Pages 1--48 from RI71004.PDF

APWU Health Plan 2000
A Managed Fee for Service Plan
with Preferred Provider Organizations and a Point of Service Product
Sponsored by the American Postal Workers Union AFL CIO

Who may enroll in this Plan All Federal and Postal Service employees and annuitants who are eligible to enroll
in the FEHB Program may become members of this Plan To enroll you must be or must become a member of
the American Postal Workers Union AFL CIO Annuitants retirees may enroll in this Plan

To become a member or associate member All active Postal Service bargaining unit employees must be or must
become dues paying members of the APWU except where exempt by law In item 1 of Part B of your
registration form enter the number of your APWU Local immediately after the name of this Plan

If you are a non postal employee annuitant you will automatically become an associate member of APWU upon
enrollment in the APWU Health Plan

Membership dues 35 per year for associate members New associate members will be billed for annual dues
when the Plan receives notice of enrollment Continuing associate members will be billed by the Plan for the
annual membership Billing usually takes place at the end of March Please do not send money to the Health
Plan APWU headquarters will bill you for the dues

Enrollment code for this Plan
471 Self only
472 Self and family

Visit the OPM website at http www opm gov insure
and
this Plan's Web site at http www apwuhp com

Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance

RI 71 004

i 2000 RI 71 004 1
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APWU Health Plan 2000
Table of Contents

Introduction 1
Plain language 1
How to use this brochure 2
Section 1 Fee for Service Plans 2
Section 2 How we change for 2000 3
Section 3 How to get benefits 4
Section 4 What if we deny your claim or request for pre authorization 9
Section 5 Benefits 11
Section 6 How to file a claim 25
Section 7 General exclusions Things we don't cover 27
Section 8 Limitations Rules that affect your benefits 28
Section 9 Fee for Service facts 33
Section 10 FEHB facts 38
Department of Defense FEHB Demonstration Project 41
Inspector General Advisory Stop Healthcare Fraud 43
Index 44
Summary of benefits Inside back cover
Premiums Back cover

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APWU Health Plan 2000
Introduction

APWU Health Plan
12345 New Columbia Pike
Silver Spring Maryland 20904

This brochure describes the benefits you can receive from APWU Health Plan under its contract CS1370 with the Office of Personnel
Management OPM as authorized by the Federal Employees Health Benefits FEHB law This Plan is underwritten by the American
Postal Workers Union AFL CIO

This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described
in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits Nothing
anyone says can modify or otherwise affect the benefits limitations and exclusions of this brochure

Because OPM negotiates benefits and premiums annually they change each year This brochure describes the only benefits available to
you under this Plan in 2000 Benefit changes are effective January 1 2000 and are shown on page 3 You do not have a right to benefits
that were available before January 1 2000 unless those benefits are also contained in this brochure Premiums are listed at the end of this
brochure

Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the
public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have worked
cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical terms
you and other personal pronouns active voice and short sentences

We refer to APWU Health Plan as this Plan throughout this brochure even though in other legal documents you will see a plan referred
to as a carrier

Sections one two four and ten are now in plain language as well as portions of sections three and eight We will rewrite the remaining
sections of this brochure including the benefits section for year 2001 Please note that the format and organization of this brochure have
changed as well

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable

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APWU Health Plan 2000
How to use this brochure

This brochure has ten sections Each section has important information you should read If you want to compare this Plan's benefits with
benefits from other FEHB plans you will find that the brochures have the same format and similar information to make comparisons easier

1 Fee for Service Plan FFS This Plan is a FFS Plan Turn to this section for a brief description of Fee for Service plans and how
they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get benefits and how we operate
4 What if we deny your claim or request for pre authorization This section tells you what to do if you disagree with our decision not to
pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information
about non FEHB benefits

6 How to file a claim Look here to find specific information on how to file claims with us
7 General exclusions Things we don't cover Look here to see benefits that we will not provide
8 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
9 Fee for Service Facts This section contains information about pre certification protection against catastrophic expenses and a
definition section

