We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Coverage under this Plan qualifies as minimum essential coverage (MEC) and satisfies the Patient Protection and ACA's individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

Our health coverage meets the minimum value standard of 60% established by the Affordable Care Act (ACA). This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

See www.opm.gov/healthcare-insurance/healthcare/ for enrollment information as well as:

• Information on the FEHB Program and plans available to you;
• A health plan comparison tool;
• A list of agencies that participate in Employee Express;
• A link to Employee Express; and
• Information on and links to other electronic enrollment systems.

Also, your employing or retirement office can answer your questions, give you other plans' brochures and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members. Family members include your spouse, and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

Contact your employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member. 

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB Plan.

If you have a qualifying life event (QLE) – such as marriage, divorce, or the birth of a child – outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below. 

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother’s maternity stay.   

You can find additional information at www.opm.gov/healthcare-insure.

OPM implements the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that  does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children. If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

The benefits in this brochure are effective on January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2024 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2023 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage, (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from the provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment; or
• You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy).

If you are an enrollee, and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof. In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the Spouse Equity Law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM's website at www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#ur=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal job, or if you are a covered child and you turn age 26, regardless of marital status.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5 from your employing or retirement office or from www.opm.gov/healthcare-insurance/healthcare/plan-information/guides. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

You may convert to a non-FEHB individual policy if:

• Your coverage under Temporary Continuation of Coverage (TCC) or the Spouse Equity Law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
• You decided not to receive coverage under TCC or the Spouse Equity Law; or
• You are not eligible for coverage under TCC or the Spouse Equity Law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions.

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider or fill a prescription at an NALC CareSelect retail pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter. 

High Option: If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 703-729-4677 or 888-636-NALC (6252), or write to us at 20547 Waverly Court, Ashburn, VA 20149.

Consumer Driven Health Plan: If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call  us at  703-729-4677 or 888-636-NALC (6252), or write to us at 20547 Waverly Court, Ashburn, VA 20149. 

FEHB Carriers must have clauses in their in-network (participating) providers agreements.  These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount.  If an in-network provider bills you for covered services over your normal cost share (deductible, copay, coinsurance) contact your Carrier to enforce the terms of its provider contract.

Covered providers are medical practitioners who perform covered services when acting within the scope of their license or certification under applicable state law and who furnish, bill, or are paid for their healthcare services in the normal course of business. Covered services must be provided in the state in which the practitioner is licensed or certified.

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.

We list network-contracted covered providers in our network provider directory, which we update periodically, and make available on our website.

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

This plan provides Care Coordinators for complex conditions and can be reached at 844-923-0805 for assistance.

Covered facilities include:

• Birthing center:  A freestanding facility that provides comprehensive maternity care in a home-like atmosphere and is licensed or certified by the jurisdiction. 
• Freestanding ambulatory facility:  An outpatient facility accredited by the Joint Commission, Accreditation Association of Ambulatory Health Care (AAAHC), American Association for the Accreditation of Ambulatory Surgery Facilities (AAAASF), Health Facilities Accreditation Program (HFAP), or that has Medicare certification. 
• Hospice:  A facility that 1) provides care to the terminally ill; 2) is licensed or certified by the jurisdiction in which it operates; 3) is supervised by a staff of physicians (M.D. or D.O.) with at least one such physician on call 24 hours a day; 4) provides 24 hours a day nursing services under the direction of a registered nurse (R.N.) and has a full-time administrator; and 5) provides an ongoing quality assurance program. 
• Hospital: 1) An institution that is accredited as a hospital under the hospital accreditation program of the Joint Commission; or 2) any other institution licensed as a hospital, operating under the supervision of a staff of physicians with 24 hours a day registered nursing service, and is primarily engaged in providing general inpatient acute care and treatment of sick and injured persons through medical, diagnostic, and major surgical facilities.  All these services must be provided on its premises or under its control. The term “hospital” does not include a convalescent home or extended care facility, or any institution or part thereof which a) is used principally as a convalescent facility, nursing home, or facility for the aged; b) furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or c) is operated as a school or residential treatment facility (except as listed in Section 5(e). Mental Health and Substance Use Disorder—In-Network Benefits). 

• Residential Treatment Center: Residential treatment centers (RTCs) are accredited by a nationally recognized organization and licensed by the state, district, or territory to provide residential treatment for medical conditions, mental health conditions, and/or substance use. Accredited healthcare facilities (excluding hospitals, skilled nursing facilities, group homes, halfway houses, schools, and similar types of facilities) provide 24-hour residential evaluation, treatment and comprehensive specialized services relating to the individual’s medical, physical, mental health, and/or substance use therapy needs.  RTCs offer programs for persons who need short-term transitional services designed to achieve predicted outcomes focused on fostering improvement or stability in functional, physical and/or mental health, recognizing the individuality, strengths, and needs of the persons served.  Benefits are available for services performed and billed by RTCs, as described in Section 5(e). Mental Health and Substance Use Disorder Benefits.  If you have questions about treatment at an RTC, please contact Optum at 877-468-1016 (High Option) or 855-511-1893 for the CDHP.
• Skilled nursing facility (SNF):  A facility eligible for Medicare payment, or a government facility not covered by Medicare, that provides continuous non-custodial inpatient skilled nursing care by a medical staff for post-hospital patients.
• Treatment facility:   A freestanding facility accredited by the Joint Commission for treatment of substance use disorder.

Specialty care: If you have a chronic or disabling condition and

• lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan, or
• lose access to your PPO specialist because we terminate our contract with your specialist for reasons other than for cause,

you may be able to continue seeing your specialist and receiving any PPO benefits for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist, and your PPO benefits continue until the end of your postpartum care, even if it is beyond the 90 days.

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Customer Service Department immediately at 703-729-4677 or 888-636-NALC (6252) for High Option. For Consumer Driven Health Plan call 855-511-1893. If you are new to the FEHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage. 

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for other services, are detailed in this Section.  A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care or services.  In other words, a pre-service claim for benefits (1) requires precertification, preauthorization, or prior approval and (2) will result in a reduction of benefits if you do not obtain precertification, preauthorization, or prior approval.

Precertification is the process by which—prior to your inpatient hospital admission—we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. Unless we are misled by the information given to us, we won’t change our decision on medical necessity.

In most cases, your physician or hospital will take care of requesting precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician or hospital whether or not they have contacted us.

Note: To determine if your inpatient surgical procedure requires prior authorization, see Other services in this section.

We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will only pay for any covered medical services and supplies that are otherwise payable on an outpatient basis.

You do not need precertification in these cases:

• You are admitted to a hospital outside the United States with the exception of surgeries which require prior approval in this section.
• You have another group health insurance policy that is the primary payor and is covering the hospital stay with the exception of surgeries which require prior approval in this section.
• Medicare Part A is the primary payor for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payor and you do need precertification, including surgeries which require prior approval in this section.

• High Option: You, your representative, your physician, or your hospital must call us at 877-220-NALC (6252) prior to admission, unless your admission is for a Residential Treatment Center or related to a mental health and substance use disorder. In that case, call 877-468-1016.

• Consumer Driven Health Plan: You, your representative, your physician, or your hospital must call us at 855-511-1893 prior to admission.
• Provide the following information: 
  • Enrollee’s name and Member identification number; 
  • Patient’s name, birth date, and phone number; 
  • Reason for hospitalization, and proposed treatment, or surgery; 
  • Name and phone number of admitting physician; 
  • Name of hospital or facility; and 
  • Number of days requested for hospital stay.
  • We will then tell the physician and/or hospital the number of approved inpatient days and send written confirmation of our decision to you, your physician, and the hospital.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.  If you do not telephone the Plan within two business days, penalties may apply -  see What happens when you do not follow the precertification rules in this section. 

You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us within two business days for precertification of additional days for your baby.

Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

If your hospital stay—including for maternity care—needs to be extended, you, your representative, your physician, or the hospital must ask us to approve the additional days.

If no one contacts us, we will decide whether the hospital stay was medically necessary.

• If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty.
• If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will pay only for covered medical supplies and services that are otherwise payable on an outpatient basis.

If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.

When we precertified the admission, but you remained in the hospital beyond the number of days we approved, and you did not get the additional days precertified, then:

• For the part of the admission that was medically necessary, we will pay inpatient benefits, but
• For the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits.

High Option: Other non-routine services require preauthorization or prior approval. See Section 5. for additional information.

• Air Ambulance Transport not related to a medical emergency or accidental injury. Call us at 888-636-NALC (6252). 
• Anti-narcolepsy, ADD/ADHD, certain analgesics, certain opioids, 510K dermatological products and artificial saliva. Call CVS Caremark® at 800-294-5979.
• Applied Behavioral Analysis (ABA) therapy. Call Optum at 877-468-1016. 
• Compound drugs. Call CVS Caremark at 800-933-NALC (6252). 
• Durable medical equipment (DME). Call us at 888-636-NALC (6252). 
• Gender affirmation surgery. Call Cigna at 877-220-NALC (6252). 
• Gene therapy. Call us at 888-636-NALC (6252). 
• Genetic testing. Call Cotiviti at 833-801-9264. 
• Mental health and substance use disorder care. Call OptumHealth Behavorial Solutions at 877-468-1016. 
• Musculoskeletal procedures, such as orthopedic surgeries and injections. Call Cigna at 877-220-NALC (6252).
• Organ/tissue transplants and donor expenses. Call Cigna at 800-668-9682.
• Radiology/imaging outpatient services such as CT/CAT, MRI, MRA, NC, or PET scans. Call Cigna at 877-220-NALC (6252).
• Specialty drugs, including biotech, biological, biopharmaceutical, and oral chemotherapy drugs. Call CVS Specialty® at 800-237-2767. 
• Spinal surgeries performed in an inpatient or outpatient setting. Call Cigna at 877-220-NALC (6252). 
• Weight loss drugs. Call CVS Caremark at 800-294-5979. 

Consumer Driven Health Plan: Other non-routine services require preauthorization or prior approval. See Section 5. for additional information.

• Air Ambulance Transport not related to a medical emergency or accidental injury. Call Cigna at 855-511-1893.
• Anti-narcolepsy, ADD/ADHD, certain analgesics, certain opioids, 510K dermatological products and artificial saliva. Call CVS Caremark at 800-294-5979. 
• Applied Behavioral Analysis (ABA) therapy. Call Cigna at 855-511-1893.
• Compound drugs. Call CVS Caremark at 800-933-NALC (6252).
• Durable medical equipment (DME). Call Cigna at 855-511-1893. 
• Gender affirmation surgery. Call Cigna at 855-511-1893.
• Gene therapy. Call us at 888-636-NALC (6252).
• Genetic testing. Call Cigna at 855-511-1893.
• Mental health and substance use disorder care. Call Cigna Behavioral Health at 855-511-1893.
• Musculoskeletal procedures, such as orthopedic surgeries and injections. Call Cigna at 855-511-1893.
• Organ/tissue transplants and donor expenses. Call Cigna at 855-511-1893.
• Radiology/imaging outpatient services such as CT/CAT, MRI, MRA, NC, or PET scans. Call Cigna at 855-511-1893.
• Specialty drugs, including biotech, biological, biopharmaceutical, and oral chemotherapy drugs. Call CVS Specialty at 800-237-2767. 
• Spinal surgeries performed in an inpatient or outpatient setting. Call Cigna at 855-511-1893.
• Weight loss drugs. Call CVS Caremark at 800-294-5979. 

You do not need precertification, preauthorization, or prior approval if you have another group health insurance policy—including Medicare—that is your primary payor and they are covering your services.

We may deny benefits if you fail to precertify or obtain prior approval for these services.

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim.

If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medication.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

High Option: You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 888-636-NALC (6252). You may also call OPM’s FEHB 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 703-729-4677 or 888-636-NALC (6252). If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

Consumer Driven Health Plan: You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let them know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal the initial decision, or by calling us at 888-636-NALC (6252). You may also call OPM’s FEHB 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, then call us at 888-636-NALC (6252). If it is determined that your claim is an urgent care claim, we will expedite the review (if they have not yet responded to your claim).

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to contraceptive drugs or devices, call 888-636-NALC (6252).

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8. 

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to

1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or

2. Ask you or your provider for more information.

• You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.
• If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.

3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by telephone, electronic mail, facsimile, or other expeditious methods.

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services. Copayments are not the same for all services. See Section 5. Benefits.

High Option example:  When you see your PPO physician, you pay a $25 copayment per office visit, and when you are admitted to a non-PPO hospital, you pay $450 per admission.

Note:  If the billed amount (or the Plan allowance that a PPO provider agrees to accept as payment in full) is less than your copayment, you pay the lower amount.

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. The family deductible is satisfied when the combined covered expenses applied to the calendar year deductible for family members total the amounts shown. Copayments and coinsurance amounts do not count toward any deductible. When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply counts toward the deductible.

High Option:

The calendar year deductible is $300 per person and $600 per family. Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $300. Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $600. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $600.

If the billed amount (or the Plan allowance that a PPO provider agrees to accept as payment in full) is less than your copayment, or less than the remaining portion of your deductible, you pay the lower amount.

Note: If you change plans during Open Season and the effective date of your new plan is after January 1 of the next year, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

Consumer Driven Health Plan:

Your deductible is your bridge between your Personal Care Account (PCA) and your Traditional Health Coverage. After you have exhausted your PCA, you must pay your deductible before your Traditional Health Coverage begins.

The calendar year deductible is $2,000 per person and $4,000 per family for In-Network providers.  The calendar year deductible is $4,000 per person and $8,000 per family for Out-of-Network providers.  Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered In-Network expenses applied to the calendar year deductible for your enrollment reach $2,000 ($4,000 for covered Out-of-Network expenses). Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered In-Network expenses applied to the calendar year deductible for your enrollment reach $4,000 ($8,000 for covered Out-of-Network expenses). Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered In-Network expenses applied to the calendar year deductible for family members reach $4,000 ($8,000 for covered Out-of-Network expenses).

Note: Your deductible in subsequent years may be reduced by rolling over any unused portion of your Personal Care Account remaining at the end of the calendar year(s).

There is no separate deductible for mental health and substance use disorder benefits under the CDHP.

High Option: Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance does not begin until you have met your calendar year deductible.

Example: When you see a non-PPO physician, your coinsurance is 35% of our allowance for office visits.

Consumer Driven Health Plan: Coinsurance is the percentage of our allowance that you must pay for your care after you have exhausted your Personal Care Account (PCA) and met your calendar year deductible.

Example: When you see an Out-of-Network physician for an office visit, your coinsurance is 50% of our Plan allowance and any difference between our allowance and the billed amount.

If your provider routinely waives (does not require you to pay) your copayments, deductibles, or coinsurance, the provider is misstating the fee and may be violating the law. In this case, when we calculate our share, we will reduce the provider’s fee by the amount waived.

For example, if your physician ordinarily charges $100 for a service but routinely waives your 35% coinsurance, the actual charge is $65. We will pay $42.25 (65% of the actual charge of $65).

In some instances, a provider may ask you to sign a “waiver” prior to receiving care. This waiver may state that you accept responsibility for the total charge for any care that is not covered by your health plan. If you sign such a waiver, whether or not you are responsible for the total charge depends on the contracts that Cigna HealthCare and OptumHealth Behavioral Solutions have with its providers. If you are asked to sign this type of waiver, please be aware that, if benefits are denied for the services, you could be legally liable for the related expenses. If you would like more information about waivers, please contact us at 888-636-NALC (6252).

High Option: Our “Plan allowance” is the amount we use to calculate our payment for covered services. Fee-for-service plans arrive at their allowances in different ways, so their allowances vary. For more information about how we determine our Plan allowance, see the definition of Plan allowance in Section 10.

Often, the provider’s bill is more than a fee-for-service plan’s allowance. Whether or not you have to pay the difference between our allowance and the bill will depend on the provider you use.

• PPO providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered charges consists only of your copayment, deductible, and coinsurance. Here is an example about coinsurance: You see a PPO physician who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just 15% of our $100 allowance ($15). Because of the agreement, your PPO physician will not bill you for the $50 difference between our allowance and the bill.
• Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. When you use a non-PPO provider, you will pay your copayment, deductible, and coinsurance, plus any difference between our allowance and charges on the bill. Here is an example: You see a non-PPO physician who charges $150 and our allowance is again $100. Because you've met your deductible, you are responsible for your coinsurance, so you pay 35% of our $100 allowance ($35). Plus, because there is no agreement between the non-PPO physician and us, the physician can bill you for the $50 difference between our allowance and the bill.

The following table illustrates the examples of how much you have to pay out-of-pocket for services from a PPO physician vs. a non-PPO physician. The table uses our example of a service for which the physician charges $150 and our allowance is $100. The example shows the amount you pay if you have met your calendar year deductible.

EXAMPLE

PPO physician
Physician's charge: $150
Our allowance: We set it at: $100
We pay: Allowance less copay: 85% of our allowance:  $85
You owe: Coinsurance: copayment: 15% of our allowance:  $15
+Difference up to charge?: No: $0
TOTAL YOU PAY: $15

Non-PPO physician
Physician's charge: $150
Our allowance: We set it at: $100
We pay: Allowance less copay: 65% of our allowance:  $65
You owe: Coinsurance: copayment: 35% of our allowance:  $35
+Difference up to charge?: Yes: $50
TOTAL YOU PAY: $85

Consumer Driven Health Plan: In-Network providers agree to accept our Plan allowance.  If you use an In-Network provider, you never have to worry about paying the difference between the Plan allowance and the billed amount for covered services. If you have exhausted your Personal Care Account (PCA), you will be responsible for paying your deductible and also the coinsurance under the Traditional Health Coverage.

