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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. 31 of Plan Document

 

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

 

Medical Calendar Year Deductible
Per Individual $400
Per Family $800

 

Maximum Out-Of-Pocket PPO or Non-PPO Providers
Per Individual $4,000
Per Family $8,000

Emergency Room Treatment
A $350 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.

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. 58 of Plan Document

 

The Navajo Nation Employee Benefits Program offers a Pharmacy Benefit Program through WellDyneRx to employees and eligible dependents.

Co-Payments:

  • $20 co-payment for generic drugs; limited to 31 day supply
  • $40 co-payment for brand drugs; limited to 31 day supply
  • $70 co-payment for non-formulary brand drugs; limited to 31 day supply
  • For Specialty Drugs, contact WellDyne Rx

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.

 

Mail Order Option


The mail order drug benefit option is available for maintenance medication (those that are taken for long periods of time, such as drugs sometimes prescribed for heart disease, high blood pressure, asthma, etc.) Copay applies. to register, please enroll online. For more information,Click Here.

  • $40 co-payment for generic drugs; limited to 90 day supply
  • $80 co-payment for brand drugs; limited to 90 day supply
  • $120 co-payment for non-formulary brand drugs; limited to 90 day supply
  • 20% up to $200 max co-payment for Specialty Drugs; limited to 31 day supply

 

Forms & Information:


WellDyneRx Member Registration (PDF)

WellDyneRx Preferred Drug List (PDF)

WellDyneRx Mail Order Prescription Delivery Service Registration (PDF)

WellDyneRx Reimbursement Claim Form (PDF)

 

For more information:
www.welldynerx.com

 

Toll free:
(888) 479-2000

Dental Benefit Program - pg. 63 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 $1,500.

 

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

Vision Benefit Program - pg. 70 of Plan Document

 

There is no deductible to be paid for Vision Benefits.

 

Vision Service Plan Pays
Maximum $200 per covered member per calendar year
Lasik Surgery $500 lifetime maximum per covered member

 

One (1) eye examination per covered member per calendar year

One (1) Set of Lenses or Contact Lenses per covered member per calendar year

One (1) Set of vision ware (frames) per covered member per calendar year

 

Lasik Surgery


For more information about Lasik surgery, visit, www.qualsight.com

OR

Qualsight Brochure (PDF)

Qualisight FAQ (PDF)

Qualsight Stuffer (PDF)

 

To access the HMA Member Portal and view your benefits details, Click Here

 

Health Claim Submission


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

 

Toll Free: 800-448-3585
For Pre-Authorizations ONLY, fax to 866-293-9665

*Health Insurance cancels at midnight at the end of the covered month of termination date.

*COBRA notification to elect continuation of Health coverage only will be mailed to the member upon termination of coverage. Qualifications must be met.

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