10 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program

Section 1 Fee for Service Plans
Fee for service plans reimburse you or your provider for covered services They do not typically provide or arrange for health care
Fee for service plans let you choose your own physicians hospitals and other health care providers

The FFS plan reimburses you for your health care expenses usually on a percentage basis These percentages as well as deductibles
methods for applying deductibles to families and the percentage of coinsurance you must pay vary by plan The type and extent of covered
services varies by plan There is a detailed explanation of the benefits we offer in this brochure you should read it carefully

This FFS plan offers a preferred provider organization PPO arrangement This arrangement with health care providers gives you
enhanced benefits or limits your out of pocket expenses

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APWU Health Plan 2000
Section 2 How we change for 2000

Program wide This year you have a right to more information about this Plan care management our networks facilities
changes and providers

If you have a chronic or disabling condition or are in the second or third trimester of pregnancy and your
provider is leaving our PPO network at our request without cause we will notify you You may continue
to receive our PPO level benefits for your specialist's services for up to 90 days after you receive notice
We will provide regular non PPO benefits for the specialist's services after the 90 day period expires

You may review and obtain copies of your medical records on request If you want copies of your medical
records ask your health care provider for them You may ask that a physician amend a record that is not
accurate not relevant or incomplete If the physician does not amend your record you may add a brief
statement to it If they do not provide you your records call us and we will assist you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer

Changes to this A Point of Service POS program is now available to members in certain counties in the State of
Plan Texas and in the Minneapolis St Paul Minnesota areas The program provides a higher level of benefits for services provided by or at the referral of the patient's selected primary care physician

Details of this program are available by contacting the Plan

The Plan now uses a smaller retail pharmacy network which will reduce the total number of participating pharmacies available and in some cases will eliminate the participation of certain
pharmacy companies from the Plan's network When filling prescriptions Plan members should first
confirm their pharmacy's continued participation in the Plan's network

For prescription drugs enrollees who have Medicare Parts A and B as their primary payer will now pay a 5 copayment for each generic drug and a 15 copayment for each brand name drug obtained
through the Plan's Mail order program
Your share of the Postal A premium will increase by 7.2 for Self Only or decrease by 5.3 for Self and Family

Your share of the Postal B premium will increase by 6.3 for Self Only or 6.8 for Self and Family
Your share of the Non Postal premium will increase by 8.2 for Self Only or 7.5 for Self and Family

The brochure has been clarified to show that weight reduction control and treatment of obesity are not covered whether or not caused by an organic condition Only recognized surgery for morbid obesity
is covered subject to prior Plan approval
The brochure has been clarified to show that specified deductibles and coinsurance will be waived when Medicare is primary only for services and supplies which are considered covered expenses of
this Plan
The Plan now recognizes audiologists as covered providers for covered services performed within the scope of their license

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APWU Health Plan 2000
Section 3 How to get benefits
How do I keep You can help
my health care
expenses down FEHB plans are expected to manage their costs prudently All FEHB plans have cost containment measures in place All fee for service plans include two specific provisions in their benefits packages

precertification of all inpatient admissions and the flexible benefits option Some include managed care
options such as PPO's to help contain costs

As a result of your cooperative efforts the FEHB Program has been able to control premium costs Please
keep up the good work and continue to help keep costs down

Precertification
Precertification evaluates the medical necessity of proposed admissions and the number of hospital days
required to treat your condition You are responsible for ensuring that the precertification requirement is
met You or your doctor must check with your Plan before being admitted to the hospital If that doesn't
happen your Plan will reduce benefits by 500 Be a responsible consumer Be aware of your Plan's cost
containment provisions You can avoid penalties and help keep premiums under control by following the
procedures specified on page 33 of this brochure

Flexible benefits option
Under the flexible benefits option the Carrier has the authority to determine the most effective way to
provide services The Carrier may identify medically appropriate alternatives to traditional care and
coordinate the provision of Plan benefits as a less costly alternative benefit Alternative benefits are
subject to ongoing review The Carrier may decide to resume regular contract benefits at its sole
discretion Approval of an alternative benefit is not a guarantee of any future alternative benefits The
decision to offer an alternative benefit is solely the Carrier's and may be withdrawn at any time It is not
subject to OPM review under the disputed claims process