Out-of-Network providers – if you use an Out-of-network provider, you will have to pay the difference between the Plan allowance and the billed amount.  You may use your Personal Care Account for this amount.

Note: In-Network providers reduce your out-of-pocket amount.

You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

High Option: For those services subject to a deductible, coinsurance and copayment (including mental health and substance use disorder care), we pay 100% of the Plan allowance for the remainder of the calendar year after your cost-share totals:

• $3,500 per person and $5,000 per family for services of PPO providers/facilities.   
• $7,000 per person or family for services of PPO and non-PPO providers/facilities, combined.
• Coinsurance amounts for prescription drugs dispensed by an NALC CareSelect Network pharmacy and mail order copayment amounts (see Section 5(f). Prescription Drug Benefits) count toward a $3,100 per person or $4,000 family annual prescription out-of-pocket maximum excluding the following amounts:
  • The 50% coinsurance for prescriptions purchased at a non-network pharmacy or for additional fills at an NALC CareSelect pharmacy.
  • Any associated costs when you purchase medications in excess of the Plan's dispensing limitations.
  • The difference in cost between a brand name and a generic drug when you elect to purchase the brand name, and a generic drug is available, and your physician has not specified "Dispense as Written". 

Note: The following cannot be counted toward out-of-pocket expenses:

• Expenses in excess of the Plan allowance or maximum benefit limitations
• Amounts you pay for non-compliance with this Plan’s cost containment requirements

You are responsible for these amounts even after the catastrophic protection out-of-pocket maximum has been met.

Note: If you are not responsible for the balance after our payment for charges incurred at a government facility (such as a facility of the Department of Veterans Affairs), the balance cannot be counted toward out-of-pocket expenses.

Consumer Driven Health Plan: If you have exceeded your Personal Care Account and satisfied your deductible, the following should apply:

When you use In-Network providers, network retail pharmacies, or our mail order pharmacy, your out-of-pocket maximum is $6,600 per person or $12,000 per family. When you use Out-of-Network providers, your out-of-pocket maximum is $12,000 per person and $24,000 per family.

Under a Self Only enrollment, the out-of-pocket maximum is considered satisfied when your covered In-Network (including preferred network retail and mail order pharmacy) deductible, copayments and coinsurances applied to the out-of-pocket maximum for your enrollment reach $6,600 ($12,000 for covered Out-of-Network expenses). Under a Self Plus One enrollment, the out-of-pocket maximum is considered satisfied when your covered In-Network (including preferred network retail and mail order pharmacy) copayments and coinsurances applied to the out-of-pocket maximum for your enrollment reach $12,000 ($24,000 for covered Out-of-Network expenses). Under a Self and Family enrollment, the out-of-pocket maximum is considered satisfied when your covered In-Network (including preferred network retail and mail order pharmacy) copayments and coinsurances applied to the out-of-pocket maximum for your enrollment reach $12,000 ($24,000 for covered Out-of-Network expenses).

The following cannot be counted toward out-of-pocket expenses:

• Any amount in excess of our Plan allowance or maximum benefit limitations or expenses not covered under the Traditional Health Coverage
• Any amounts you pay because benefits have been reduced for non-compliance with this Plan’s cost containment requirements (see pages 18 - 25, Section 3. How you get care)

• The 50% coinsurance for prescriptions purchased at a non-network pharmacy or for additional fills at an NALC CareSelect pharmacy

• The difference in cost between a brand name and a generic drug when you elect to purchase the brand name, and a generic drug is available, and your physician has not specified "Dispense as Written" 

• Any associated costs when you purchase medications in excess of the Plan's dispensing limitations

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services. 

A surprise bill is an unexpected bill you receive for

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from surprise bills. 

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.nalchbp.org or contact the health plan at 888-636-NALC (6252).

• Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26).
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

Professional services of physicians (including specialists) or urgent care centers

• Office or outpatient visits
• Office or outpatient consultations
• Office or outpatient virtual visits 
• Second surgical opinions

PPO: $25 copayment per visit (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Telehealth professional services through NALCHBP Telehealth:

• Urgent Care for minor acute conditions (See Section 10, page (Applies to printed brochure only) for definition)
• Dermatology for chronic conditions such as acne, rosacea, or psoriasis

Note: Additional diagnostic, lab or prescription services done in conjunction with a telehealth visit will be subject to the applicable coinsurance and deductible.

Note: For more information on NALCHBP Telehealth benefits, see Section 5(h). Wellness and Other Special Features.

Note: For telemental or mental health and substance use disorder benefits, see Section 5(e). Mental Health and Substance Use Disorder Benefits.

PPO: $10 copayment per visit (No deductible)

Non-PPO: All charges

Professional services of physicians

• Hospital care
• Skilled nursing facility care
• Inpatient medical consultations
• Home visits
• Emergency room physician care (non-accidental injury)

Note: For initial examination of a newborn child covered under a family enrollment, see Preventive care, children in this section. Note: For routine post-operative surgical care, see Section 5(b). Surgical procedures.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: 

• Routine eye and hearing examinations (except as listed in Preventive care, children and Hearing services... in this section)
• Nonsurgical treatment for weight reduction or obesity (except as listed in Educational classes and programs in this section)

Tests and their interpretation, such as: 

• Blood tests
• Urinalysis
• Non-routine Pap test
• Pathology
• X-ray 
• Neurological testing
• Non-routine mammogram
• Ultrasound
• Non-routine sonogram
• Electrocardiogram (EKG)
• Electroencephalogram (EEG)
• Bone density study 
• CT/CAT Scan/MRI/MRA/NC/PET (Outpatient requires precertification - See Section 3)
• Genetic counseling
• Genetic testing - requires prior approval (See Section 3. How You Get Care)
• Urine drug testing/screening for non-cancerous chronic pain and substance use disorder is limited to:
  • 16 definitive (quantitative) drug tests per calendar year
  • 32 presumptive (qualitative) drug tests per calendar year
• Annual skin cancer screening

Note:  For definitions of definitive and presumptive drug tests, see Section 10. Definitions of Terms We Use in This Brochure

Note: Benefits are available for diagnostic genetic testing, including genetic counseling, when it is medically necessary to diagnose and/or manage a patient’s medical condition. Genetic testing requires prior authorization. See Section 3. How you get care.

Note: When tests are performed during an inpatient confinement, no deductible applies.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

If LabCorp or Quest Diagnostics performs your covered lab services, you will have no out-of-pocket expense and you will not have to file a claim. Ask your doctor to use LabCorp or Quest Diagnostics for lab processing. To find a location near you, call 877-220-NALC (6252), or visit our website at www.nalchbp.org.

Note: Covered lab tests not performed at LabCorp or Quest Diagnostics are subject to the calendar year deductible and applicable coinsurance.

• Routine examinations, limited to:
  • Routine physical exam—one annually, age 22 or older
  • Initial office visit associated with a covered routine sigmoidoscopy or colonoscopy screening test
• The following preventive services are covered at the time interval recommended at each of the links below.
  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
  • Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations 
  • A1C test—one annually, age 18 or older
  • Individual counseling on prevention and reducing health risks
  • Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
  • Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations.
  • To build your personalized list of preventive services go to  https://health.gov/myhealthfinder
• Biometric screening- one annually; including:
  • calculation of body mass index (BMI)
  • waist circumference measurement
  • total blood cholesterol
  • blood pressure check
  • fasting blood sugar
• Routine mammogram for women—age 35 and older, as follows:
  • Age 35 through 39—one during this five year period
  • Age 40 and older—one every calendar year

Note:  When the NALC Health Benefit Plan is the primary payor for medical expenses, the Plan will cover FDA-approved vaccines when administered by a pharmacy that participates in the NALC Health Benefit Plan Broad Vaccine Administration Network.  A full list of participating pharmacies is available at www.nalchbp.org or call CVS Caremark Customer Service at 800-933-NALC (6252) to locate a local participating pharmacy. Pharmacy participation may vary based on state law.  

Note: You can receive $10 in health savings rewards for having an annual flu vaccine and $10 in health savings rewards for having an annual pneumococcal vaccine. Please see Section 5(h). Wellness Incentive Programs for details.

Note: You can receive $50 in health savings rewards for having an annual biometric screening. Please see Section 5(h). Wellness Incentive Programs for details.

Note: Breast tomosynthesis (3-D mammogram) is considered a preventive care screening test as long as it is performed in conjunction with a routine screening mammography.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

PPO: Nothing (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Routine lab tests, except listed under Preventive care, adult in this section.
• Immunizations, boosters, and medications for travel or work-related exposure.
• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.

• Well-child visits, examinations, and immunizations as described in the Bright Futures Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to  https://brightfutures.aap.org.
  • Examinations, limited to: 
    • Initial examination of a newborn child covered under a family enrollment
    • Well-child care—routine examinations through age 2
    • Routine physical exam (including camp, school, and sports physicals)—one annually, age 3 through 21
    • Examinations done on the day of covered immunizations, age 3 through 21
• A1C test—one annually, age 18 or older
• Immunizations such as DTap/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
• You may also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
   
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Note: Camp, school and sports physicals are not covered when rendered at CVS MinuteClinic®.

Note: You can earn $50 in health savings rewards for completing 6 well-child visits through age 15 months as recommended above. Please see Section 5(h). Wellness and Other Special Features for details.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Note: When the NALC Health Benefit Plan is the primary payor for medical expenses, the Plan will cover FDA-approved vaccines when administered by a pharmacy that participates in the NALC Health Benefit Plan Broad Vaccine Administration Network.  A full list of participating pharmacies is available at www.nalchbp.org or call CVS Caremark Customer Service at 800-933-NALC (6252) to locate a local participating pharmacy. Pharmacy participation may vary based on state law.  

Note: You can receive $10 in health savings rewards for having an annual flu vaccine. Please see Section 5(h). Wellness Incentive Programs for details.

PPO: Nothing (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Routine hearing testing, except as listed in Preventive care, children and Hearing services... in this section
• Routine lab tests, except as listed in Preventive care, children in this section

Complete maternity (obstetrical) care, limited to:

• Prenatal and postpartum care
• Delivery
• Amniocentesis
• Anesthesia related to delivery or amniocentesis
• Group B streptococcus infection screening
• Routine sonograms 
• Fetal monitoring
• Tetanus-diphtheria, pertussis (Tdap)-one dose during each pregnancy 
• Breastfeeding support and counseling
• Rental or purchase of breastfeeding equipment

Note: We cover services related to a miscarriage or stillbirth under the Maternity care benefit.

Note: We cover up to four (4) outpatient visits at 100% to treat postpartum depression or depression during pregnancy when you use an In-Network mental health provider. See Section 5(e). Mental Health and Substance Use Disorder Benefits.

Preventive medicine counseling and screening tests as recommended by the USPSTF for pregnant women, limited to:

• Screening and counseling for prenatal and postpartum depression 
• Gestational diabetes
• Hepatitis B
• Human immunodeficiency virus (HIV)
• Iron deficiency anemia
• Lactation support and counseling for breastfeeding
• Preeclampsia screening
• Rh screening
• Syphilis
• Tobacco use counseling
• Urine culture for bacteria
• Urine testing for bacteriuria

Note:  Virtual lactation support visits are offered through NALCHBP Telehealth, see Section 5(h). Wellness and Other Special Features.

PPO: Nothing (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Other tests medically indicated for the unborn child or as part of the maternity care

Note: Here are some things to keep in mind:

• Genetic tests performed as part of a routine pregnancy require prior authorization.
• You do not need to precertify your vaginal or cesarean delivery; see Section 3. How to get approval for… for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will cover an extended stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment if we cover the infant under a Self Plus One or Self and Family enrollment.
• The circumcision charge for an infant covered under a Self Plus One or Self and Family enrollment is payable under surgical benefits. See Section 5(b). Surgical procedures.
• We pay hospitalization, anesthesia, and surgeon services for non-maternity care the same as for illness and injury.
• To reduce your out-of-pocket costs for laboratory services use LabCorp or Quest Diagnostics, see Lab, X-ray, and other diagnostic tests in this section.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).
• Non-routine sonograms are payable under diagnostic testing. See Lab, X-ray, and other diagnostic tests in this section.

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Doula services provided by a certified doula, limited to a maximum Plan payment of $500 per pregnancy. See Section 10. Definitions.

Note: Maximum payment is based on the Plan allowance, not charged amount.

PPO: Nothing up to the Plan limit and all charges after we pay $500 (No deductible)

Non-PPO: Nothing up to the Plan limit and all charges after we pay $500 (No deductible)

• Contraceptive counseling on an annual basis
• Tubal ligation or tubal occlusion/tubal blocking procedures only
• Vasectomy
• Surgical placement of implanted contraceptives
• Removal of a birth control device
• Management of side effects of birth control
• Services related to follow up of services listed above
• Office visit associated with a covered family planning service

Note: Outpatient facility charges related to tubal ligation or tubal occlusion/tubal blocking procedures only are payable under outpatient hospital benefit. See Section 5(c). Outpatient hospital. For anesthesia related to tubal ligation or tubal occlusion/tubal blocking procedures only, see Section 5(b). Anesthesia.

PPO: Nothing (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

A range of voluntary family planning services, limited to:

• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms

Note:  We cover oral contraceptives under the prescription drug benefit. 

PPO: Nothing (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: 

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling except as listed in this section.

Infertility is a disease or medical condition of the reproductive system. The Plan covers the diagnosing and treatment of infertility as well as treatment needed to conceive, including covered artificial insemination procedures. Infertility may also be established through an evaluation based on medical history and diagnostic testing.

• Diagnostic services
• Laboratory tests
• Fertility drugs
• Artificial insemination (Up to 3 cycles):
• Intravaginal insemination (IVI)
• Intracervical insemination (ICI)
• Intrauterine insemination (IUI)

You may also visit our website at www.nalchbp.org/infertility for additional information on infertility benefits. 

Note: Prescription drugs (Up to 3 cycles of IVF-related drugs) are covered for the treatment of infertility.

PPO: 15% of the Plan allowance and all charges after 3-cycle limit 

Non-PPO: 35% of the Plan allowance, any difference between our allowance and the billed amount, and all charges after 3-cycle limit

Benefits are available for fertility preservation for medical reasons that cause irreversible infertility such as chemotherapy or radiation treatment. Services include the following procedures, when provided by or under the care or supervision of a Physician:

• Cryopreservation of sperm
• Embryo cryopreservation
• Cryopreservation of reproductive tissue, testicular or ovarian
• Mature oocyte cryopreservation
• Storage costs up to one year

Note: These services are only covered while you are enrolled in the Plan.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Infertility services after voluntary sterilization
• Assisted reproductive technology (ART) procedures related to IVF or embryo transfer such as:
  • In vitro fertilization (IVF)
  • Embryo transfer and gamete intrafallopian transfer (GIFT) and zygot intrafallopian transfer (ZIFT)
• Services and supplies related to IVF or embryo transfer procedures
• Services, supplies, or drugs provided to individuals not enrolled in this Plan
• Cost of donor sperm
• Cost of donor egg
• Cryopreservation, sperm banking, or thawing procedures, except as listed above
• Preimplantation diagnosis, testing, and/or screening of eggs, sperm, or embryos
• Elective preservation for reasons other than listed above
• Long-term storage costs (greater than one year)

• Testing
• Treatment, except for allergy injections
• Allergy serum

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Allergy injections

PPO: $5 copayment each (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Provocative food testing and sublingual allergy desensitization, including drops placed under the tongue
• Environmental control units, such as air conditioners, purifiers, humidifiers, and dehumidifiers

• Gene therapy products and services directly related to their administration are covered when medically necessary. Gene therapy is a category of pharmaceutical products approved by the U.S. Food and Drug Administration (FDA) to treat or cure a disease by:
  • Replacing a disease-causing gene with a healthy copy of the gene
  • Inactivating a disease-causing gene that may not be functioning properly
  • Introducing a new or modified gene into the body to help treat a disease

Coverage includes the cost of the gene therapy product, the medical, surgical, and facility services directly related to administration of the gene therapy product, and the professional services. Gene therapy products and their administration are covered when preauthorized to be received at participating PPO facilities specifically contracted for the specific gene therapy service. When approved, the Gene Therapy Travel Program will help cover the cost of travel and lodging to a gene therapy network provider, up to $10,000 per gene therapy. Gene therapy products and their administration received at other facilities are not covered. Call 703-729-4677 for more information and for preauthorization.

PPO: 15% of the Plan allowance

Non-PPO: All charges

• Intravenous (IV)/Infusion Therapy—Home IV and antibiotic therapy 
• Respiratory and inhalation therapies
• Growth hormone therapy (GHT)
• Cardiac rehabilitation therapy - Phases I and II only
• Pulmonary rehabilitation therapy

Note: Phase I begins in the hospital after a major heart event and includes visits by the cardiac rehab team, education, and nutritional counseling, along with rehab. Phase II begins after leaving the hospital and is a comprehensive program consisting of medical evaluation, prescribed exercise, behavior modification, heart monitoring, education, and counseling, typically performed in an outpatient setting. Phases III and IV are supervised safe exercise (performed in the home or gym) and are not covered by the Plan.

Note: Specialty drugs, including biotech, biological, biopharmaceutical, and oral chemotherapy drugs, available through CVS Specialty are covered only under the Prescription Drug Benefit. Prior approval is required for all specialty drugs used to treat chronic medical conditions. See instructions for approval in Section 5(f). Prescription Drug Benefits—These are the dispensing limitations.

• Dialysis—hemodialysis and peritoneal dialysis
• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed in Section 5(b). Organ/tissue transplants.

