Limits
Medical/Surgical/Mental health and substance abuse care	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.
You pay nothing for covered prescription drugs after coinsurance amounts for prescription drugs purchased at a network retail pharmacy and mail order copayment amounts for specialty drugs (only) total $4,000 per person or family.
*In addition, you are responsible for the difference, if any, between the Plan allowance and the billed amount.