PPO
This Plan offers most of its members the opportunity to reduce out of pocket expenses by choosing
providers who participate in the Plan's preferred provider organization PPO Consider the PPO cost
savings when you review Plan benefits and check with the Carrier to see whether PPO providers are
available in your area

In addition to a preferred provider network your Plan has discount arrangements with other hospitals
around the country Their terms vary but the purpose is the same to reduce your out of pocket expenses
on covered services

POS
This Plan offers a Point of Service POS program in certain counties in Texas and in the Minneapolis St
Paul Minnesota service areas The POS program offers a higher level of benefits when services are
provided or referred by a participating primary care physician selected by the member or non PPO
benefits for services received without a referral An addendum and a POS selection form that outline
benefit levels and special requirements of the POS program are available by calling the APWU Health
Plan at 1 800 222 APWU

How much do I You must share the cost of some services These cost sharing measures include deductibles coinsurance
pay for services and copayments These and other measures are described in more detail below

Deductibles

A deductible is the amount of expense an individual must incur for covered services and supplies before
the Plan starts paying benefits for the expense involved A deductible is not reimbursable by the Plan and
benefits paid by the Plan do not count toward the deductible When a benefit is subject to a deductible
only expenses allowable under that benefit count toward the deductible

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APWU Health Plan 2000
How much do I Calendar year
pay for services The calendar year deductible is the amount of expense an individual must incur for covered services and
continued supplies each calendar year before the Plan pays certain benefits The deductible is 250 and applies to

Surgical Benefits Maternity Benefits and Other Medical Benefits

Hospital admission
The per admission deductible is the amount of covered room and board expenses an individual must incur
during each non PPO hospital admission before the Plan pays benefits The per admission deductible is
200

Prescription drugs
A prescription drug deductible applies to drugs obtained through a retail pharmacy This deductible is
50 per person each calendar year maximum 100 per Self and Family enrollment per year Drugs
obtained through the mail order drug program are not subject to any deductible

Mental conditions Substance abuse
A separate deductible applies each calendar year to covered services for inpatient and or outpatient
treatment of mental conditions or substance abuse This deductible is 250 per person for services by a
PPO provider or 750 per person for services by a non PPO provider

Carryover
If you changed to this Plan during open season from a plan with a deductible and the effective date of the
change was after January 1 any expenses that would have applied to that plan's deductible in the prior
year will be covered by your old plan if they are for care you got in January before the effective date of
your coverage in this Plan If you have already met the deductible in full your old plan will reimburse
these covered expenses If you have not met it in full your old plan will first apply your covered expenses
to satisfy the rest of the deductible and then reimburse you for any additional covered expenses The old
plan will pay these covered expenses according to this year's benefits benefit changes are effective on
January 1

Family limit
There is a separate calendar year deductible of 250 per person However under a family enrollment
when the combined covered expenses applied to the deductible for all family members reach 500 during
a calendar year the family deductible is satisfied and benefits for which the calendar year deductible
applies are payable for all family members

Coinsurance
Coinsurance is the stated percentage of covered charges you must pay after you have met any applicable
deductible The Plan will base this percentage on either the billed charge or the reasonable and customary
charge whichever is less For instance when a plan pays 70 percent of reasonable and customary charges
for a covered service you are responsible for 30 percent of the reasonable and customary charges i e the
coinsurance In addition you may be responsible for any excess charge over the Plan's reasonable and
customary allowance For example if the provider ordinarily charges 100 for a service but the Plan's
reasonable and customary allowance is 95 the Plan will pay 70 percent of the allowance 66.50 You
must pay the 30 percent coinsurance 28.50 plus the difference between the actual charge and the
reasonable and customary allowance 5 for a total member responsibility of 33.50 Remember if you
use preferred providers your share of covered charges after meeting any deductible is limited to the
stated coinsurance amount

When hospital charges are limited by law
When inpatient claims are paid according to a Diagnostic Related Group DRG limit for instance for
admissions of certain retirees who do not have Medicare see page 31 the Plan will pay 30 percent of
the total covered amount as room and board charges and 70 percent as other charges and will apply your
coinsurance accordingly