Note: Oral chemotherapy drugs available through CVS Caremark are covered only under the Prescription Drug Benefit. Section 5(f). Prescription Drug Benefits—These are the dispensing limitations.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Applied Behavioral Analysis (ABA) therapy for children through age 18 with autism spectrum disorder rendered by a PPO provider

Note: Prior authorization is required for ABA therapy.  Call 877-468-1016 to find a covered provider and to obtain prior authorization.

PPO: 15% of the Plan allowance

Non-PPO: All charges

Not covered:

• Chelation therapy, except as treatment for acute arsenic, gold, lead, or mercury poisoning
• Prolotherapy
• ABA therapy not prior authorized

• A combined total of 75 rehabilitative and habilitative visits per calendar year for treatment provided by a licensed registered therapist or physician for the following:
  • Physical therapy
  • Occupational therapy
  • Cognitive rehabilitation therapy 
  • Speech therapy

Therapy is covered when the attending physician:

• Orders the care;
• Identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• Indicates the length of time the services are needed.

Note: There is no member cost share when you access virtual physical therapy through Hinge Health. See Section 5(h). Wellness and Other Special Features.

Note: For accidental injuries, see Section 5(d). Emergency Services/Accidents.

Note: For therapies performed on the same day as outpatient surgery, see Section 5(c). Outpatient hospital or ambulatory surgical center.

Note: Physical therapy by a chiropractor is covered when the service performed is within the scope of their license.

PPO: 15% of the Plan allowance and all charges after 75-visit limit 

Non-PPO: 35% of the Plan allowance, any difference between our allowance and the billed amount, and all charges after 75-visit limit

• Physical therapy to prevent falls for community- dwelling adults age 65 and older as recommended by the U.S. Preventive Services Task Force (USPSTF)

Therapy is covered when the attending physician:

• Orders the care;
• Identifies the specific professional skills the patient requires; and
• Indicates the length of time the services are needed. 

PPO: Nothing (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Dry needling
• Exercise programs
• Maintenance rehabilitative therapy that maintains a functional status or prevents decline in function

• For treatment (excluding hearing aids) related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants, including batteries
• Examinations related to the prescribing of hearing aids

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Hearing aid(s), limited to a maximum Plan payment of $2,500 with replacements covered every 3 years.
• Hearing aids for children through age 18, limited to a maximum Plan payment of $2,500 with replacements covered annually.

Note: Maximum payment is based on the Plan allowance, not charged amount.

PPO: Nothing up to the Plan limit and all charges after we pay $2,500 (No deductible)

Non-PPO: Nothing up to the Plan limit and all charges after we pay $2,500 (No deductible)

Not covered:

• Routine hearing testing (such as testing for routine hearing loss as a result of aging), except as listed in Preventive care, children and Hearing services... in this section
• Auditory device except as described above
• Hearing aid batteries, except as described above

• Office visit for eye examinations for covered diagnoses, such as cataract, diabetic retinopathy and glaucoma

PPO: $25 copayment per visit (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or following intraocular surgery (such as for cataracts) when purchased within one year
• Tests and their interpretations for covered diagnoses, such as:
  • Fundus photography
  • Visual field
  • Corneal pachymetry

Note: We only cover the standard intraocular lens prosthesis, such as for cataract surgery.

Note: For childhood preventive vision screenings, see Preventive care, children in this section.

Note: See Section 5(h). Wellness and Other Special Features, Healthy Rewards Program for discounts available for vision care.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Eyeglasses or contact lenses and examinations for them, except as described above
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery
• Refractions
• Polarization
• Scratch-resistant coating

• Nonsurgical routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes
• One pair of diabetic shoes every calendar year

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Surgical procedures for routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes
• Open cutting, such as the removal of bunions or bone spurs

PPO: 15% of the Plan allowance (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Cutting, trimming, or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions
  of the foot, except as stated above
• Treatment of weak, strained, or flat feet; bunions or spurs;
  and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)
• Foot orthotics (shoe inserts) except as listed under Orthopedic and prosthetic devices in this section
• Arch supports, heel pads, and heel cups
• Orthopedic and corrective shoes
• Repair to custom functional foot orthotics
• Extracorporeal shock wave treatment

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Custom-made durable braces covered every 3 years for legs, arms, neck, and back
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Internal prosthetic devices covered every 3 years, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b). Surgical procedures. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services.

Note: Internal prosthetic devices billed by the hospital are paid as hospital benefits. See Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services. 

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Wigs for hair loss due to the treatment of cancer (with a maximum Plan payment of $350 per lifetime).

PPO: 15% of the Plan allowance and all charges after we pay $350 per lifetime (No deductible)

Non-PPO: 35% of the Plan allowance and all charges after we pay $350 per lifetime (No deductible)

• Two pairs of custom functional foot orthotics, including casting, when prescribed by a physician

PPO: 15% of the Plan allowance and all charges after the 2-pair annual limit

Non-PPO: 35% of the Plan allowance and all charges after the 2-pair annual limit 

Not covered:

• Wigs (cranial prosthetics) except as listed in this section
• Orthopedic and corrective shoes
• Arch supports, heel pads and heel cups
• Foot orthotics (shoe inserts) except as listed under Orthopedic and prosthetic devices in this section
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Bionic prosthetics (including microprocessor-controlled prosthetics)

Durable medical equipment (DME) is equipment and supplies that:

1. Are prescribed by your attending physician (i.e., the physician who is treating your illness or injury);

2. Are medically necessary;

3. Are primarily and customarily used only for a medical purpose;

4. Are generally useful only to a person with an illness or injury;

5. Are designed for prolonged use; and

6. Serve a specific therapeutic purpose in the treatment of an illness or injury.

Note: Call us at 703-729-4677 or 888-636-NALC (6252) as soon as your physician prescribes equipment or supplies. The Plan requires a letter of medical necessity, or a copy of the prescription, from the prescribing physician which details the medical necessity to consider charges for the purchase or rental of DME.

We cover rental or purchase (at our option) including repair and adjustment of durable medical equipment every 3 years, such as:

• Oxygen and oxygen apparatus
• Dialysis equipment
• Continuous glucose monitors
• Insulin pumps
• Manual and semi-electric hospital beds
• Wheelchairs
• Crutches, canes, and walkers

Note: We limit the Plan allowance for our DME rental benefit to an amount no greater than what we would have considered if the equipment had been purchased.

We also cover supplies, such as:

• Insulin and diabetic supplies
• One pair of diabetic shoes every calendar year
• Needles and syringes for covered injectables
• Ostomy and catheter supplies

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Speech generating devices, limited to $1,250 per calendar year

Note:  Covered devices include digitized speech devices using pre-recorded messages and synthesized speech devices requiring multiple methods of message formulation and device access. Also included are software programs, mounting systems, and accessories.

PPO: 15% of the Plan allowance and all charges after we pay $1,250 in a calendar year

Non-PPO: 35% of the Plan allowance, any difference between our allowance and the billed amount, and all charges after we pay $1,250 in a calendar year

Not covered:

• DME replacements (including rental) provided less than 3 years after the last one we covered
• Bathroom equipment, such as whirlpool baths, grab bars, shower chairs, commode chairs, and shower commode chairs
• Sun or heat lamps, shower commode chairs, and similar household equipment
• Exercise equipment, such as treadmills, exercise bicycles, stair climbers, and free weights
• Car seats of any kind
• Functional electrical stimulation equipment
• Total electric hospital beds
• Furniture, such as adjustable mattresses and recliners, even when prescribed by a physician
• Enhanced vision systems, computer switch boards,
  or environmental control units
• Heating pads, air conditioners, purifiers, and humidifiers
• Safety and convenience equipment, such as stair climbing equipment, stair glides, ramps, and elevators
• Modifications or alterations to vehicles or households
• Equipment or devices, such as iBOT Mobility
  System that allow increased mobility, beyond what is provided by standard features of DME
• Other items that do not meet the criteria 1 thru 6 in this Section

Home nursing care for 2 hours per day up to 50 days per calendar year when:

• a registered nurse (R.N.), licensed practical nurse
  (L.P.N.), or licensed vocational nurse (L.V.N.) provides the services;
• the attending physician orders the care;
• the physician identifies the specific professional skills required by the patient and the medical necessity for skilled services; and
• the physician indicates the length of time the services are needed.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient's family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
• Private duty nursing

All charges

Limited to:

• One set of spinal X-rays annually

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Limited to:

• Initial office visit or consultation
• 24 office visits per calendar year when rendered on the same day as a covered spinal or extraspinal manipulation
• 24 spinal or extraspinal manipulations per calendar year

PPO: $25 copayment per visit (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: Any treatment not specifically listed as covered

Limited to:

• Initial office visit or consultation to assess patient for acupuncture treatment

PPO: $25 copayment per visit (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Limited to:

• Acupuncture, by a doctor of medicine or osteopathy, or a licensed or certified practitioner. Benefits are limited to 25 acupuncture visits per person per calendar year.
• 25 office visits per calendar year when rendered on the same day as a covered acupuncture treatment

PPO: $25 copayment per visit (No deductible) and all charges after 25-visit limit

Non-PPO: 35% of the Plan allowance, any difference between our allowance and the billed amount, and all charges after 25-visit limit

Not covered:

• Services performed by an acupuncturist who is not licensed or certified, even if the state where services are performed does not require acupuncturists to be licensed or certified
• Naturopathic services
• Cosmetic acupuncture

• Quit for Life is a voluntary tobacco cessation program offered by the Plan which includes:
  • Five coaching interactions to guide participants through the quit process
    • One-on-one coaching interactions (telephonic, chat and text are available)
    • Group video sessions
  • Online tools
  • Over-the-counter nicotine replacement therapy (including combination therapy) for participants that qualify 
  • Toll-free phone access to Tobacco Coaches for one year

For more information on the program or to join, visit www.quitnow.net/nalc or call 866-QUIT-4-LIFE (866-784-8454).

Note: For group and individual counseling for tobacco cessation, see Preventive care, adult in this section.

Note: FDA-approved prescription medications and over-the-counter medications (when purchased with a prescription) for tobacco cessation are covered only under the Prescription Drug Benefit. See Section 5(f). Prescription Drug Benefits.

You can earn $50 in health savings rewards for participation in this program. Eligibility will be determined by your Quit for Life Coach and you must have at least 5 coaching interactions. See Section 5(h). Wellness Incentive Programs for more details.

PPO: Nothing (No deductible)

Non-PPO: All charges

• Educational classes and nutritional therapy when:
  
  • Prescribed by the attending physician, and
  • Administered by a covered provider, such as a registered nurse or a licensed or registered dietician/nutritionist.

Note: To join our Weight Management Program, see Section 5(h). Wellness and Other Special Features.

PPO: Nothing (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

The Real Appeal® Program through Optum® is an online weight loss program that offers group and one-on-one personalized coaching through an online and mobile platform. The program focuses on weight loss through proper nutrition, exercise, sleep and stress management. Members will have access to a Transformation Coach and a suite of online tools to help track food and activity. Members will also receive a Success Kit to support their weight loss journey including a food and weight scale, resistance band, access to Fitness on Demand and more!

Coaching sessions are scheduled online at the members’ convenience and educational content is provided throughout the year. Coaches will be able to see the participants’ progress throughout the course of the program and be able to offer personalized support. Real Appeal encourages members to make small changes toward larger long-term health results with sustained support throughout the duration of the program.

Members can enroll in the Real Appeal Program online at www.nalchbp.org.

PPO: Nothing for services obtained through the Real Appeal Program offered by the Plan (No deductible)

Non-PPO: All charges

Not covered:

• Over-the-counter medications or dietary supplements prescribed for weight loss

All charges

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies
• Insertion of internal prosthetic devices. See Section 5(a). Orthopedic and prosthetic devices, for device coverage information.
• Debridement of burns

Note: When multiple or bilateral surgical procedures add complexity to an operative session, the Plan allowance for the second or less expensive procedure is one-half of what the Plan allowance would have been if that procedure had been performed independently.

Note: The Plan allowance for an assistant surgeon will not exceed 25% of our allowance for the surgeon.

Note: When a surgery requires two primary surgeons (co-surgeons), the Plan allowance for each surgeon will not exceed 62.5% of our allowance for a single surgeon to perform the same procedure(s).

Note: Simple repair of a laceration (stitches) and immobilization by casting, splinting, or strapping of a sprain, strain, or fracture, will be considered under this benefit when services are rendered after 72 hours of the accident.

Note: We only cover the standard intraocular lens prosthesis for cataract surgery.

Note: Initial inpatient (non-elective) surgery rendered by a non-PPO surgeon for the surgical treatment of appendicitis, brain aneurysms, burns, or gunshot wounds will be paid at the PPO benefit level.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

• Surgical treatment of severe obesity (bariatric surgery) is covered when:

1. Clinical records support a body mass index (BMI) of 35 or greater, or 30 or greater with at least one clinically significant obesity-related comorbidity including but not limited to diabetes mellitus, cardiovascular disease, hypertension, obstructive sleep apnea, hyperlipidemia, or debilitating arthritis.
2. Diagnosis of severe obesity for a period of one year prior to surgery.
3. The patient has participated in a supervised weight-loss program, of at least six months duration, that includes dietary therapy, physical activity and behavior modification. Evidence in the medical record that attempts at weight loss in the one year period prior to surgery have been ineffective.
4. The patient is age 13 or older.
5. Medical and psychological evaluations have been completed and the patient has been recommended for bariatric surgery.
6. A repeat or revised bariatric surgical procedure
   is covered only when determined to be medically necessary or a complication has occurred.

Note: A revisional surgery not related to a complication and performed more than 2 years from the date of the original surgery will require medical documentation as listed in requirements 1-5.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

• Gender affirming chest, genital, and facial feminization/masculinization surgeries are covered when medically necessary and meet the following criteria: 

• The patient must meet all requirements.
  • Prior approval is obtained
  • Patient must be at least 18 years of age at the time prior approval is requested and the treatment plan is submitted
  • Diagnosis of gender dysphoria by a qualified healthcare professional
    • Patient’s gender dysphoria is not a symptom of another mental disorder
    • Gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning
  • 6 months of continuous hormone therapy appropriate to the patient’s gender identity
  • One referral letter of support from a qualified mental health professional who has competencies in the assessment of transgender and gender diverse people is needed 
  • If medical or mental health concerns are present, they are being optimally managed and are reasonably well-controlled
• Reversal of a gender affirmation surgery is covered only when determined to be medically necessary or a complication occurs.

Note: Prior approval is required for gender affirmation surgery.  For more information about prior approval, please refer to Section 3. How You Get Care or visit our website at www.nalchbp.org.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

• Tubal ligation or tubal occlusion/tubal blocking procedures only
• Vasectomy
• Surgical placement of implanted contraceptives
• Insertion of intrauterine devices (IUDs)
• Removal of birth control device

Note:  We cover intrauterine devices and implanted contraceptives, (such as Implanon) only under the Prescription Drug Benefit. See Section 5(f). Prescription Drug Benefits.

PPO: Nothing

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingival and alveolar bone), except as listed in Section 5(g). Dental Benefits
• Cosmetic services that are not medically necessary
• Radial keratotomy and other refractive surgery
• Procedures performed through the same incision deemed incidental to the total surgery, such as appendectomy, lysis of adhesion, puncture of ovarian cyst
• Reversal of voluntary sterilization
• Services of a standby surgeon, except during angioplasty or other high risk procedures when we determine standby surgeons are medically necessary
• Cutting, trimming, or removal of corns, calluses, or the free edge of toenails; and similar routine treatment of conditions of the foot, except as listed under Section 5(a). Foot care
• Weight loss surgery for implantable devices such as Maestro Rechargeable System

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • The condition produced a major effect on the member’s appearance; and
  • The condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a congenital anomaly (condition that existed at or from birth and is a significant deviation
  from the common form or norm). Examples of congenital anomalies are protruding ear deformities; cleft lip; cleft palate; birthmarks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • Surgery to produce a symmetrical appearance of breasts
  • Treatment of any physical complications, such as lymphedemas

Note: Congenital anomaly does not include conditions related to teeth or intra-oral structures supporting the teeth.

Note: We cover internal and external breast prostheses, surgical bras and replacements. See Section 5(a). Orthopedic and prosthetic devices, and Section 5(c). Inpatient hospital.

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain
in the hospital up to 48 hours after the procedure.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

Not covered:

• Cosmetic services that are not medically necessary
• Injections of silicone, collagens, and similar substances
• Surgery related to sexual dysfunction 

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion
• Removal of stones from salivary ducts
• Excision of leukoplakia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Other surgical procedures that do not involve the teeth or their supporting structures
• Removal of impacted teeth that are not completely erupted (bony, partial bony and soft tissue impaction)

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone), except as listed in Section 5(g). Dental Benefits and Oral and maxillofacial surgery in
  this section

Cigna LifeSOURCE Transplant Network®—The Plan participates in the Cigna LifeSOURCE Transplant Network. Before your initial evaluation as a potential candidate for a transplant procedure, you or your physician must contact Cigna HealthCare at 800-668-9682 and speak to a referral specialist in the Comprehensive Transplant Case Management Unit. You will be given information about this program including a list of participating providers.

Charges for services performed by a Cigna LifeSOURCE Transplant Network provider, whether incurred by the recipient or donor are paid at 85% including inpatient hospital, surgical and any other medical expenses. Participants in the program must obtain prior approval from the Plan to receive limited travel and lodging benefits.

15% of the Plan allowance for services obtained through the Cigna LifeSOURCE Transplant Network

Limited Benefits—If you do not obtain prior approval or do not use a designated facility, or if we are not the primary payor, we pay a maximum of $100,000 for each listed transplant (kidney limit, $50,000), for these combined expenses: pre-transplant evaluation; organ procurement;
and inpatient hospital, surgical and medical expenses. We pay benefits according to the appropriate benefit section, such as Section 5(c). Inpatient hospital, and Surgical procedures in this section. The limitation applies to expenses incurred by either the recipient or donor.

