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    November 2, 2005      
2005
Benefit Topics:
Official Brochure
Benefits At-A-Glance
Physicians
Hospital
Prescription Drugs
Catastrophic Protection
Other Benefits

 

 

2005 Benefits At-A-Glance

If you prefer, a PDF version of this summary is available.
Refer to the 2005 NALC Health Benefit Plan brochure (RI 71-009) for complete details.

Benefit Description
YOU PAY
PPO*
Non-PPO**

Inpatient hospitalization: medical/maternity (Precertification required)

 10% of Plan Allowance (no deductible) $100 copayment per admission and 30% of Plan Allowance (no deductible)
Inpatient hospitalization: mental health/substance abuse (Precertification required) Nothing (No deductible) $500 copayment per admission;
50% of Plan Allowance and all charges after 50 days (no deductible)
Outpatient hospital: surgery performed, no surgery, and medical emergency care 15% of Plan Allowance 30% of Plan Allowance
Surgical treatment/Maternity (delivery) 10% of Plan Allowance 30% of Plan Allowance
Accidental injury (nonsurgical care)

Within 72 hours: Nothing (no deductible)
After 72 hours: 15% of Plan Allowance

Within 72 hours: Nothing (no deductible)
After 72 hours: 30% of Plan Allowance
Medical physician benefits, such as, office visits, lab, x-ray and diagnostic services $20 copayment per office visit (no deductible);
15% of Plan Allowance for most nonsurgical services		 30% of Plan Allowance
Medical emergency treatment (nonsurgical) 15% of Plan Allowance 30% of Plan Allowance
Mental health and substance abuse (MHSA) physician benefits $20 copayment per office visit (no deductible);
15% of Plan Allowance		 50% of Plan Allowance for the first 30 visits and all charges after 30 visits.
Well child care (up to age 3) and immunizations (up to age 22) Nothing (no deductible) Nothing (no deductible)

*Subject to the $250 PPO/Network calendar year deductible unless otherwise noted. There is a separate $250 MHSA deductible.

**Subject to the $300 Non-PPO/out-of-network calendar year deductible unless otherwise noted. There is a separate $300 MHSA deductible.

You are responsible for the difference, if any, between our payment and the billed amount for all charges billed by a Non-PPO/out-of-network provider.

Prescription Drug Coverage
When NALC is the Primary Carrier
When you use:
You pay:
Claim Filing:

A network retail pharmacy for the 1st or 2nd fill of (up to) a 30-day supply of medication
  • 25% of cost
    (no deductible)
  • N/A

A network retail pharmacy to refill a prescription more than once

or

A non-network retail pharmacy
  • Full cost at time of purchase
  • Submit a completed claim form to receive 50% reimbursement* of the Plan allowance (after deductible is met).
The NALC Mail Order Prescription Program
  • $8 generic/$24 name brand for 60-day supply of medication (no deductible)
  • $12 generic/$35 name brand for
    90-day supply of medication (no deductible)

 
  • N/A

 

Prescription Drug Coverage
When Medicare Part B is the Primary Care
When you use:
You pay:
Claim Filing:

A network retail pharmacy for the 1st or 2nd fill of (up to) a 30-day supply of medication
  • 15% of cost*
    (no deductible)
  • N/A

A network retail pharmacy to refill a prescription more than once

or

A non-network retail pharmacy
  • Full cost at time of purchase
  • Submit a completed claim form to receive 50% reimbursement* of the Plan allowance (no deductible).
The NALC Mail Order Prescription Program
  • $7 generic/$20 name brand for 60-day supply of medication (no deductible)
  • $10 generic/$30 name brand for
    90-day supply of medication (no deductible)

 
  • N/A

*This is a mandatory generic program with a 30-day dispensing limit.

**New for 2005: Prior approval is required for certain specialty drugs including biotech drugs. Call Caremark Specialty Pharmacy Services at
1-800-237-2767 to obtain approval.