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APWU Health Plan 2000
How much do I Copayments
pay for services
continued A copayment is the stated amount the Plan requires you to pay for certain covered services such as 15 per office visit at a PPO provider

If provider waives your share
If a provider routinely waives does not require you to pay your share of the charge for services rendered
the Plan is not obligated to pay the full percentage of the amount of the provider's original charge it would
otherwise have paid A provider or supplier who routinely waives coinsurance copayments or
deductibles is misstating the actual charge This practice may be in violation of the law The Plan will
base its percentage on the fee actually charged For example if the provider ordinarily charges 100 for a
service but routinely waives the 30 coinsurance the actual charge is 70 The Plan will pay 49
70 of the actual charge of 70

Lifetime maximums
For Smoking Cessation Benefit the Plan will pay up to 100 for enrollment in one smoking cessation
program per member per lifetime

For substance abuse the Plan will pay up to 3,000 for one treatment program per member per lifetime

Do I have to You usually do not have to submit claims to us if you use preferred providers If you file a claim please
submit claims send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show

that circumstances beyond your control prevented you from filing on time

Please see section 6 How to file a claim for specific information you need to know before you file a claim
with us

Who provides In a Fee for Service Plan you may choose any covered facility or provider
my health care Covered facilities

Freestanding ambulatory facility
An out of hospital facility such as a medical cancer dialysis or surgical center or clinic and licensed
outpatient facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations for
treatment of substance abuse

Hospital
1 An institution which is accredited as a hospital under the Hospital Accreditation Program of the Joint
Commission on Accreditation of Healthcare Organizations or

2 Any other institution which is operated pursuant to law under the supervision of a staff of doctors and
twenty four hour a day nursing service and which is primarily engaged in providing

a general inpatient care and treatment of sick and injured persons through medical diagnostic
and major surgical facilities all of which must be provided on its premises or under its
control or

b specialized inpatient medical care and treatment of sick or injured persons through medical
and diagnostic facilities including X ray and laboratory on its premises under its control or
through a written agreement with a hospital as defined above or with a specialized provider
of those facilities

The term hospital shall not include a skilled nursing facility a convalescent nursing home or institution
or part thereof which 1 is used principally as a convalescent facility rest facility residential treatment
center nursing facility or facility for the aged or 2 furnishes primarily domiciliary or custodial care
including training in the routines of daily living

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APWU Health Plan 2000
Who provides Covered providers
my health care For purposes of this Plan covered providers include
continued
1 Doctor A licensed doctor of medicine M D a licensed doctor of osteopathy D O a licensed
doctor of podiatry D P M or for certain specified services covered by this Plan a licensed dentist
licensed chiropractor or licensed clinical psychologist practicing within the scope of the license

2 Alternate Provider Alternate providers are covered when performing certain specified services
covered by this Plan and when such treatment is within the scope of the provider's license Alternate
providers are limited to licensed physical occupational and speech therapists licensed physician's
assistants Registered Nurses R N Licensed Practical Nurses L P N Licensed Vocational
Nurses L V N and Certified Registered Nurse Anesthetists C R N A

3 Other covered providers include a qualified clinical psychologist clinical social worker optometrist
audiologist nurse midwife nurse practitioner clinical specialist and nursing school administered
clinic For purposes of this FEHB brochure the term doctor includes all of these providers when
the services are performed within the scope of their license or certification

Coverage in medically underserved areas
Within States designated as medically underserved areas any licensed medical practitioner will be treated
as a covered provider for any covered services performed within the scope of that license For 2000 the
States designated as medically underserved are Alabama Idaho Kentucky Louisiana Mississippi
Missouri New Mexico North Dakota South Carolina South Dakota Utah and Wyoming

PPO arrangements
Benefits under this Plan are available from facilities such as hospitals and from providers such as
pharmacies doctors and other health care personnel who provide covered services This Plan covers two
types of facilities and providers 1 those who participate in a preferred provider organization PPO and
2 those who do not Who these health care providers are and how benefits are paid for their services
are explained below In general it works like this