Note: Some transplants listed may not be covered through the Cigna LifeSOURCE Transplant Network.

Note: We cover related medical and hospital expenses of the donor only when we cover the recipient.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan.  See Other services in Section 3 for prior authorization procedures.  Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants 
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney/pancreas
• Liver
• Lung single/bilateral/lobar
• Pancreas

15% of the Plan allowance for services obtained through the Cigna LifeSOURCE Transplant Network

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. See Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for:
  • AL Amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

15% of the Plan allowance for services obtained through the Cigna LifeSOURCE Transplant Network

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

Blood or marrow stem cell transplants 

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant. These blood or marrow stem cell transplants are subject to medical necessity review by the Plan. See Other services in Section 3 for prior authorization procedures.

15% of the Plan allowance for services obtained through the Cigna LifeSOURCE Transplant Network

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

• Allogeneic transplants for diseases such as:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Hodgkin’s lymphoma 
  • Myeloproliferative Disorders (MPDs)
  • Neuroblastoma
  • Non-Hodgkin’s lymphoma 
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy disorders
  • Infantile malignant osteoporosis
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic syndromes
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe aplastic anemia
  • Sickle Cell Anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for diseases such as:
  • Acute non-lymphocytic (i.e., myelogenous) leukemia
  • Hodgkin’s lymphoma 
  • Non-Hodgkin’s lymphoma 
  • Amyloidosis
  • Multiple myeloma
  • Neuroblastoma
  • Testicular and Ovarian germ cell tumors

15% of the Plan allowance for services obtained through the Cigna LifeSOURCE Transplant Network

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

Blood or marrow stem cell transplants covered only in a National Cancer Institute (NCI) or National Institutes of Health (NIH) approved clinical trial at a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocols, such as:

• Autologous transplants for:
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Aggressive non-Hodgkin’s lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms) 
  • Breast cancer
  • Childhood rhabdomyosarcoma
  • Epithelial ovarian cancer
  • Mantle Cell (non-Hodgkin’s lymphoma)

Note: If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial.  Section 9 has additional information on costs related to clinical trials.  We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

15% of the Plan allowance for services obtained through the Cigna LifeSOURCE Transplant Network 

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. 

See Other services in Section 3 for prior authorization procedures.

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

Note: If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial.  Section 9 has additional information on costs related to clinical trials.  We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

15% of the Plan allowance for services obtained through the Cigna LifeSOURCE Transplant Network

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

Not covered:

• Donor screening tests and donor search expenses, except those performed for the actual donor
• Travel and lodging expenses, except when approved by the Plan
• Implants of artificial organs
• Transplants and related services and supplies not listed as covered

All charges

Professional services provided in:

• Hospital (inpatient)

Note: If surgical services (including maternity) are rendered at a PPO hospital, we will pay up to the Plan allowance for services of non-PPO anesthesiologists at the PPO benefit level.

Note: When a CRNA is medically directed by an anesthesiologist, then the applicable Plan allowance will be split 50/50 between the CRNA and the anesthesiologist.

PPO: Nothing when services are related to the delivery of a newborn. 15% of the Plan allowance for anesthesia services for all other conditions.

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Professional services provided in:

• Hospital outpatient department
• Ambulatory surgical center
• Office
• Other outpatient facility

Note: If surgical services are rendered at a PPO hospital or ambulatory surgical center, we will pay up to the Plan allowance for services of non-PPO anesthesiologists at the PPO benefit level.

Note: When a CRNA is medically directed by an anesthesiologist, then the applicable Plan allowance will be split 50/50 between the CRNA and the anesthesiologist.

PPO: Nothing when services are related to the delivery of a newborn. 15% of the Plan allowance (calendar year deductible applies)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

Professional services provided for:

• Tubal ligation or tubal occlusion/tubal blocking procedures only
• Vasectomy

Note: When a CRNA is medically directed by an anesthesiologist, then the applicable Plan allowance will be split 50/50 between the CRNA and the anesthesiologist.

PPO: Nothing

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Room and board, such as:

• Ward, semiprivate, or intensive care accommodations
• Birthing room
• General nursing care
• Meals and special diets

Note: We cover a private room only when you must be isolated to prevent contagion. Otherwise, we pay the hospital’s average charge for semiprivate accommodations. If the hospital has private rooms only, we base our payment on the average semiprivate rate of the most comparable hospital in the area.

Note: When the non-PPO hospital bills a flat rate, we will exclude all charges and request an itemized bill.

Note: When room and board charges are billed by a hospital, inpatient benefits apply. For Observation room charges billed, see Outpatient hospital or ambulatory surgical center in this section.

PPO: Nothing when services are related to the delivery of a newborn. $350 copayment per admission for all other admissions.

Non-PPO: $450 copayment per admission and 35% of the Plan allowance and any difference between our allowance and the billed amount 

15% of the Plan allowance for services obtained through the Cigna LifeSOURCE Transplant Network

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Preadmission testing (within 7 days of admission), limited to:
  • Chest X-rays
  • Electrocardiograms
  • Urinalysis
  • Blood work
• Blood or blood plasma, if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Internal prostheses
• Occupational, physical, cognitive, and speech therapy

Note: We base payment on who bills for the services or supplies. For example, when the hospital bills for its nurse anesthetist’s services, we pay hospital benefits and when
the anesthesiologist bills, we pay anesthesia benefits. See Section 5(b). Surgical procedures.

Note: We cover your admission for dental procedures only when you have a nondental physical impairment that makes admission necessary to safeguard your health. We do not cover the dental procedures or the anesthesia service when billed by the anesthesiologist.

Note: We cover your admission for inpatient foot treatment even if no other benefits are payable.

Note: Diagnostic tests, such as magnetic resonance imaging, throat cultures, or similar studies are not considered as preadmission testing.

PPO: Nothing when services are related to the delivery of a newborn. $350 copayment per admission for all other admissions.

Non-PPO: $450 copayment per admission and 35% of the Plan allowance and any difference between our allowance and the billed amount 

15% of the Plan allowance for services obtained through the  Cigna LifeSOURCE Transplant Network

Take-home items:

• Medical supplies, appliances, and equipment; and any covered items billed by a hospital for use at home

PPO: 15% of the Plan allowance (calendar year deductible applies)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

Not covered:

• Any part of a hospital admission that is not medically necessary (See Section 10. Definitions . . . Medical Necessity), such as subacute care, long term care, long term acute care, intermediate care, or when you do not need acute hospital inpatient care, but could receive care in some other setting without adversely affecting your condition or the quality of your medical care. In this event, we pay benefits for services and supplies other than room and board and in-hospital physician care at the level they would have been covered if provided in an alternative setting.
• Custodial care; see Section 10. Definitions . . . Custodial care
• Non-covered facilities, such as nursing homes, extended care facilities, and schools
• Personal comfort items, such as telephone, television, barber services, guest meals and beds
• Private nursing care

Services and supplies, such as:

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
• Physical, occupational, cognitive, and speech therapy (when surgery performed on the same day)

Note: When surgery is not performed on the same day, see Section 5(a). Physical, occupational, cognitive, and speech therapies for coverage of these therapies.

Note: For accidental injuries, see Section 5(d). Emergency Services/Accidents. For accidental dental injuries, see Section 5(g). Dental Benefits.

Note: We cover hospital services and supplies related to dental procedures when necessitated by a nondental physical impairment or as the result of an accidental dental injury as defined in Section 5(g). Dental Benefits. We do not cover the dental procedures or the anesthesia service when billed by the anesthesiologist.

Note: Specialty drugs, including biotech, biological, biopharmaceutical, and oral chemotherapy drugs dispensed in an outpatient hospital are subject to the Specialty Drug copayment. See Outpatient hospital or ambulatory surgical center, in this section.

PPO: 15% of the Plan allowance (calendar year deductible applies)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

• Outpatient observation room and all related services

PPO: $350 copayment

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

• Outpatient services and supplies for the delivery of a newborn
• Outpatient services and supplies for a tubal ligation or tubal occlusion/tubal blocking procedures only

PPO: Nothing 

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

Plan pays for pre-operative testing within 7 days of surgery. Screening tests, limited to:

• Chest X-rays
• Electrocardiograms
• Urinalysis
• Blood work

Note: To reduce your out-of-pocket costs for laboratory services use LabCorp or Quest Diagnostics, see Section 5(a). Lab, X-ray and other diagnostic tests.

Note: Diagnostic tests, such as magnetic resonance imaging, throat cultures, or similar studies are not considered as preadmission testing.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Specialty drugs, including biotech, biological, biopharmaceutical, and oral chemotherapy drugs

Note: Prior approval is required for all specialty drugs used to treat chronic medical conditions. Call CVS Specialty at 800-237-2767 to obtain prior approval, more information, or a complete list.

PPO:  

• 30-day supply: $200 
• 60-day supply: $300  
• 90-day supply: $400 

Non-PPO:  

• 30-day supply: $200 and any difference between our Plan allowance and the charged amount
• 60-day supply: $300 and any difference between our Plan allowance and the charged amount
• 90-day supply: $400 and any difference between our Plan allowance and the charged amount

Not covered: Personal comfort items

When your Medicare Part A is primary, and:

• Medicare has made payment, we cover the applicable copayments; or
• Medicare’s benefits are exhausted, we cover semiprivate room, board, services, and supplies in a SNF, for the first 30 days of each admission, provided:
  1. You are admitted directly from a hospital stay of at least 3 consecutive days;
  2. You are admitted for the same condition as the hospital stay; and
  3. Your skilled nursing care is supervised by a physician and provided by an R.N., L.P.N., or L.V.N.

PPO: Nothing

Non-PPO: Nothing

When this Plan is your primary insurance:

Inpatient confinement at a skilled nursing facility following transfer from a covered acute inpatient confinement when skilled care is still required.

Benefits are limited to 30 days per person, per calendar year. Precertification is required. See Section 3. How You Get Care.

Note: This benefit does not apply if Medicare A is primary.

PPO: 15% of the Plan allowance and all charges after 30-day annual limit

Non-PPO: 35% of the Plan allowance, any the difference between our allowance and the billed amount, and all charges after 30-day annual limit

Not covered: Custodial care

Hospice is a coordinated program of maintenance, palliative and supportive care for the terminally ill provided by a medically supervised team under the direction of a Plan-approved independent hospice administration.

Limited benefits: We pay up to 30 days annually for a combination of inpatient and outpatient hospice services. 

PPO: 15% of the Plan allowance and all charges after 30-day annual limit (calendar year deductible applies)

Non-PPO: 35% of the Plan allowance and all charges after 30-day annual limit (calendar year deductible applies)

Not covered:

• Private nursing care
• Homemaker services
• Bereavement services

• Professional ground or air ambulance service to the nearest outpatient hospital or ambulatory surgical center equipped to handle your condition

Note: Prior approval is required for all non-emergency air ambulance transport.

Note: When air ambulance transportation to the nearest facility equipped to handle your condition is provided by a non-PPO provider, we will pay up to the Plan allowance at the PPO benefit level.

Note: When ambulance transportation to the nearest PPO facility is provided by a non-PPO provider, we will pay up to the Plan allowance at the PPO benefit level.

PPO: 15% of the Plan allowance (calendar year deductible applies)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

• Professional ground or air ambulance service to the nearest inpatient hospital equipped to handle your condition

Note: Prior approval is required for all non-emergency air ambulance transport.

Note: When air ambulance transportation to the nearest facility equipped to handle your condition is provided by a non-PPO provider, we will pay up to the Plan allowance at the PPO benefit level.

Note: When ambulance transportation to the nearest PPO facility is provided by a non-PPO provider, we will pay up to the Plan allowance at the PPO benefit level.

PPO: 15% of the Plan allowance 

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount 

If you receive the care within 72 hours after your accidental injury, we cover:

• Related non-surgical treatment, including office or outpatient services and supplies
• Related surgical treatment, limited to:
  • Simple repair of a laceration (stitching of a superficial wound)
  • Immobilization by casting, splinting, or strapping of a sprain, strain, or fracture
• Local professional ambulance service to the nearest outpatient hospital equipped to handle your condition when medically necessary

Note: For surgeries related to your accidental injury not listed above, see Section 5(b). Surgical procedures.

Note: We pay inpatient professional, outpatient observation room and all related services, and/or hospital benefits if you are admitted as an inpatient. Accidental Injury benefits no longer apply. See Section 5(a). Diagnostic and treatment services,  Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals, and Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services. 

Note: For dental benefits for accidental injury, see Section 5(g). Dental Benefits.

PPO: Nothing (No deductible)

Non-PPO: Nothing and any difference between the Plan allowance and the billed amount (No deductible)

Medical and outpatient hospital benefits apply. See Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals, Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Healthcare Professionals and Section 5(c). Outpatient hospital or ambulatory surgical center for the benefits we provide.

Outpatient hospital medical emergency service for a medical emergency condition

Note: When you need outpatient medical emergency services for a medical emergency and cannot access a PPO hospital, we will pay the non-PPO hospital charges, up to the Plan allowance, at the PPO benefit level.

PPO: 15% of the Plan allowance

Non-PPO: 15% of the Plan allowance and any difference between our allowance and the billed amount

Professional services of physicians and urgent care centers:

• Office or outpatient visits
• Office or outpatient consultations

PPO: $25 copayment per visit (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Emergency room physician care not related to Accidental injury or Medical emergency. See Section 5(a). Diagnostic and treatment services.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount   

PPO: 15% of the Plan allowance (No deductible)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

Professional ambulance service to the nearest facility equipped to handle your condition when medically necessary, not related to an accidental injury

Note: When air ambulance transportation to the nearest facility equipped to handle your condition is provided by a non-PPO provider, we will pay up to the Plan allowance at the PPO benefit level.

Note: When ambulance transportation to the nearest PPO facility is provided by a non-PPO provider, we will pay up to the Plan allowance at the PPO benefit level.

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Outpatient professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social workers
• Outpatient medication management

Note: Applied Behavioral Analysis (ABA) therapy benefit is listed in Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals.

Note: For assistance in finding In-Network services and treatment options, such as Medication-Assisted Therapy (MAT) for Substance Use Disorder (SUD), call 855-780-5955.

In-Network: $25 copayment (No deductible)

Out-of-Network: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Outpatient telemental or virtual visits rendered by providers such as psychiatrists, psychologists, or clinical social workers

Note: To find a telemental/virtual visit provider call Optum at 877-468-1016.

In-Network: $10 copayment (No deductible)

Out-of-Network: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Outpatient professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social workers, to treat postpartum depression or depression during pregnancy.

Note:  Maximum of four (4) visits paid at 100%, then regular mental health benefits apply.

In-Network: Nothing (No deductible)

Out-of-Network: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Outpatient diagnostic tests
• Inpatient professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social workers
• Lab and other diagnostic tests performed in an office or urgent care setting
• Professional ground or air ambulance service to the nearest outpatient hospital equipped to handle your condition
• Urine drug testing/screening for non-cancerous chronic pain and substance use disorder is limited to:
  • 16 definitive (quantitative) drug tests per calendar year
  • 32 presumptive (qualitative) drug tests per calendar year

Note:  For definitions of definitive and presumptive drug tests, see Section 10. Definitions of Terms We Use in This Brochure.

Note: Prior approval is required for all non-emergency air ambulance transport.

Note: When air ambulance transportation to the nearest facility equipped to handle your condition is provided by an Out-of-Network provider, we will pay up to the Plan allowance at the In-Network benefit level.

Note: When ambulance transportation to the nearest In-Network facility is provided by an Out-of-Network provider, we will pay up to the Plan allowance at the In-Network benefit level.

In-Network: 15% of the Plan allowance

Out-of-Network: 35% of the Plan allowance and any difference between our allowance and the billed amount

If LabCorp or Quest Diagnostics performs your covered lab services, you will have no out-of-pocket expense and you will not have to file a claim. Ask your doctor to use LabCorp or Quest Diagnostics for lab processing. To find a location near you, call 877-220-NALC (6252), or visit our website at www.nalchbp.org.

Note: Covered lab tests not performed at LabCorp or Quest Diagnostics are subject to the calendar year deductible and applicable coinsurance.

• Professional ground or air ambulance service to the nearest inpatient hospital equipped to handle your condition

Note: When air ambulance transportation to the nearest facility equipped to handle your condition is provided by an Out-of-Network provider, we will pay up to the Plan allowance at the In-Network benefit level.

Note: When ambulance transportation to the nearest In-Network facility is provided by an Out-of-Network provider, we will pay up to the Plan allowance at the In-Network benefit level.

In-Network: 15% of the Plan allowance (No deductible)

Out-of-Network: 35% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

• Outpatient observation room and all related services

In-Network: $350 copayment (No deductible)

Out-of-Network: 35% of the Plan allowance and any difference between our allowance and the billed amount 

Outpatient services provided and billed by a hospital or other covered facility, such as:

• Partial hospitalization (PHP)
• Intensive outpatient treatment (IOP)

 Note: For definition of partial hospitalization, see Section 10. Definitions of Terms We Use in This Brochure.

In-Network: 15% of the Plan allowance

Out-of-Network: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Inpatient room and board provided by a hospital or other treatment facility
• Other inpatient services and supplies provided by:
  • Hospital or other facility
  • Approved alternative care settings such as half-way house, residential treatment and full-day hospitalization

In-Network: $350 copayment per admission (No deductible)

Out-of-Network: $450 copayment per admission and 35% of the Plan allowance (No deductible)

Residential Treatment Center (RTC) - Precertification prior to admission is required.

