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2005
Physician Benefits
Refer
to the 2005 NALC Health Benefit
Plan brochure (RI 71-009) for complete details.
The NALC Health Benefit
Plan offers comprehensive coverage for your medical needs whether
you need diagnostic and treatment services, maternity care, or well-child
care. You can see a provider that is in our network or one that
is not, but by choosing physicians and facilities that are in our
network of preferred providers, you'll save money and avoid having
to file claims.
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Medical/Maternity
Physician Benefits
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Benefit
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You
pay at
PPO Provider
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You
pay at
Non-PPO Provider
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Surgical treatment
Maternity (delivery)
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- 10% of negotiated
rate (1)
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- 30% of Plan
Allowance, and the difference, if any, between our payment
and the billed amount (2)
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| Diagnostic
and treatment services |
- $20 copayment
per office visit;
- Other nonsurgical
services, 15% of negotiated rate (1)
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- 30% of Plan
Allowance, and the difference, if any, between our payment
and the billed amount (2)
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Accidental
Injury
(nonsurgical care) |
- Within 72 hours:
Nothing (no deductible)
After 72 hours: 15% of negotiated rate (1)
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- Within 72 hours:
Nothing except the difference, if any, between our payment
and the billed amount 6(no deductible).
After 72 hours: 30% of Plan Allowance, and the difference,
if any, between our payment and the billed amount (2)
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| Well
child care (up to age 3) and immunizations (up to age 22) |
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- The difference,
if any, between our payment and the billed amount (no deductible)
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| Medical
emergency treatment (nonsurgical) |
- 15% of negotiated
rate (1)
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- 30% of Plan
Allowance, and the difference, if any, between our payment
and the billed amount (2)
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(1) Subject to the
$250 PPO calendar year deductible.
(2) Subject to the $300 Non-PPO calendar year deductible. |
The First Health PPO
Network
More than 472,000 outpatient
care providers are in the network, so most members can take advantage
of the PPO savings. Finding a PPO provider is easy: call the PPO
Locator at 1-800-622-6252. Tell the representative the type of provider
you are looking for, and the representative will help you find a
provider near your home or work, wherever is convenient for you!
PPO providers offer you
services at negotiated rates that generally are less than the cost
would be if the provider were not in our network. You are not responsible
for charges above the negotiated amount.
To receive the greatest
benefit, use a PPO provider whenever you can. When no PPO provider
is available, non-PPO benefits apply. For instance, when you use
a PPO hospital, some of the professionals you see, such as the radiologist
and anesthetist, may not be preferred providers. If they are not,
they will be paid as non-PPO providers.
United Behavioral Health
(UBH)
Our network provider
for mental health and substance abuse benefits is United Behavioral
Health (UBH). The network has 60,000 professionals—specialists
recognized for their clinical specialty and quality rating to ensure
that each patient receives the most skilled clinician possible.
To receive the maximum
benefit, you must follow a treatment plan authorized by UBH. Call
1-877-468-1016 to locate network clinicians and to receive authorization
to see a provider. An Intake Counselor will assess your needs and
refer you to an appropriate hospital or practitioner. A Care Manager
will evaluate the practitioner's clinical assessment and the recommended
treatment plan, and will certify the appropriate care.
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