NALC Health Benefit Plan

1 nalc Health Benefit plan 888-636-6252 2018 A fee-for-service plan (High Option, Consumer Driven Health plan , Value Option) with a preferred provider organization important Rates: Back Cover Changes for 2018: Page 17 Summary of benefits : Page 197 This plan 's Health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 4 for details. This plan is accredited. See page 13. Sponsored and administered by the National Association of Letter Carriers ( nalc ), AFL-CIO Who may enroll in this plan : A federal or Postal employee or annuitant eligible to enroll in the Federal Employees Health benefits Program; A former spouse eligible for coverage under the Spouse Equity Law; or An employee, former spouse, or child eligible for Temporary Continuation of Coverage (TCC). To enroll, you must be or become a member of the National Association of Letter Carriers. To become a member: If you are a Postal Service employee, you must be a dues-paying member of an nalc local branch.

2 See page 164 and the back cover for more details. If you are a non-Postal employee, annuitant, survivor annuitant, or a Spouse Equity or TCC enrollee, you become an associate member of nalc when you enroll in the nalc Health Benefit plan . See page 164 and the back cover for more details. Membership dues: nalc dues vary by local branch for Postal employees. Associate members will be billed by the nalc for the $36 annual membership fee, except where exempt by law. Call Membership at 202-662-2856 for inquiries regarding membership, union dues, fees, or information on the nalc union. To enroll, you must be or become a member of the National Association of Letter Carriers. Enrollment codes for this plan High Option: 321-Self Only; 323-Self Plus One; 322-Self and Family CDHP: 324-Self Only; 326-Self Plus One; 325-Self and Family Value Option: KM1-Self Only; KM3-Self Plus One; KM2-Self and Family RI 71-009 important notice from nalc Health Benefit plan About Our prescription Drug Coverage and MedicareOPM has determined that the nalc Health Benefit plan prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage.

3 This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage. However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare. Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program. Please be advisedIf you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that s at least as good as Medicare s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1% per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage.

4 In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D. Medicare s Low Income BenefitsFor people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at , or call the SSA at 800-772-1213 (TTY 800-325-0778).You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places: Visit for personalized help. Call 800-MEDICARE (800-633-4227), (TTY: 877-486-2048). Table of Contents Cover Page ..1 important notice ..1 Table of Contents ..1 Introduction ..4 Plain Language ..4 Stop Health Care Fraud! ..4 Discrimination is Against the Law ..6 Preventing Medical Mistakes ..6 FEHB Facts ..8 Coverage information ..8 No pre-existing condition limitation ..8 Where you can get information about enrolling in the FEHB Program.

5 8 Types of coverage available for you and your family ..8 Family Member Coverage ..9 Children's Equity Act ..9 When benefits and premiums start ..10 When you retire ..10 When you lose benefits ..11 When FEHB coverage ends ..11 Upon divorce ..11 Temporary Continuation of Coverage (TCC) ..11 Converting to individual coverage ..11 Health Insurance Marketplace ..12 Section 1. How this plan works ..13 General features of our plan ..13 We have a Preferred Provider Organization (PPO): ..13 How we pay providers ..13 Your rights and responsibilities ..15 Your medical and claims records are confidential ..16 Section 2. Changes for 2018 ..17 Changes to this plan ..17 Clarifications to this plan ..18 Section 3. How you get care ..19 Identification cards ..19 Where you get covered care ..19 Covered providers ..19 Covered facilities ..19 What you must do to get covered care ..20 Transitional care ..20 If you are hospitalized when your enrollment begins ..21 You need prior plan approval for certain services.

6 21 Inpatient hospital admission ..21 Precertification of radiology/imaging services ..23 Precertification, prior authorization, or prior approval for other services ..23 Other services ..23 Non-urgent care claims ..24 1 2018 nalc Health Benefit plan Table of Contents Urgent care claims ..24 Concurrent care claims ..25 If you disagree with our pre-service claim decision ..25 To reconsider a non-urgent care claim ..25 To reconsider an urgent care claim ..26 To file an appeal with OPM ..26 Section 4. Your costs for covered services ..27 Cost-sharing ..27 Copayments ..27 Deductible ..27 Coinsurance ..28 If your provider routinely waives your cost ..28 Waivers ..28 Differences between our allowance and the bill ..28 Your catastrophic protection out-of-pocket maximum for deductible, coinsurance and copayments ..29 Carryover ..31 If we overpay you ..31 When Government facilities bill us ..31 Section 5. High Option benefits ..32 Section 5(a). Medical services and supplies provided by physicians and other Health care professionals.