A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (residential treatment center (RTC)), and case manager prior to admission.

We cover inpatient care provided and billed by an RTC for members enrolled and participating in an approved plan of care, and when the care is medically necessary for treatment of a medical, mental health, and/or substance use disorder:

• Room and board, such as semiprivate room, nursing care, meals, special diets, ancillary charges, and covered therapy services when billed by the facility.

Note: RTC benefits are not available for facilities licensed as a skilled nursing facility, group home, halfway house, school, or similar type facility.

Note: Benefits are not available for non-covered services, including: respite care; outdoor residential programs; wilderness treatment or services provided outside of the provider's scope of practice; recreational therapy; educational therapy; educational classes; bio-feedback; Outward Bound programs; equine
therapy provided during the approved stay; personal comfort items, such as guest meals and beds, telephone, television, beauty and barber services; custodial or long term care and domiciliary care provided because care in the home is not available or is unsuitable.

Note: Failure to precertify a Residential Treatment Center admission will result in a denial of charges and a $500 reduction in benefits if later approved upon review.

In-Network: $350 copayment per admission (No deductible)

Out-of-Network: $450 copayment per admission and 35% of the Plan allowance (No deductible)

Not covered:

• Services we have not approved
• Treatment for learning disabilities and intellectual disabilities
• Treatment for marital discord
• Services rendered or billed by schools, residential treatment centers, or half-way houses, and/or members of their staff except when preauthorized
• Nursing care requested by, or for the convenience of, the patient or the patient’s family
• Home care primarily for personal assistance that does not include a mental component and is not diagnostic,
  therapeutic, or rehabilitative
• Transportation (other than professional ambulance services), such as by ambulette or medicab

Note: Exclusions that apply to other benefits apply to these mental health and substance use disorder benefits, unless the services are included in a treatment plan that we approve.

All charges

OptumHealth Behavioral Solutions provides our mental health and substance use disorder benefits. Call 877-468-1016 to locate In-Network clinicians who can best meet your needs.

For services that require prior authorization, you must follow all of the following network authorization processes:

• Call 877-468-1016 to receive authorization to see a provider when we are your primary payor. You and your provider will receive written confirmation of the authorization from OptumHealth Behavioral Solutions for the initial and any ongoing authorizations.

Note: You do not need to preauthorize treatment for mental health and substance use disorder services rendered outside of the United States.

• When Medicare is your primary payor, call the Plan at 703-729-4677 or 888-636-NALC (6252) to preauthorize treatment if:
  • Medicare does not cover your services; or
  • Medicare hospital benefits are exhausted and you do not want to use your Medicare lifetime reserve days.

Note: You do not need to preauthorize treatment when Medicare covers your services.

Claims should be submitted to:

                     OptumHealth Behavioral Solutions
                     P.O. Box 30755 
                     Salt Lake City, UT 84130-0755
                     Questions? 877-468-1016

Note: If you are using an In-Network provider for mental health or substance use disorder treatment, you will not have to submit a claim. OptumHealth Behavioral Solutions In-Network providers are responsible for filing.

You may purchase the following medications and supplies from a pharmacy or by mail:

• Drugs and medications (including those administered during a non-covered admission or in a non-covered facility) that by federal law of the United States require a physician’s prescription for their purchase, except as shown in Not covered
• Insulin
• Needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction, when the dysfunction is caused by medically documented organic disease
• Vitamins and minerals that by federal law of the United States require a physician's prescription for their purchase
• Drugs to treat gender dysphoria such as testosterones, progestin, estrogens, and aldosterone antagonists
• Prescription drugs for the treatment of infertility, including up to 3 cycles of IVF-related drugs 
• FDA-approved prescription weight loss drugs (prior authorization required)

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. 

Note: We will waive the one 30-day fill and one refill limitation at retail for the following: 

• patients confined to a nursing home that require less than a 90-day fill,
• patients who are in the process of having their medication regulated, or
• when state law prohibits the medication from being dispensed in a quantity greater than 30 days.

Call the Plan at 888-636-NALC (6252) to have additional refills at a network retail pharmacy authorized.

Note: For coverage of continuous glucose monitors and insulin pumps, see Section 5(a). Durable medical equipment (DME).  

Note: When Medicare Part B is your primary payer, you should file a claim directly to Medicare for diabetic test strips and lancets.

Retail:

• Network retail:
  • Generic: 20% of cost (10% of cost for hypertension, diabetes, and asthma)
  • Formulary brand: 30% of cost
  • Non-formulary brand: 50% of cost
• Non-network retail: 50% of the Plan allowance and any difference between our allowance and the billed amount

Retail Medicare:

• Network retail Medicare:
  • Generic: 10% of cost (5% of cost for hypertension, diabetes, and asthma)
  • Formulary brand: 20% of cost
  • Non-formulary brand: 40% of cost
• Non-network retail Medicare: 50% of the Plan allowance and any difference between our allowance and the billed amount

Mail order:

• 60-day supply: $10 generic/$60 Formulary brand/$84 Non-formulary brand
• 90-day supply: $15 generic/$90 Formulary brand/$125 Non-formulary brand (for hypertension, diabetes, and asthma:
  $8 generic/$50 Formulary brand/$70 Non-formulary brand)

Mail order Medicare:

• 60-day supply: $7 generic/$50 Formulary brand/$75 Non-formulary brand
• 90-day supply: $10 generic/$75 Formulary brand/$110 Non-formulary brand (for hypertension, diabetes, and asthma:
  $4 generic/$40 Formulary brand/$60 Non-formulary brand)

Note: If there is no generic equivalent available, you pay the brand name copayment.

Note: If the cost of a prescription is less than the mail order copayment amount, you will pay the cost of the prescription.

Note: Non-network retail includes additional fills of a maintenance medication at a Network pharmacy without prior Plan authorization. This does not include prescriptions purchased at a CVS Caremark Pharmacy through our Maintenance Choice Program.

Specialty drugs – including biotech, biological, biopharmaceutical, and oral chemotherapy drugs. 

All specialty drugs require prior approval. Call CVS Specialty at 800-237-2767 to obtain prior approval, more information, or a complete list. You may also obtain a list of specialty drugs by visiting www.nalchbp.org. 

Note: Some specialty medications may qualify for third party copayment assistance programs which could lower your out-of-pocket costs for those medications. When specialty medication is purchased with a third party copayment assistance coupon, rebate, or card, the Plan will not apply the amount of the discount towards your out-of-pocket maximum.

Non-Medicare/Medicare:

• CVS Specialty Mail Order:
  • 30-day supply: $200 
  • 60-day supply: $300 
  • 90-day supply: $400 

Note: Refer to dispensing limitations in this section.

• Medical foods and nutritional supplements when
  administered by catheter, gastrostomy, jejunostomy or nasogastric tubes
• Medical foods formulated to be administered orally or enterally for Inborn Errors of Metabolism (IEM)

Note: If medical foods or nutritional supplements are dispensed by a pharmacy, you will pay the appropriate pharmacy copay/coinsurance.

PPO: 15% of the Plan allowance (calendar year deductible applies)

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

Opioid Reversal Agents 

• Medication Assisted Treatment (MAT) drugs, including Buprenorphine, Buprenorphine-naloxone and Naltrexone used for treatment of opioid use disorders

Retail:

• Network retail: Nothing, up to a 90-day supply per calendar year (No deductible)
• Non-network retail: 50% of the Plan allowance and any difference between our allowance and the billed amount

Retail Medicare:

• Network retail Medicare: Nothing, up to a 90-day supply per calendar year (No deductible)
• Non-network retail Medicare: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Drugs and supplies when prescribed for cosmetic purposes
• Nutrients and food supplements, even when a physician prescribes or administers them, except as listed in this section
• Over-the-counter medications or dietary supplements prescribed for weight loss
• Specialty drugs for which prior approval has been denied or not obtained
• Anti-narcolepsy, ADD/ADHD, and certain analgesic/opiod medications for which prior approval has been denied or not obtained
• Certain compounding chemicals (over-the-counter (OTC) products, bulk powders, bulk chemicals, and proprietary bases)
• Certain topical analgesics for the temporary relief of minor aches and muscle pains that may be marketed contrary to the Federal Food, Drug and Cosmetic Act (the FD&C Act)
• Non-prescription medications unless specifically indicated elsewhere

Note: See Section 5(h). Wellness and Other Special Features for information on the Enhanced CaremarkDirect Retail Program where you may obtain non-covered medications at a discounted rate.

All charges

Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients.  For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations.

The following drugs and supplements are covered without cost-share, even if over-the-counter, when prescribed by a healthcare professional and filled at a network pharmacy.

• Over-the-counter low-dose aspirin (75 and 81 mg) for the prevention of colorectal cancer and cardiovascular disease for adults age 50-59 as recommended by the USPSTF (prescription required)
• Over-the-counter low-dose aspirin for pregnant women at high risk for preeclampsia (prescription required)
• Over-the-counter vitamin supplements containing 0.4 to 0.8 mg (400 to 800 mcg) of folic acid for women planning a pregnancy or capable of becoming pregnant  (prescription required)
• Prescription oral fluoride supplements for children from age 6 months through 5 years

Retail:

• Network retail: Nothing
• Non-network retail: 50% of the Plan allowance and any difference between our allowance and the billed amount.

Retail Medicare:

• Network retail Medicare: Nothing
• Non-network retail Medicare: 50% of the Plan allowance and any difference between our allowance and the billed amount.

• FDA-approved prescription medications for tobacco cessation
• Over-the-counter medications for tobacco cessation (prescription required)
• Contraceptive drugs and devices as listed in the ACA/HRSA site. 

  Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below.  

  Your healthcare provider can seek a contraceptive exception by calling CVS Caremark® Prior Authorization at 800-294-5979 and completing the Preventive Services Contraception Zero Copay Exception Form. 

  To receive reimbursement for over-the-counter contraceptives, you must submit a short-term prescription form to the NALC Prescription Drug Program. The short-term prescription form can be found on our website at www.nalchbp.org. 
  
  If individuals have concerns about the plan’s compliance, the requirements mentioned or other OPM guidance, you can contact OPM directly at contraception@opm.gov. You can find more information concerning Contraceptive coverage at www.opm.gov/ or www.nalchbp.org.

• Diaphragms
• Intrauterine devices
• Medications, for risk reduction of primary breast cancer for women who are at increased risk for breast cancer as recommended by the USPSTF, limited to:
  • Anastrozole
  • Exemestane
  • Raloxifene
  • Tamoxifen
• Statin preventive medications for adults at increased risk of cardiovascular disease (CVD), age 40 through 75, with a calculated 10-year CVD event risk of 10% or greater, as recommended by the USPSTF

Retail:

• Network retail: Nothing
• Non-network retail: 50% of the Plan allowance and any difference between our allowance and the billed amount.

Retail Medicare:

• Network retail Medicare: Nothing
• Non-network retail Medicare: 50% of the Plan allowance and any difference between our allowance and the billed amount.

Mail order:

• 60-day supply: Nothing
• 90-day supply: Nothing

Mail order Medicare:

• 60-day supply: Nothing
• 90-day supply: Nothing

• HIV pre-exposure prophylaxisis (PrEP) 

Note: The "morning after pill" is considered a preventive service under contraceptives, with no cost to the member if prescribed by a physician and purchased at a network pharmacy. 

Note: Call us at 703-729-4677 or 888-636-NALC (6252) prior to purchasing this medication at a Network retail or mail order pharmacy.

Retail:

• Network retail: Nothing
• Non-network retail: 50% of the Plan allowance and any difference between our allowance and the billed amount.

Retail Medicare:

• Network retail Medicare: Nothing
• Non-network retail Medicare: 50% of the Plan allowance and any difference between our allowance and the billed amount.

Mail order:

• 60-day supply: Nothing
• 90-day supply: Nothing

Mail order Medicare:

• 60-day supply: Nothing
• 90-day supply: Nothing

Not covered:

• Over-the-counter medications, vitamins, minerals, and supplies, except as listed above 
• Over-the-counter tobacco cessation medications purchased without a prescription
• Tobacco cessation medications purchased at a non-network retail pharmacy
• Prescription oral fluoride supplements purchased at a non-network retail pharmacy
• Prescription contraceptives for women purchased at a non-network retail pharmacy

Note: See Section 5(h). Wellness and Other Special Features for information on the Enhanced CaremarkDirect Retail Program where you may obtain non-covered medications at a discounted rate.

All charges

PPO: 15% of the Plan allowance

Non-PPO: 35% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

Not covered:

• Dental services not rendered or completed within 72 hours
• Bridges, oral implants, dentures, crowns
• Orthodontic treatment
• Night splint/guard
  

You may call 877-468-1016, 24 hours a day, 7 days a week, to access in-person support for a wide range of concerns, including depression, eating disorders, coping with grief and loss, alcohol or drug dependency, physical abuse and managing stress.

Call CareAllies 24-Hour Health Information Line at 877-220-NALC (6252) to access a registered nurse 24 hours a day, 7 days a week. This nurse line seeks to influence consumer behavior by providing tools, education, counseling and support to help members make decisions with respect to their health and use of healthcare services.

Consumers may contact a CareAllies registered nurse at any time of the day or night, for:

• Answers to questions about medical conditions, diagnostic tests or treatments prescribed by their physicians, or other health or wellness topics
• Assistance to determine the appropriate level of healthcare services (emergency room, doctor visit, self care, etc.) required to address a current symptom
• Self care techniques for home care of minor symptoms
• Referrals for case management or other appropriate services
• Introduction to the online health resources available at www.nalchbp.org  

Bend’s Behavioral Health Coaching Program through Optum is a live video-based service that supports children and families seeking to modify challenging behavior to achieve their behavioral health goals. Along with age and symptom-specific care programs, the coaching program offers interactive content, resources, parenting tips, tools, and peer community support (for caregivers) that members can access to support their progress.

Onboarding and assessment protocols ensure that clinically appropriate care programs are selected and provide ongoing monitoring of progress, risks, and clinical needs. In addition, coaches are supervised by licensed mental health providers at all times to ensure the appropriateness of services and the potential need for a higher level of care.

Members can enroll in the Bend Health program online at www.bendhealth.com/NALC.  

Visit our website at www.nalchbp.org for information and tips on weight management and overcoming childhood obesity. You can access numerous articles on food, nutrition, exercise and fitness specifically geared for children of all ages. You can also find recipes, meal suggestions, and a BMI chart designed for children from age 2 through 20.

Through this online tool, parents can sign up for a free OptumHealth Live and Work Well monthly email newsletter that can be tailored to their child’s age and special interests.

Accordant Health Management offers programs for the following complex chronic medical conditions:

• Amyotrophic Lateral Sclerosis (ALS-Lou Gehrig's Disease)
• Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)
• Crohn's Disease
• Cystic Fibrosis (CF)
• Dermatomyositis
• Gaucher Disease
• Hemophilia
• Hereditary Angioedema
• Human Immunodeficiency Virus (HIV)
• Multiple Sclerosis (MS)
• Myasthenia Gravis (MG)
• Parkinson's Disease (PD)
• Polymyositis
• Rheumatoid Arthritis (RA)
• Scleroderma
• Seizure disorders (Epilepsy)
• Sickle Cell Disease (SCD)
• Systemic Lupus Erythematosus (SLE)
• Ulcerative Colitis

For more information on the Accordant Health Management programs, please call toll-free 844-923-0805.

This program helps deliver better overall care and lower costs for members with diabetes. Your enrollment in this program includes a connected glucometer, unlimited test strips and lancets, medication therapy counseling from a pharmacist, two annual diabetes screenings at a CVS MinuteClinic and a suite of digital resources through the CVS mobile App, all at no cost.  Please call CVS Caremark at 800-933-NALC (6252) for more information.

This program integrates medical, pharmacy, and laboratory data to identify and address members’ gaps in care. Gaps in care occur when individuals do not receive or adhere to care that is consistent with medically proven guidelines for prevention or treatment. This is an outreach program for both you and your physician. Members and their physicians are informed by mail of potential gaps and are instructed on how to improve adherence to existing therapies. Some examples of conditions that are managed through the program are: diabetes, hypertension, and cardiac disorders.

Through a clinical identification process, individuals are identified who have a chronic health condition such as asthma, COPD, depression, diabetes, or heart disease. Health advocates trained as nurses, coaches, nutritionists, and clinicians use a one-on-one approach to help individuals:

• Recognize worsening symptoms and know when to see a doctor 
• Establish questions to discuss with their doctor 
• Understand the importance of following doctors' orders 
• Develop health habits related to nutrition, sleep, exercise, weight, tobacco, and stress
• Prepare for a hospital admission or recover after a hospital stay 
• Make educated decisions about treatment options 

You may call 877-220-NALC (6252) to speak to a health advocate.

You can earn $50 in health savings rewards once you achieve a fitness, diet, or health goal with the assistance of a trained health coach. Only one incentive can be earned per calendar year. See Wellness Incentive Programs in this section.

You can purchase non-covered drugs through your local CVS network pharmacy and receive the convenience, safety, and confidentiality you already benefit from with covered prescriptions. Our Enhanced CaremarkDirect Retail is offered at no additional charge to you. Using this program at your local CVS pharmacy, as well as all major chains, for both covered and non-covered prescriptions will help ensure overall patient safety. The program allows you to get a discount on many prescription drugs not covered by our prescription benefit.

Enhanced CaremarkDirect Retail is a value-added program that provides you with safe, convenient access to competitively priced, non-covered prescriptions, and certain over-the-counter drugs.

You may call 800-933-NALC (6252), 24 hours a day, 7 days a week, for a complete listing of available medications and their cost.

