Health

Navajo Nation Plan offers medical, prescription drug, dental, vision and short-term disability benefits. Currently, there are two (2) tiers of coverage: individual coverage(self only) and family coverage(self plus eligible dependents). Election of coverage for an employee includes medical, prescription drug, dental, vision and short-term disability. Election of coverage for dependent(s) includes medical, prescription drug, dental and vision only. 


Medical Benefit Program - pg. 29 of Plan Document

A standard Medical Calendar Year deductible applies and must be met before claims are paid.

Medical Calendar Year Deductible
Per Individual $250
Per Family $500
The Plan pays all covered expenses at 80% per calendar year, when an out-of-pocket maximum is met, the plan will pay 100% of eligible charges for the remainder of the calendar year or to the maximums of the Plan, whichever occurs first.

The maximum out-of-pocket expense is the maximum amount of covered expenses you and/or your family must pay for medical expenses during a calendar year.

The maximum out-of-pocket expenses include both PPO Network and Non-Network Providers as indicated below:

Maximum Out-Of-Pocket PPO or Non-PPO Providers
Per Individual $2,750
Per Family $5,500
(Pre-Authorization is required for all non-emergency hospitalization or claims exceeding $300)

Emergency Room Treatment
A $250 co-payment will apply per visit if treatment does not result in hospital confinement.

In-Patient Hospital Admission
A $250 co-payment will apply per in-patient admission. 

Dental Benefit Program - pg. 62 of Plan Document

A standard Dental Calendar Year deductible applies and must be met before claims are paid:
Dental Calendar Year Deductible
Per Individual $100
Per Family $300
The Dental Benefit is divided into four types of classes:
Dental Service Plan Pays
Class I - Preventative Services (no deductible) plan pays 100% of covered expenses
Class II - Basic Services 80% of covered expenses, after calendar year deductible
Class III - Major Services 80% of covered expenses, after calendar year deductible
Class IV - Orthodontic Services 50% of covered expenses, after calendar year deductible
The annual maximum benefits for Class I, II, and III services combined are $2,000.

There is a lifetime benefit amount for Class IV - orthodontic services of $2,000.

Vision Benefit Program - pg. 69 of Plan Document

There is no deductible to be paid for Vision Benefits.

One (1) eye examination per year
Lenses or Contact Lenses
Frames (One frame every 24 months)

Lasik Surgery
Lifetime benefit: $500 per individual

More information, visit:
www.qualsight.com

Information:
Qualsight Brochure (PDF)
Qualisight FAQ (PDF)
Qualsight Stuffer (PDF)

Health Claim Submission:
Navajo Nation Employee Benefit Plan
Hawaii-Mainland Administrators, LLC
PO BOX 22009
Tempe, AZ 85285-2009

Toll Free: 800-448-3585

Native Traditional Healing Benefit - pg. 39 of Plan Document

The maximum benefit per covered family is $350.00 per calendar year

Traditional ceremony must be directly related to health of an employee or his/her covered dependent. 

Must be conducted by a Native Healing Practitioner for the benefit of an employee or covered dependent. 

The Plan reserves the right to verify native practitioner information prior to the processing of a claim. 

Claim Process:
Native Traditional Healing Benefit form must be completed and original form submitted to our office. Fax or photocopy will not be accepted.

Must be filed after ceremony has been performed and no later than 12 months from the date of service. 

Does not cover dwelling, livestock and others not considered health-related.

Receipts are not required.

Forms:
Native Traditional Healing Procedures (PDF)
Native Traditional Healing Benefit Form (PDF)

Pharmacy Benefit Program - pg. 57 of Plan Document

The Navajo Nation Employee Benefits Program offers a Pharmacy Benefit Program through WellDyneRx to employees and eligible dependents. The Pharmacy Benefit Program coverage is available for eligible employee, spouse, and children up to the twenty-sixth (26) birthday, if qualifications are satisfied.

You will be required to pay a co-payment (specific dollar amount) at the time of purchase. The co-payment will not be credited toward satisfying the deductible or out-of-pocket maximum, and will continue to be charged once the out-of-pocket maximum is met.

Co-payments:
$10 co-payment for generic drugs
$20 co-payment for brand drugs
$35 co-payment for non-formulary brand drugs

A listing of various drugs is provided and as a member you should take this list with you every time you visit your doctor. For the Preferred Drug List Brochure, Click Here.

Forms:
WellDyneRx Member Registration (PDF)
WellDyneRx Preferred Drug List (PDF)
WellDyneRx Prescription Delivery Service Registration (PDF)
WellDyneRx Reimbursement Claim Form (PDF)

For more information:
www.welldynerx.com

Toll free:
(888) 479-2000

*Health and life Insurance cancel at midnight at the end of the month of termination date.
*Notice of continuation of health coverage through COBRA as well as continuation of life insurance will be offered upon termination of coverage.

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