7 34 Section 5(b). Surgical and anesthesia services provided by physicians and other Health care professionals ..57 Section 5(c). Services provided by a hospital or other facility, and ambulance services ..68 Section 5(d). Emergency services/accidents ..74 Section 5(e). Mental Health and substance misuse disorder benefits ..77 Section 5(f). prescription drug benefits ..81 Section 5(g). Dental benefits ..88 Section 5(h). Wellness and Other Special Features ..89 Consumer Driven Health plan /Value Option benefits ..94 Consumer Driven Health plan /Value Option Overview ..96 Section 5. CDHP/Value Option Personal Care Account ..98 Section 5. Traditional Health Coverage ..101 Section 5. Preventive Care ..105 Section 5(a). Medical services and supplies provided by physicians and other Health care professionals ..114 Section 5(b). Surgical and anesthesia services provided by physicians and other Health care professionals ..129 Section 5(c). Services provided by a hospital or other facility, and ambulance services.

8 140 Section 5(d). Emergency services/accidents ..146 Section 5(e). Mental Health and substance misuse disorder benefits ..149 Section 5(f). prescription drug benefits ..153 Section 5(g). Dental benefits ..160 Section 5(h). Wellness and Other Special Features ..161 Non-FEHB benefits available to plan members ..164 Section 6. General exclusions services, drugs, and supplies we do not cover ..165 Section 7. Filing a claim for covered services ..167 Section 8. The disputed claims process ..170 Section 9. Coordinating benefits with Medicare and other coverage ..173 When you have other Health coverage ..173 What is Medicare? ..175 Should I enroll in Medicare? ..176 The Original Medicare plan (Part A or Part B) ..176 2 2018 nalc Health Benefit plan Table of Contents Tell us about your Medicare coverage ..177 Private Contract with your physician ..177 Medicare Advantage (Part C) ..178 Medicare prescription drug coverage (Part D) ..178 Section 10. Definitions of terms we use in this brochure.

9 183 Section 11. Other Federal Programs ..188 The Federal Flexible Spending Account Program - FSAFEDS ..188 The Federal Employees Dental and Vision Insurance Program - FEDVIP ..189 The Federal Long Term Care Insurance Program - FLTCIP ..190 The Federal Employees' Group Life Insurance Program - FEGLI ..190 Index ..191 Notes ..193 Summary of benefits for the nalc Health Benefit plan High Option - 2018 ..197 Summary of benefits for the Consumer Driven Health plan (CDHP) and Value Option - 2018 ..200 2018 Rate Information for the nalc Health Benefit plan ..202 3 2018 nalc Health Benefit plan Table of Contents Introduction This brochure describes the benefits of the nalc Health Benefit plan under our contract (CS 1067) with the United States Office of Personnel Management (OPM), as authorized by the Federal Employees Health benefits law. Customer Service may be reached at 888-636- nalc (6252) for High Option or through our website: The address and phone number for the nalc Health Benefit plan High Option administrative office is: nalc Health Benefit plan 20547 Waverly Court Ashburn, VA 20149 703-729-4677 or 888-636- nalc (6252) The address and phone number for the nalc Consumer Driven Health plan and Value Option is: nalc Consumer Driven Health plan or Value Option Box 182223 Chattanooga, TN 37422-7223 855-511-1893 This brochure is the official statement of benefits .

10 No verbal statement can modify or otherwise affect the benefits , limitations, and exclusions of this brochure. It is your responsibility to be informed about your Health benefits . If you are enrolled in this plan , you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits . If you are enrolled in Self Plus One coverage, you and one eligible family member that you designate when you enroll are entitled to these benefits . You do not have a right to benefits that were available before January 1, 2018, unless those benefits are also shown in this negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2018, and changes are summarized on page 17. Rates are shown at the end of this brochure. Coverage under this plan qualifies as minimum essential coverage (MEC) and satisfies the Patient Protection and Affordable Care Act's (ACA) individual shared responsibility requirement.