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative.  If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary.  Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.

Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

A free Health Assessment is available under Quicklinks at www.nalchbp.org.  The Health Assessment is an online program that analyzes your health related responses and gives you a personalized plan to achieve specific health goals. Your Health Assessment profile provides information to put you on a path to good physical and mental health. 

Any eligible member or dependent over the age of 18 can earn $30 in health savings rewards by completing the Health Assessment. See Wellness Incentive Programs in this section for more details.  Or, you may be eligible to choose from the following:

• When one covered member completes the Health Assessment, you may choose one of the following:
  • Self only CignaPlus Savings^® discount dental program. We will pay the CignaPlus Savings discount dental premium for the remainder of the calendar year in which you completed the Health Assessment provided you remain enrolled in our Plan;
  • Waiver of two $25 PPO medical office visit copayments (when the Plan is the primary payor) incurred in the same year as the Health Assessment is completed. Copayment waivers will be applied to claims for services rendered after completion of the Health Assessment; or
  • A wearable activity tracking device.
• When two or more covered family members (including the member) complete the Health Assessment, you may choose one of the following:
  • Family CignaPlus Savings discount dental program. We will pay the CignaPlus Savings discount dental premium for the remainder of the calendar year in which you completed the Health Assessment provided you remain enrolled in our Plan;
  • Waiver of four $25 PPO medical office visit copayments (when the Plan is the primary payor) incurred in the same year as the Health Assessment is completed. Copayment waivers will be applied to claims for services rendered after completion of the Health Assessment; or
  • A wearable activity tracking device (limit 2 devices per enrollment).

Note:  You must be 18 years or older to be eligible to complete the Health Assessment. Individuals age 13 and older can access other services offered by CareAllies/Cigna. CignaPlus Savings is a discount dental program that provides members access to discounted fees with participating dental providers. For more information on this program, call 877-521-0244 or visit www.cignaplussavings.com.

This is a voluntary program for all expectant mothers. You will receive access to preconception planning tools and resources, along with educational information and support throughout your entire pregnancy and after.  You will speak to a pregnancy specialist and receive unlimited coaching calls to provide you with caring support to optimize your chances of having a healthy, full-term pregnancy. There will be ongoing assessments to help with early detection of a high risk pregnancy or other special needs you may have during your pregnancy.  Healthy Pregnancies, Healthy Babies will work together with you and your doctor to develop a plan of care. After delivery, you will also be screened for signs of postpartum depression. 

Get live support 24 hours a day, seven days a week. Call 877-220-6252 to enroll in the Healthy Pregnancies, Healthy Babies program. You may also connect with this program through the Cigna Healthy Pregnancy®  mobile app available for download from Google Play^TM or the Apple App Store. This valuable resource offers you an easy way to track and learn about your pregnancy. It also provides support for your baby’s first two years.

In order to be eligible for $50 in health savings rewards, you must enroll in your 1st or 2nd trimester and stay engaged with a pregnancy specialist during your pregnancy to complete at least 3 calls, one of which includes the post-partum call for closure. See Wellness Incentive Programs in this section for more details.

Cigna Healthy Rewards® has deep retail discounts for customers allowing them to save on products and services for a well-balanced lifestyle. With Healthy Rewards, you can save time and money on a wide variety of health products, wellness programs, and other services, including:

• Fitness and exercise
• Nutrition
• Hearing and vision care
• Financial coaching

Healthy Rewards programs are not insurance. Rather, these programs give a discount on the cost of certain goods and services. The customer must pay the entire discounted cost. Some Healthy Rewards programs are not available in all states and programs may be discontinued at any time. Participating providers are solely responsible for their goods and services. For more information call 800-870-3470 or visit our website at www.nalchbp.org.

An essential tool for remote care of cardiac conditions. This program enables you to measure your blood pressure using a free FDA-cleared monitor and allows you to send the data privately to your doctor. This program empowers you to improve your lifestyle through coaching on your smartphone or tablet. You will have access to the most advanced hypertension management tools on the market, all at no cost. Text NALC to 75706 or visit join.helloheart.com/NALC to register.

Our Musculoskeletal Program through Hinge Health offers a convenient way to help you overcome back and joint pain, avoid surgeries, and reduce medication usage - all from the comfort of your home. This program is offered at no cost to you and your dependents. Once enrolled, you may receive:

• Access to a personal care team, including a physical therapist and health coach 
• A tablet and wearable sensors that guide you through the exercises 
• Video visits with your care team, delivered through the Hinge Health app 

For more information or to enroll call 855-902-2777 or visit hingehealth.com/nalc. 

Access the NALC Health Benefit Plan’s Member Access Portal through our website at www.nalchbp.org, by clicking on the Member Login/Register tab. To have quick access to the member portal, use the Plan’s mobile application which is available for download for both iOS and Android mobile devices. The portal provides members with 24/7 access to helpful features, tools and information related to their Health Plan benefits. Members can log in and create a unique username and password to access personal healthcare information such as benefits, out-of-pocket costs, deductibles, and claims. They can also download Explanations of Benefits (EOBs) and member ID cards. The portal also provides direct links to our vendor partners Amwell, Cigna, CVS Health®, Hinge Health and Optum.

The Personal Health Notes section of our member portal allows you to create and maintain a complete, comprehensive, and confidential medical record containing information on allergies, immunizations, medical providers, medications, past medical procedures, and more. Participation is voluntary and access is secured. Access the Personal Health Notes through the NALC Health Benefit Plan Member Access Portal (mobile application).

TTY lines are available for the following:

CVS Caremark: 800-238-1217
(prescription benefit information)

OptumHealth Behavioral Solutions: 800-842-2479
(mental health and substance use disorder information)

For members or spouses that are caring for an elderly relative or disabled dependent, this program provides expert assistance from a Care Advocate, a registered nurse with geriatric, disability and community health experience. Your benefit gives you a bank of six free hours per calendar year, which may be used for any combination of the following services:

•  Evaluating the elder’s/dependent’s living situation
•  Identifying medical, social and home needs (present and future)
•  Recommending a personalized service plan for support, safety and care
•  Finding and arranging all necessary services
•  Monitoring care and adjusting the service plan when necessary

Whether it’s arranging transportation to doctors’ appointments, explaining insurance options, having safety equipment installed, or coordinating care with multiple providers, the Care Advocate will help ensure that your elderly relative or disabled dependent maintains a safe, healthy lifestyle.

You can call 866-463-5337 to speak with a Care Advocate from 7:00 a.m. to 5:00 p.m. (CST) Monday through Friday.

You may also access educational resources and discounted products and services anytime online at www.uhc.com/caregiving. An account is not required to access Solutions for Caregivers services.

This enhanced service combines the services of CVS pharmacy and CVS Specialty by offering expanded choices and greater access to specialty medications and services.  Specialty prescriptions can be submitted to any local CVS pharmacy or to our Specialty mail pharmacies.  Members will receive telephonic clinical support from our Specialty pharmacy Care Team and will have the added option to pick up their specialty medication at a CVS pharmacy or to have them delivered to the location of their choice. Call 800-237-2767 for more information.

This program offers assistance in finding In-Network providers and treatment options in the area and provides education about the SUD condition. Call Optum at 855-780-5955 to speak with a licensed clinician who can help guide you to an In-Network treatment provider or treatment center. Better treatment outcomes occur when you have a clear individualized treatment plan within your community.

This clinical care management outreach program through Optum provides ongoing support for those individuals impacted by substance use. Participants are assigned a master’s level clinician to provide phone based support and advocacy including, but not limited to:

•  Toxicology screening
•  Meetings with patient’s family
•  Referral management and appointment setting
•  Unlimited after hours support for both patients and family members
•  Regular reporting

This program is designed to engage participants in successful recovery by developing the best treatment options and guiding the participants to the right care.

Telehealth services are available through NALCHBP Telehealth powered by Amwell. To download the mobile app for Android or iOS mobile devices go to Google Play™ or the Apple App Store, visit www.nalchbptelehealth.org or call 888-541-7706 to access high quality, affordable care, when you need it, where you need it. 

• Urgent Care Visits can be used for adults or children with minor acute, non-emergency medical conditions such as flu, sinus problems, allergies, abrasions or minor wounds. Care is provided by
  U.S. board licensed and credentialed physicians and nurse practitioners who can write a prescription for medication, if appropriate. On-demand visits are available 24 hours per day, 7 days a week. 
• The Nutrition Counseling program offers counseling by trained registered dieticians who help design personalized nutrition plans for a variety of chronic conditions and health concerns. Visits are conducted in the comfort and privacy of the patient’s home. Thirty-minute appointments are available 7 days a week, including evenings. Services are available for all ages. A multiway video chat allows the dietician to support the patient by reviewing food ingredient labels together and suggesting strategies for success.  Structured, personalized meal plans and recipes are delivered to the patient’s inbox after their visit. The dietician can help the patient improve their overall health and well-being, productivity, and reduce healthcare costs.
• Women’s Health Services give women 18 years of age or older access to convenient, specialized care. Clinicians cater to the full care continuum across life stages and provide medical care for women-specific health issues, ranging from prenatal and postnatal support to menopause care. Clinicians can help answer questions, provide treatment, and prescribe medication if medically necessary. On-demand visits are available 7 days a week. 
• Lactation Support is available for women who have breastfeeding questions or concerns, including latching issues, milk supply, pumping, mastitis, thrush, and more.  Appointments with board-certified lactation consultants are available.
• Dermatology Support gives adults and children of any age an online program to help manage chronic conditions like acne, rosacea, psoriasis, or skin cancer checks by scheduling with board-certified dermatologists. Asynchronous visits are available 24 hours per day, 7 days week where patients will receive a written summary of treatment within 72 hours, including prescribed medications if medically necessary.

Note: For telemental or mental health and substance use disorder benefits, see Section 5(e). Mental Health and Substance Use Disorder Benefits.

The Real Appeal Program through Optum is an online weight loss program that offers group and one-on-one personalized coaching through an online and mobile platform. The program focuses on weight loss through proper nutrition, exercise, sleep and stress management. Members will have access to a Transformation Coach and a suite of online tools to help track food and activity. Members will also receive a Success Kit to support their weight loss journey including a food and weight scale, resistance band, access to Fitness on Demand and more!

Coaching sessions are scheduled online at the members’ convenience and educational content is provided throughout the year. Coaches will be able to see the participants’ progress throughout the course of the program and be able to offer personalized support. Real Appeal encourages members to make small changes toward larger long-term health results with sustained support throughout the duration of the program.

Members can enroll in the Real Appeal Program online at www.nalchbp.org.

You can earn valuable health savings rewards to use towards eligible medical expenses. We will send each eligible member, 18 years of age and older, a debit card to access their account. If you or your eligible dependent(s) take any of the actions that would make you eligible for health account dollars, you are entitled to receive those health account dollars on a debit card that will automatically be sent to you from our wellness program partner. Please keep your card for future use even if you use all your health account dollars; you may be eligible for wellness incentives in subsequent benefit years. Our wellness program partner does not send new cards to continuing participants until the card expires. If you leave the NALC Health Benefit Plan, any money remaining in your account will be forfeited. Below is a list of programs, screenings, and preventive services that are eligible for a health savings reward. See criteria to receive the reward in the Section indicated.

• Your Health First Disease Management Program - $50. See Disease management program - Your Health First in this section for details.
• Healthy Pregnancies, Healthy Babies - $50. See Healthy Pregnancies, Healthy Babies Program in this section for details.
• Quit for Life Tobacco Cessation Program - $50. See Section 5(a). Educational classes and programs for details.
• Annual biometric screening - $50. See Section 5(a). Preventive care, adults for details.
• Health Assessment - $30. See Health Assessment in this section for details.
• Annual influenza vaccine - $10. See Section 5(a). Preventive care, adults or Preventive care, children for details.
• Annual pneumococcal vaccine - $10. See Section 5(a). Preventive care, adults for details.
• Completion of 6 well-child visits through age 15 months - $50. See Section 5(a). Preventive care, children for details.

An eligible medical expense is defined as those expenses paid for care as described in Section 213 (d) of the Internal Revenue Code. Please visit our website for a list to help you determine whether an expense is eligible. You are only eligible to receive one (1) reward amount per person, per program or wellness activity per calendar year.

A CDHP Personal Care Account (PCA) is provided by the Plan for each Open Season enrollment. See the Important section for enrollments outside of Open Season. Each full year the Plan adds to your account:

• $1,200  per year for Self Only
• $2,400 per year for Self Plus One or
• $2,400  per year for Self and Family

The CDHP PCA covers eligible expenses at 100%. For example, if you are ill and go to a network doctor for a $60 visit, the doctor will submit your claim and the cost of the visit will be deducted automatically from your PCA; you pay nothing.

Balance in CDHP PCA
for Self Only                                    $1,200
Less: Cost of visit                                  -60 
Remaining Balance in
CDHP PCA                                      $1,140

Note: PCA expenses are the same medical, surgical, hospital, emergency, mental health and substance use disorder, and prescription drug services and supplies covered under the Traditional Health Coverage (see CDHP, Section 5 for details) 
To make the most of your PCA you should:

• Use network providers wherever possible; and
• Use generic prescriptions wherever possible.

In-Network and Out-of-Network: Nothing up to $1,200 for Self Only, $2,400 for Self Plus One, or $2,400 for Self and Family

Not covered:

• Orthodontia
• Dental treatment for cosmetic purposes including teeth whitening
• Out-of-network preventive care services not included under CDHP Section 5(a)
• Services or supplies shown as not covered under Traditional Health Coverage (see CDHP Section 5(c)

When you are enrolled in the CDHP and your PCA has exhausted, you must satisfy your calendar year deductible before your Traditional Health Coverage begins.

Your deductible is $2,000 for Self Only, $4,000 for Self Plus One, or $4,000 for Self and Family for In-Network providers. Your deductible for Out-of-Network providers is $4,000 for Self Only, $8,000 for Self Plus One, or $8,000 for Self and Family. See Section 4. Your Costs for Covered Services for more information.

Note: You must use any available PCA benefits, including any amounts rolled over from previous years, before Traditional Health Coverage begins when you are enrolled in the CDHP.

See below for how your PCA and deductible work.

Expenses paid by PCA:  $1,200 Self Only/$2,400 Self Plus One/$2,400 Self and Family
Deductible paid by you: $800/Self Only/$1,600 Self Plus One/$1,600 Self and Family 
Traditional Health Coverage starts after: $2,000 Self Only/$4,000 Self Plus One/$4,000 Self and Family 

Any PCA dollars that you roll over at the end of the year will reduce your deductible next year up to the maximum amount allowed in your PCA of $5,000 for Self Only, or $10,000 for Self Plus One, or $10,000 for Self and Family.

In future years, the amount of your deductible may be lower if you roll over PCA dollars at the end of the year. For example, if you roll over $300 at the end of the year:

PCA for year 2/Rollover from year 1: $1,200 + $300 = $1,500 Self Only/$2,400 + $300 =$2,700 Self Plus One/$2,400 + $300 = $2,700 Self and Family
Deductible paid by you: + $500 Self Only/+$1,300 Self Plus One/+$1,300 Self and Family
Traditional Health Coverage starts when eligible expenses total:  $2,000 Self Only/$4,000 Self Plus One/$4,000 Self and Family

In-Network: $800 per Self Only, $1,600 per Self Plus One, or $1,600 per Self and Family

Out-of-Network: $2,800 per Self Only, $5,600 per Self Plus One, or $5,600 per Self and Family

The “You pay” shown above may be reduced for year 2 due to any roll over amount in your PCA.

• Routine examinations, limited to:
  • Routine physical exam—one annually, age 22 or older
  • Initial office visit associated with a covered routine sigmoidoscopy or colonoscopy screening test
• The following preventive services are covered at the time interval recommended at each of the links below.
  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV). For a complete list of immunizations, go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
  • Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings, go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
  • A1C test—one annually, age 18 or older
  • Individual counseling on prevention and reducing health risks
  • Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women, go to the Health and Human Services (HHS) website at  https://www.healthcare.gov/preventive-care-women/
  • Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations.
  • To build your personalized list of preventive services go to https://health.gov/myhealthfinder
• Biometric screening- one annually; including:
  • calculation of body mass index (BMI)
  • waist circumference measurement
  • total blood cholesterol
  • blood pressure check
  • fasting blood sugar
• Routine mammogram for women—age 35 and older, as follows:
  • Age 35 through 39—one during this five year period
  • Age 40 and older—one every calendar year

Note: When the NALC Health Benefit Plan CDHP is the primary payor for medical expenses, the Plan will cover FDA-approved vaccines when administered by a pharmacy that participates in the NALC Health Benefit Plan Broad Vaccine Administration Network. A full list of participating pharmacies is available at www.nalchbp.org or call CVS Caremark Customer Service at 800-933-NALC (6252) to locate a local participating pharmacy. Pharmacy participation may vary based on state law. 

Note: You can earn $5 in health savings rewards for having an annual flu vaccine and $5 in health savings rewards for having an annual pneumococcal vaccine.  Please see Section 5(h). Wellness Incentive Programs for more details.

Note: You can earn $30 in health savings rewards for having an annual biometric screening. Please see Section 5(h). Wellness Incentive Programs for more details.

Note: Breast tomosynthesis (3-D mammogram) is considered a preventive care screening test as long as it is performed in conjunction with a routine screening mammography.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

In-Network: Nothing

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount. (calendar year deductible applies)

Not covered:

• Routine lab tests, except listed under Preventive care, adult in this section.
• Immunizations, boosters, and medications for travel or work-related exposure.
• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines, go to https://brightfutures.aap.org
  • Examinations, limited to:
    • Initial examination of a newborn child covered under a family enrollment
    • Well-child care-routine examinations through age 2
    • Routine physical exam (including camp, school, and sports physicals)-one annually, age 3 through 21
• A1C test—one annually, age 18 or older
• Immunizations such as DTap/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations, go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
• You may also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Note: Camp, school and sports physicals are not covered when rendered at CVS MinuteClinic.

Note: You can earn $30 in health savings rewards for completing 6 well-child visits through age 15 months as recommended above. Please see Section 5(h). Wellness and Other Special Features for details.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Note: When the NALC Health Benefit Plan CDHP is the primary payor for medical expenses, the Plan will cover FDA-approved vaccines when administered by a pharmacy that participates in the NALC Health Benefit Plan Broad Vaccine Administration Network. A full list of participating pharmacies is available at www.nalchbp.org or call CVS Caremark Customer Service at 800-933-NALC (6252) to locate a local participating pharmacy. Pharmacy participation may vary based on state law. 

Note: You can earn $5 in health savings rewards for having an annual flu vaccine.  Please see Section 5(h). Wellness Incentive Programs for more details.

In-Network: Nothing

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount. (calendar year deductible applies)

Not covered:

• Routine hearing testing, except as listed in Preventive care, children and Hearing services... in this section
• Routine lab tests, except as listed in Preventive care, children in this section

Professional services of physicians (including specialists) or urgent care centers

• Office or outpatient visits
• Office or outpatient consultations
• Office or outpatient virtual visits
• Second surgical opinions

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Telehealth professional services for:

• Minor acute conditions (See Section 10, page (Applies to printed brochure only) for definition)

Note: For more information on telehealth benefits, see Section 5(h). Wellness and Other Special Features.

In-Network: 10% of the Plan allowance

Out-of-Network: All charges

Professional services of physicians

• Hospital care
• Skilled nursing facility care
• Inpatient medical consultations
• Home visits
• Emergency room physician care (non-accidental injury)

Note: For initial examination of a newborn child covered under a family enrollment, see Preventive care, children in CDHP Section 5.

Note: For routine post-operative surgical care, see CDHP Section 5(b). Surgical procedures.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Routine eye and hearing examinations (except as listed in Preventive care, children and Hearing services... in CDHP Section 5)
• Nonsurgical treatment for weight reduction or obesity (except as listed in Educational classes and programs in this section)

Tests and their interpretation, such as: 

• Blood tests
• Urinalysis
• Non-routine Pap test
• Pathology
• X-ray
• Neurological testing
• Non-routine mammogram
• Ultrasound
• Electrocardiogram (EKG)
• Electroencephalogram (EEG)
• Bone density study 
• CT/CAT Scan/MRI/MRA/NC/PET (Outpatient requires precertification - See Section 3)
• Genetic counseling
• Genetic testing - requires prior approval. See Section 3. How You Get Care
• Urine drug testing/screening for non-cancerous chronic pain and substance use disorder is limited to:
  • 16 definitive (quantitative) drug tests per calendar year
  • 32 presumptive (qualitative) drug tests per calendar year
• Annual skin cancer screening

Note:  For definitions of definitive and presumptive drug tests, see Section 10. Definitions of Terms We Use in This Brochure.

Note: Benefits are available for diagnostic genetic testing, including genetic counseling, when it is medically necessary to diagnose and/or manage a patient’s medical condition. Genetic testing requires prior authorization. See Section 3. How you get care.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Complete maternity (obstetrical) care, limited to:

• Prenatal and postpartum care
• Delivery
• Amniocentesis
• Anesthesia related to delivery or amniocentesis
• Group B streptococcus infection screening
• Sonograms 
• Fetal monitoring
• Tetanus-diphtheria, pertussis (Tdap)-one dose during each pregnancy 

Note: We cover services related to a miscarriage or stillbirth under the Maternity care benefit.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• Breastfeeding support and counseling
• Rental or purchase of breastfeeding equipment

In-Network: Nothing (No deductible)

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Preventive medicine counseling and screening tests as recommended by the USPSTF for pregnant women, limited to:

• Screening and counseling for prenatal and postpartum depression 
• Gestational diabetes
• Hepatitis B
• Human immunodeficiency virus (HIV)
• Iron deficiency anemia
• Lactation support and counseling for breastfeeding
• Preeclampsia screening
• Rh screening
• Syphilis
• Tobacco use counseling
• Urine culture for bacteria
• Urine testing for bacteriuria

In-Network: Nothing (No deductible) 

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• Other tests medically indicated for the unborn child or as part of the maternity care

Note: Here are some things to keep in mind:

• Genetic tests performed as part of a routine pregnancy require prior authorization
• You do not need to precertify your vaginal or cesarean delivery; see Section 3. How to get approval for… for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will cover an extended stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment if we cover the infant under Self Plus One or Self and Family enrollment.
• The circumcision charge for an infant covered under Self Plus One or Self and Family enrollment is payable under surgical benefits. See CDHP Section 5(b). Surgical procedures.
• We pay hospitalization, anesthesia, and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under CDHP Section 5(c) and Surgical benefits under CDHP Section 5(b).

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• Contraceptive counseling on an annual basis
• Tubal ligation or tubal occlusion/tubal blocking procedures only
• Vasectomy
• Surgical placement of  implanted contraceptives
• Removal of a birth control device
• Management of side effects of birth control
• Services related to follow up of services listed above
• Office visit associated with a covered family planning service

Note: Outpatient facility charges related to tubal ligation or tubal occlusion/tubal blocking procedures only are payable under outpatient hospital benefit. See CDHP Section 5(c). Outpatient hospital. For anesthesia related to tubal ligation or tubal occlusion/tubal blocking procedures only, see CDHP Section 5(b). Anesthesia.

In-Network: Nothing (No deductible)

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

A range of voluntary family planning services, limited to:

• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms

Note:  We cover oral contraceptives under the prescription drug benefit. 

In-Network: Nothing (No deductible)

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: 

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling except as listed in this section.

Infertility is a disease or medical condition of the reproductive system. The Plan covers the diagnosing and treatment of infertility as well as treatment needed to conceive, including covered artificial insemination procedures. Infertility may also be established through an evaluation based on medical history and diagnostic testing.

• Diagnostic services
• Laboratory tests
• Fertility drugs
• Artificial insemination (Up to 3 cycles):
• Intravaginal insemination (IVI)
• Intracervical insemination (ICI)
• Intrauterine insemination (IUI)

You may also visit our website at www.nalchbp.org/infertility for additional information on infertility benefits. 

Note: Prescription drugs (Up to 3 cycles of IVF-related drugs) are covered for the treatment of infertility.

In-Network: 20% of the Plan allowance and all charges after 3-cycle limit

Out-of-Network: 50% of the Plan allowance, any difference between our allowance and the billed amount, and all charges after 3-cycle limit

Benefits are available for fertility preservation for medical reasons that cause irreversible infertility such as chemotherapy or radiation treatment. Services include the following procedures, when provided by or under the care or supervision of a Physician:

• Cryopreservation of sperm
• Embryo cryopreservation
• Cryopreservation of reproductive tissue, testicular or ovarian
• Mature oocyte cryopreservation
• Storage costs up to one year

 Note: These services are only covered while you are enrolled in the Plan.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Infertility services after voluntary sterilization
• Assisted reproductive technology (ART) procedures related to IVF or embryo transfer such as:
  • In vitro fertilization (IVF)
  • Embryo transfer and gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT)
• Services and supplies related to IVF or embryo transfer procedures
• Services, supplies, or drugs provided to individuals not enrolled in this Plan
• Cost of donor sperm
• Cost of donor egg
• Cryopreservation, sperm banking, or thawing procedures, except as listed above
• Preimplantation diagnosis, testing, and/or screening of eggs, sperm, or embryos
• Elective preservation for reasons other than listed above
• Long-term storage costs (greater than one year)

All charges

• Testing
• Treatment
• Allergy serum 
• Allergy injections 

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Provocative food testing and sublingual allergy desensitization, including drops placed under the tongue
• Environmental control units, such as air conditioners, purifiers, humidifiers, and dehumidifiers

• Gene therapy products and services directly related to their administration are covered when medically necessary. Gene therapy is a category of pharmaceutical products approved by the U.S. Food and Drug Administration (FDA) to treat or cure a disease by:
• Replacing a disease-causing gene with a healthy copy of the gene
• Inactivating a disease-causing gene that may not be functioning properly
• Introducing a new or modified gene into the body to help treat a disease

Coverage includes the cost of the gene therapy product, the medical, surgical, and facility services directly related to administration of the gene therapy product, and the professional services. Gene therapy products and their administration are covered when preauthorized to be received at participating In-Network facilities specifically contracted for the specific gene therapy service. When approved, the Gene Therapy Travel Program will help cover the cost of travel and lodging to a gene therapy network provider, up to $10,000 per gene therapy. Gene therapy products and their administration received at other facilities are not covered. Call 855-511-1893 for more information and for preauthorization.

In-Network: 20% of the Plan allowance

Out-of-Network: All charges

• Intravenous (IV)/Infusion Therapy—Home IV and antibiotic therapy
• Respiratory and inhalation therapies
• Growth hormone therapy (GHT)
• Cardiac rehabilitation therapy - Phases I and II only
• Pulmonary rehabilitation therapy

Note: Phase I begins in the hospital after a major heart event and includes visits by the cardiac rehab team, education, and nutritional counseling, along with rehab. Phase II begins after leaving the hospital and is a comprehensive program consisting of medical evaluation, prescribed exercise, behavior modification, heart monitoring, education, and counseling, typically performed in an outpatient setting. Phases III and IV are supervised safe exercise (performed in the home or gym) and are not covered by the Plan.

Note: Specialty drugs, including biotech, biological, biopharmaceutical, and oral chemotherapy drugs, available through CVS Specialty are covered only under the Prescription drug benefit. See CDHP Section 5(f). Prescription Drug Benefits.

Note: Prior approval is required for all specialty drugs used to treat chronic medical conditions. See instructions for approval in CDHP Section 5(f). Prescription Drug Benefits—These are the dispensing limitations.

• Dialysis—hemodialysis and peritoneal dialysis
• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed in CDHP Section 5(b). Organ/tissue transplants.

Note: Oral chemotherapy drugs available through CVS Caremark are covered only under the Prescription Drug Benefit. See CDHP Section 5(f). Prescription Drug Benefits—These are the dispensing limitations.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• Applied Behavioral Analysis (ABA) therapy for children through age 18 with autism spectrum disorder rendered by an In-Network provider

In-Network: 20% of the Plan allowance

Out-of-Network: All charges

Not covered:

• Chelation therapy, except as treatment for acute arsenic, gold, lead, or mercury poisoning
• Prolotherapy
• ABA therapy not prior authorized

• A combined total of 50 rehabilitative and habilitative visits per calendar year for treatment provided by a licensed registered therapist or physician for the following:
  
  • Physical therapy
  • Occupational therapy
  • Speech therapy

Therapy is covered when the attending physician:

• Orders the care;
• Identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• Indicates the length of time the services are needed.

Note: There is no member cost share when you access virtual physical therapy through Hinge Health. See Section 5(h). Wellness and Other Special Features.

Note: For accidental injuries, see Section 5(d). Emergency Services/Accidents.

Note: For therapies performed on the same day as outpatient surgery, see Section 5(c). Outpatient hospital or ambulatory surgical center.

Note: Physical therapy by a chiropractor is covered when the service performed is within the scope of their license.

In-Network: 20% of the Plan allowance and all charges after 50-visit limit

Out-of-Network: 50% of the Plan allowance, any difference between our allowance and the billed amount, and all charges after 50-visit limit

• Physical therapy to prevent falls for community-dwelling adults age 65 and older as recommended by the U.S. Preventive Services Task Force (USPSTF)

Therapy is covered when the attending physician:

• Orders the care;
• Identifies the specific professional skills the patient requires; and
• Indicates the length of time the services are needed.

In-Network: Nothing (No deductible)

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Dry needling
• Exercise programs
• Maintenance rehabilitative therapy that maintains a functional status or prevents decline in function

• For treatment (excluding hearing aids) related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants, including batteries
• First hearing aid and examination, limited to services necessitated by accidental injury 

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• Hearing aid(s), limited to a maximum Plan payment of $1,500 with replacements covered every 3 years.
• Hearing aids for children through age 18, limited to a maximum Plan payment of $1,500 with replacements covered annually.

Note: Maximum payment is based on the Plan allowance, not charged amount.

In-Network: 20% of the Plan allowance and all charges after we pay $1,500 (No deductible)

Out-of-Network: 50% of the Plan allowance, any difference between our allowance and the billed amount, and all charges after we pay $1,500 (No deductible)

Not covered:

• Routine hearing testing (such as testing for routine hearing loss as a result of aging), except as listed in Preventive care, children and Hearing services... in this CDHP Section 5
• Auditory device except as described above
• Hearing aid batteries, except as described above

All charges

• Office visit for eye examinations for covered diagnoses, such as cataract, diabetic retinopathy and glaucoma

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or following intraocular surgery (such as for cataracts) when purchased within one year
• Tests and their interpretations for covered diagnoses, such as:
  • Fundus photography
  • Visual field
  • Corneal pachymetry

Note: We only cover the standard intraocular lens prosthesis, such as for cataract surgery.

Note: For childhood preventive vision screenings, see Preventive care, children in Section 5.

Note: See CDHP Section 5(h). Wellness and Other Special Features for discounts available for vision care.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Eyeglasses or contact lenses and examinations for them, except as described above
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery
• Refractions
• Polarization
• Scratch-resistant coating

• Nonsurgical routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes 
• One pair of diabetic shoes every calendar year

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• Surgical procedures for routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes
• Open cutting, such as the removal of bunions or bone spurs

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Cutting, trimming, or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained, or flat feet; bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)
• Foot orthotics (shoe inserts) except as listed under Orthopedic and prosthetic devices in this section
• Arch supports, heel pads, and heel cups
• Orthopedic and corrective shoes
• Repair to custom functional foot orthotics
• Extracorporeal shock wave treatment

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Custom-made durable braces covered every 3 years for legs, arms, neck, and back
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Internal prosthetic devices covered every 3 years, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.

Note: For information on the professional charges for the surgery to insert an implant, see CDHP Section 5(b). Surgical procedures. For information on the hospital and/or ambulatory surgery center benefits, see CDHP Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services.

Note: Internal prosthetic devices billed by the hospital are paid as hospital benefits. See CDHP Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services.

Note: We only cover the standard intraocular lens prosthesis, such as for cataract surgery.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Wigs for hair loss due to the treatment of cancer (with a maximum Plan payment of $200 per lifetime)

In-Network: 20% of the Plan allowance and all charges after we pay $200 per lifetime (No deductible)

Out-of-Network: 50% of the Plan allowance and all changes after we pay $200 per lifetime (No deductible)

• Two pairs of custom functional foot orthotics, including casting, when prescribed by a physician

In-Network: 20% of the Plan allowance and all charges after the two pair annual limit 

Out-of-Network: 50% of the Plan allowance, any difference between our allowance and the billed amount, and all charges after the two pair annual limit 

Not covered:

• Wigs (cranial prosthetics) except as described above
• Orthopedic and corrective shoes
• Arch supports, heel pads and heel cups
• Foot orthotics (shoe inserts) except as listed under Orthopedic and prosthetic devices in this section
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Bionic prosthetics (including microprocessor- controlled prosthetics)
• Hearing aid batteries, except as described above

Durable medical equipment (DME) is equipment and supplies that:

1. Are prescribed by your attending physician (i.e., the physician who is treating your illness or injury);
2. Are medically necessary;
3. Are primarily and customarily used only for a medical purpose;
4. Are generally useful only to a person with an illness or injury;
5. Are designed for prolonged use; and
6. Serve a specific therapeutic purpose in the treatment of an illness or injury.

Note: Call us at 855-511-1893 as soon as your physician prescribes equipment or supplies. The Plan requires a letter of medical necessity, or a copy of the prescription, from the prescribing physician which details the medical necessity to consider charges for the purchase or rental of DME.

We cover rental or purchase (at our option) including repair and adjustment of durable medical equipment every 3 years, such as:

• Oxygen and oxygen apparatus
• Dialysis equipment
• Continuous glucose monitors
• Insulin pumps
• Manual and semi-electric hospital beds
• Wheelchairs
• Crutches, canes, and walkers

Note: We limit the Plan allowance for our DME rental benefit to an amount no greater than what we would have considered if the equipment had been purchased.

We also cover supplies, such as:

• Insulin and diabetic supplies
• One pair of diabetic shoes every calendar year
• Needles and syringes for covered injectables
• Ostomy and catheter supplies

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• DME replacements (including rental) provided less than 3 years after the last one we covered.
• Bathroom equipment, such as whirlpool baths, grab bars, shower chairs, commode chairs, and shower commode chairs
• Sun or heat lamps and similar household equipment
• Exercise equipment, such as treadmills, exercise bicycles, stair climbers, and free weights
• Car seats of any kind
• Functional electrical stimulation equipment
• Communication equipment including computer "story boards" or "light talkers"
• Total electric hospital beds
• Furniture, such as adjustable mattresses and recliners, even when prescribed by a physician
• Enhanced vision systems, computer switch boards, or environmental control units
• Heating pads, air conditioners, purifiers, and humidifiers
• Safety and convenience equipment, such as stair climbing equipment, stair glides, ramps, and elevators
• Modifications or alterations to vehicles or households
• Equipment or devices, such as iBOT Mobility System that allow increased mobility, beyond what is provided by standard features of DME
• Other items (such as wigs) that do not meet the criteria 1 thru 6 in this Section.

Home nursing care for 2 hours per day up to 25 days per calendar year when:

• a registered nurse (R.N.), licensed practical nurse (L.P.N.), or licensed vocational nurse (L.V.N.) provides the services;
• the attending physician orders the care;
• the physician identifies the specific professional skills required by the patient and the medical necessity for skilled services; and
• the physician indicates the length of time the services are needed.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient's family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
• Private duty nursing

Limited to:

• One set of spinal X-rays annually
• 12 spinal or extraspinal manipulations per calendar year

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Limited to:

• Initial office visit or consultation
• 12 office visits per calendar year when rendered on the same day as a covered spinal or extraspinal manipulation

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Limited to:

• Initial office visit or consultation to assess patient for acupuncture treatment

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Limited to:

• Acupuncture, by a doctor of medicine or osteopathy, or a state licensed or certified practitioner. Benefits are limited to 25 acupuncture visits per person per calendar year.
• 25 office visits per calendar year when rendered on the same day as a covered acupuncture treatment

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance, any difference between our allowance and the billed amount, and all charges after 25-visit limit

Not covered:

• Services performed by an acupuncturist who is not licensed or certified, even if the state where services are performed does not require acupuncturists to be licensed or certified
• Naturopathic services
• Cosmetic acupuncture

• A voluntary tobacco cessation program offered by the Plan which includes:
  • Unlimited professional 20-30 minute telephonic counseling sessions per quit attempt
  • Online tools
  • Over-the-counter nicotine replacement therapy

For more information on the program or to join, visit www.mycigna.com or call 855-246-1873.

Note: For group and individual counseling for tobacco cessation, see Preventive care, adult in this section.

Note: FDA-approved prescription medications and over-the-counter medications (when purchased with a prescription) for tobacco cessation are covered only under the Prescription drug benefit. See CDHP Section 5(f). Prescription Drug Benefits.

Note: You can earn $30 in health savings rewards for participation in this program. Eligibility will be determined by your health coach and you must have at least 5 telephonic counseling sessions. See Section 5(h). Wellness Incentive Programs for more details.

In-Network: Nothing (No deductible)

Out-of-Network: All charges

• Educational classes and nutritional therapy when:
  
  • Prescribed by the attending physician, and
  • Administered by a covered provider, such as a registered nurse or a licensed or registered dietician/nutritionist.

Note: To join our Weight Management Program, see CDHP Section 5(h). Wellness and Other Special Features.

In-Network: Nothing (No deductible)

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Over-the-counter medications or dietary supplements prescribed for weight loss

All charges

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies
• Insertion of internal prosthetic devices. See CDHP Section 5(a). Orthopedic and prosthetic devices, for device coverage information.
• Debridement of burns

Note: When multiple or bilateral surgical procedures add complexity to an operative session, the Plan allowance for the second or less expensive procedure is one-half of what the Plan allowance would have been if that procedure had been performed independently.

Note: The Plan allowance for an assistant surgeon will not exceed 25% of our allowance for the surgeon.

Note: When a surgery requires two primary surgeons (co-surgeons), the Plan allowance for each surgeon will not exceed 62.5% of our allowance for a single surgeon to perform the same procedure(s).

Note: Simple repair of a laceration (stitches) and immobilization by casting, splinting, or strapping of a sprain, strain, or fracture, will be considered under this benefit when services are rendered after 72 hours of the accident.

Note: We only cover the standard intraocular lens prosthesis for cataract surgery.

Note: Initial inpatient (non-elective) surgery rendered by a Out-of-Network surgeon for the surgical treatment of appendicitis, brain aneurysms, burns, or gunshot wounds will be paid at the In-Network benefit level.

In-Network: 20% of the Plan allowance 

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• Surgical treatment of severe obesity (bariatric surgery) is covered when:

1. Clinical records support a body mass index (BMI) of 35 or greater, or 30 or greater with at least one clinically significant obesity-related comorbidity including, but not limited to: weight-related degenerative joint disease, diabetes mellitus, cardiovascular disease, hypertension, obstructive sleep apnea, hyperlipidemia, or debilitating arthritis.
2. Diagnosis of severe obesity for a period of one year prior to surgery.
3. The patient has participated in a supervised weight-loss program of at least six months duration, that includes dietary therapy, physical activity, and behavioral modification. Evidence in the medical record that attempts at weight loss in the one year period prior to surgery have been ineffective.
4. The patient is age 13 or older.
5. Medical and psychological evaluations have been completed and the patient has been recommended for bariatric surgery.
6. A repeat or revised bariatric surgical procedure is covered only when determined to be medically necessary or a complication has occurred.

Note: A revisional surgery not related to a complication and performed more than 2 years from the date of the original surgery will require medical documentation as listed in requirements 1-5.

In-Network: 20% of the Plan allowance 

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• Gender affirming chest, genital, and facial feminization/masculinization surgeries are covered when medically necessary and meet the following criteria: 
•  The patient must meet all requirements.
  • Prior approval is obtained
  • Patient must be at least 18 years of age at the time prior approval is requested and the treatment plan is submitted
  • Diagnosis of gender dysphoria by a qualified healthcare professional
    • Patient’s gender dysphoria is not a symptom of another mental disorder
    • Gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning
  • 6 months of continuous hormone therapy appropriate to the patient’s gender identity
  • One referral letter of support from a qualified mental health professional, who has competencies in the assessment of transgender and gender diverse people is needed 
  • If medical or mental health concerns are present, they are being optimally managed and are reasonably well-controlled
• Reversal of a gender affirmation surgery is covered only when determined to be medically necessary or a complication occurs.

Note: Prior approval is required for gender affirmation surgery.  For more information about prior approval, please refer to Section 3. How You Get Care or visit our website at www.nalchbp.org.

In-Network: 20% of the Plan allowance 

Out-of-Network: 50% of the Plan allowance and the difference, if any, between our allowance and the billed amount

• Tubal ligation or tubal occlusion/tubal blocking procedures only
• Vasectomy
• Surgical placement of implanted contraceptives
• Insertion of intrauterine devices (IUDs)
• Removal of birth control device

Note: We cover intrauterine devices and implanted contraceptives, (such as Implanon) only under the Prescription Drug Benefit. See CDHP Section 5(f). Prescription Drug Benefits.

In-Network: Nothing (No deductible)

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingival and alveolar bone)
• Cosmetic services that are not medically necessary
• Radial keratotomy and other refractive surgery
• Procedures performed through the same incision deemed incidental to the total surgery, such as appendectomy, lysis of adhesion, puncture of ovarian cyst
• Reversal of voluntary sterilization
• Services of a standby surgeon, except during angioplasty or other high risk procedures when we determine standby surgeons are medically necessary
• Cutting, trimming, or removal of corns, calluses, or the free edge of toenails; and similar routine treatment of conditions of the foot, except as listed under CDHP Section 5(a). Foot care
• Weight loss surgery for implantable devices such as Maestro Rechargeable System

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • The condition produced a major effect on the member’s appearance; and
  • The condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a congenital anomaly (condition that existed at or from birth and is a significant deviation from the common form or norm). Examples of congenital anomalies are protruding ear deformities; cleft lip; cleft palate; birthmarks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • Surgery to produce a symmetrical appearance of breasts
  • Treatment of any physical complications, such as lymphedemas

Note: Congenital anomaly does not include conditions related to teeth or intra-oral structures supporting the teeth.

Note: We cover internal and external breast prostheses, surgical bras and replacements. See CDHP Section 5(a). Orthopedic and prosthetic devices, and CDHP Section 5(c). Inpatient hospital.

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

In-Network: 20% of the Plan allowance 

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Cosmetic services that are not medically necessary
• Injections of silicone, collagens, and similar substances
• Surgery related to sexual dysfunction

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion
• Removal of stones from salivary ducts
• Excision of leukoplakia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Other surgical procedures that do not involve the teeth or their supporting structures
• Removal of impacted teeth that are not completely erupted (bony, partial bony and soft tissue impaction)

In-Network: 20% of the Plan allowance 

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone).

Cigna LifeSOURCE Transplant Network® - The Plan participates in the Cigna LifeSOURCE Transplant Network. Before your initial evaluation as a potential candidate for a transplant procedure, you or your physician must contact Cigna HealthCare at 855-511-1893 and speak to a referral specialist in the Comprehensive Transplant Case Management Unit. You will be given information about this program including a list of participating providers. 

Charges for services performed by a Cigna LifeSOURCE Transplant Network provider, whether incurred by the recipient or the donor, are paid at 80% including inpatient hospital, surgical and any other medical expenses. Participants in the program must obtain prior approval from the Cigna LifeSOURCE Transplant Network to receive limited travel and lodging benefits. 

20% of the Plan allowance for services obtained through the Cigna LifeSOURCE Transplant Network

Limited Benefits—If you do not obtain prior approval or do not use a designated facility, or if we are not the primary payor, we pay a maximum of $100,000 for each listed transplant (kidney limit, $50,000), for these combined expenses: pre-transplant evaluation; organ procurement; and inpatient hospital, surgical and medical expenses. We pay benefits according to the appropriate benefit section, such as CDHP Section 5(c). Inpatient hospital, and Surgical procedures in this section. The limitation applies to expenses incurred by either the recipient or donor.

Note: Some transplants listed may not be covered through the Cigna LifeSOURCE Transplant Network.

Note: We cover related medical and hospital expenses of the donor only when we cover the recipient.

In-Network: 30% of the Plan allowance 

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services in Section 3 for prior authorization procedures. Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney/pancreas
• Liver
• Lung single/bilateral/lobar
• Pancreas

20% of the Plan allowance for services obtained through the Cigna LifeSOURCE Transplant Network

In-Network: 30% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. See Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for:
  • AL Amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

20% of the Plan allowance for services obtained through the Cigna LifeSOURCE Transplant Network

In-Network: 30% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Blood or marrow stem cell transplants 

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant. These blood or marrow stem cell transplants are subject to medical necessity review by the Plan. See Other services in Section 3 for prior authorization procedures.

• Allogeneic transplants for diseases such as:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Hodgkin’s lymphoma 
  • Non-Hodgkin’s lymphoma 
  • Myeloproliferative Disorders (MPDs)
  • Neuroblastoma
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy disorders
  • Infantile malignant osteoporosis
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome,  Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic syndromes
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe aplastic anemia
  • Sickle Cell Anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for diseases such as:
  • Acute non-lymphocytic (i.e., myelogenous) leukemia
  • Hodgkin’s lymphoma 
  • Non-Hodgkin’s lymphoma 
  • Amyloidosis
  • Multiple myeloma
  • Neuroblastoma
  • Testicular and Ovarian germ cell tumors

20% of the Plan allowance for services obtained through the Cigna LifeSOURCE Transplant Network

In-Network: 30% of the Plan allowance 

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Blood or marrow stem cell transplants covered only in a National Cancer Institute (NCI) or National Institutes of Health (NIH) approved clinical trial at a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocols, such as:

• Autologous transplants for:
  • Aggressive non-Hodgkin’s lymphomas (Mantle Cell lymphoma), adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms
  • Breast cancer
  • Epithelial ovarian cancer
  • Childhood rhabdomyosarcoma
  • Advanced Ewing sarcoma
  • Advanced childhood kidney cancers
  • Mantle Cell (non-Hodgkin’s lymphoma)

Note: If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

20% of the Plan allowance for services obtained through the Cigna LifeSOURCE Transplant Network

In-Network: 30% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and the difference, if any, between our Plan allowance and the billed amount

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

See Other services in Section 3 for prior authorization procedures.

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Acute myeloid leukemia
  • Advanced Myeloproliferative Disorders (MPDs)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

Note: If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

20% of the Plan allowance for services obtained through the Cigna LifeSOURCE Transplant Network

In-Network: 30% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Donor screening tests and donor search expenses, except those performed for the actual donor
• Travel and lodging expenses, except when approved by the Cigna LifeSOURCE Transplant Network
• Implants of artificial organs
• Transplants and related services and supplies not listed as covered

Professional services provided in:

• Hospital (inpatient)

Note: If surgical services (including maternity) are rendered at an In-Network hospital, we will pay up to the Plan allowance for services of Out-of-Network anesthesiologists at the In-Network benefit level.

In-Network: 20% of the Plan allowance 

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Professional services provided in:

• Hospital outpatient department
• Ambulatory surgical center
• Office
• Other outpatient facility

Note: If surgical services (including maternity) are rendered at an In-Network hospital or ambulatory surgical center, we will pay up to the Plan allowance for services of Out-of-Network anesthesiologists at the In-Network benefit level.

In-Network: 20% of the Plan allowance 

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Professional services provided for:

• Tubal ligation or tubal occlusion/tubal blocking
  procedures only
• Vasectomy

In-Network: Nothing (No deductible)

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Room and board, such as:

• Ward, semiprivate, or intensive care accommodations
• Birthing room
• General nursing care
• Meals and special diets

Note: We cover a private room only when you must be isolated to prevent contagion. Otherwise, we pay the hospital’s average charge for semiprivate accommodations. If the hospital has private rooms only, we base our payment on the average semiprivate rate of the most comparable hospital in the area.

Note: When the Out-of-Network hospital bills a flat rate, we will exclude all charges and request an itemized bill.

Note: When room and board charges are billed by a hospital, inpatient benefits apply. For Observation room charges billed, see Outpatient hospital or ambulatory surgical center in this section.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Preadmission testing (within 7 days of admission), limited to:
  • Chest X-rays
  • Electrocardiograms
  • Urinalysis
  • Blood work
• Blood or blood plasma, if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Internal prostheses
• Professional ground or air ambulance service to the nearest hospital equipped to handle your condition
• Occupational, physical, and speech therapy

Note: We base payment on who bills for the services or supplies. For example, when the hospital bills for its nurse anesthetist’s services, we pay hospital benefits and when the anesthesiologist bills, we pay anesthesia benefits. See CDHP Section 5(b). Surgical procedures.

Note: We cover your admission for dental procedures only when you have a non-dental physical impairment that makes admission necessary to safeguard your health. We do not cover the dental procedures or the anesthesia service when billed by the anesthesiologist.

Note: We cover your admission for inpatient foot treatment even if no other benefits are payable.

Note: Diagnostic tests, such as magnetic resonance imaging, throat cultures, or similar studies are not considered as preadmission testing.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Take-home items:

•  Medical supplies, appliances, and equipment; and any covered items billed by a hospital for use at home

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Any part of a hospital admission that is not medically necessary (See Section 10. Definitions. . . Medical Necessity), such as subacute care, long term care, long term acute care, intermediate care, or when you do not need acute hospital inpatient care, but could receive care in some other setting without adversely affecting your condition or the quality of your medical care. In this event, we pay benefits for services and supplies other than room and board and in-hospital physician care at the level they would have been covered if provided in an alternative setting.
• Custodial care (See Section 10. Definitions . . . Custodial care)
• Non-covered facilities, such as nursing homes, extended care facilities, and schools
• Personal comfort items, such as telephone, television, barber services, guest meals and beds
• Private nursing care

Services and supplies, such as:

• Observation, operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
• Physical, occupational, and speech therapy (when surgery performed on the same day)

Note: When surgery is not performed on the same day, see CDHP Section 5(a). Physical, occupational, and speech therapies for coverage of these therapies.

Note: For accidental injuries, see CDHP Section 5(d). Emergency Services/Accidents.

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures or the anesthesia service when billed by the anesthesiologist.

Note: Specialty drugs, including biotech, biological, biopharmaceutical, and oral chemotherapy drugs dispensed in an outpatient hospital are subject to the Specialty Drug copayment. See Outpatient hospital or ambulatory surgical center, in this section.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• Outpatient services and supplies for the delivery of a newborn

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• Outpatient services and supplies for a tubal ligation or tubal occlusion/tubal blocking procedures only

In-Network: Nothing (No deductible)

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Plan pays for pre-operative testing within 7 days of surgery. Screening tests, limited to:

• Chest X-rays
• Electrocardiograms
• Urinalysis
• Blood work

Note: Diagnostic tests, such as magnetic resonance imaging, throat cultures, or similar studies are not considered as preadmission testing.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• Specialty drugs, including biotech, biological, biopharmaceutical, and oral chemotherapy drugs

Note: Prior approval is required for all specialty drugs used to treat chronic medical conditions. Call CVS Specialty at 800-237-2767 to obtain prior approval, more information, or a complete list.

In-Network:

• 30-day supply: $250
• 90-day supply: $450

Out-of-Network:

• 30-day supply: $250 and any difference between our Plan allowance and the charged amount
• 90-day supply: $450 and any difference between our Plan allowance and the charged amount

Not covered: Personal comfort items

• Professional ground or air ambulance service to the nearest outpatient hospital or ambulatory surgical center equipped to handle your condition

Note: Prior approval is required for all non-emergency air ambulance transport.

Note: When air ambulance transportation to the nearest facility equipped to handle your condition is provided by an Out-of-Network provider, we will pay up to the Plan allowance at the In-Network benefit level.

Note: When ambulance transportation to the nearest In-Network facility is provided by an Out-of-Network provider, we will pay up to the Plan allowance at the In-Network benefit level.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• Professional ground or air ambulance service to the nearest inpatient hospital equipped to handle your condition

Note: Prior approval is required for all non-emergency air ambulance transport.

Note: When air ambulance transportation to the nearest facility equipped to handle your condition is provided by an Out-of-Network provider, we will pay up to the Plan allowance at the In-Network benefit level.

Note: When ambulance transportation to the nearest In-Network facility is provided by an Out-of-Network provider, we will pay up to the Plan allowance at the In-Network benefit level.

In-Network: 20% of the Plan allowance

Out-of-Network: 50% of the Plan allowance and any difference between our allowance and the billed amount