PPO facilities and providers have agreed to provide services to Plan members at a lower cost than you'd
usually pay a non PPO provider Although PPO's are not available in all locations or for all services
when you use these providers you help contain health care costs and reduce what you pay out of pocket
The selection of PPO providers is solely the Carrier's responsibility continued participation of any
specific provider cannot be guaranteed While PPO providers agree with the Carrier to provide covered
services final decisions about health care are the sole responsibility of the doctor and patient and are
independent of the terms of the insurance contract

PPO benefits apply only when you use a PPO provider Provider networks may be more extensive in
some areas than others The availability of every specialty in all areas cannot be guaranteed If no PPO
provider is available or you do not use a PPO provider the standard non PPO benefits apply

When you use a PPO hospital keep in mind that the professionals who provide services to you in the
hospital such as radiologists anesthesiologists and pathologists may not all be preferred providers If
they are not they will be paid by this Plan as non PPO providers Also use of a PPO facility does not
necessarily increase the likelihood that you will be referred to other facilities or health professionals in the
network It is your responsibility to confirm the network participation of a facility or provider prior to
obtaining services

Non PPO facilities and providers do not have special agreements with the Plan The Plan makes its
regular payments toward the bills and you are responsible for any balance

This Plan's PPO
The Plan has established a network of doctors and hospitals that have agreed to reduce their charges to
members who voluntarily seek them out for covered services If you are admitted to a PPO hospital the
Plan will pay 90 of covered Inpatient hospital charges Precertification of all hospital admissions is still
required as outlined on page 33 If you use the services of a PPO doctor the Plan will pay in full after a
15 copayment for outpatient visits and pay 90 of other negotiated fees for covered services

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APWU Health Plan 2000
Who provides Enrollees who reside in a PPO area will receive information concerning the PPO in their region
my health care Additional locations may become available throughout 2000 If you need assistance in identifying a
continued participating provider call the Plan's PPO administrator for your state Alliance PPO Inc 1 800 342 3289 for providers in the District of Columbia Maryland Virginia and West Virginia Beech

Street 1 800 923 3248 for providers in California Florida Georgia Ohio Oklahoma Tennessee Texas
and Washington MultiPlan 1 800 672 2140 for providers in New Jersey and New York MedNet
1 800 556 1144 for providers in Maine PreferredOne 1 800 451 9597 for providers in Minnesota or First
Health 1 800 447 1704 for all other states For mental conditions substance abuse providers all states
call ValueOptions toll free 1 888 700 7965 Including a provider in the PPO does not represent a
warranty of services by the Plan nor does it constitute medical advice When you phone for an
appointment please remember to verify that the physician is still a PPO provider

What do I do if First call our customer service department at 1 800 222 APWU If you are new to the FEHB Program
I'm in the we will reimburse your covered expenses If you are currently in the FEHB Program and are switching to
hospital when I us your former plan will pay for the hospital stay until
join this Plan You are discharged not merely moved to an alternative care center or You exhaust the benefits available from your former plan or

The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized

What if I have a Please contact us if you believe your condition is chronic or disabling If it is you may be able to continue
serious illness seeing your provider for up to 90 days after you receive notice that we are terminating our contract with
and my provider the provider unless the termination is for cause If you are in the second or third trimester of pregnancy
leaves the Plan or you may continue to see your OB GYN until the end of your postpartum care
this Plan leaves You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
the Program you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic

condition or are in your second or third trimester Your new plan will pay for or provide your care for up
to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your
second or third trimester your new plan will pay for the OB GYN care you receive from your current
provider until the end of your postpartum care

If you continue seeing your specialist or OB GYN under these conditions your cost will be no more than
you would normally pay for the services covered

How do you Determination of experimental investigational status may require review by a specialty appropriate boardcertified
decide if a service health care provider or appropriate government publication s such as those of the National
is experimental Institute of Health National Cancer Institute Food and Drug Administration Agency of Health Care
or Policy Research and the National Library of Medicine
investigational Definition of experimental or investigational

A drug device or biological product is experimental or investigational if the drug device or biological
product cannot be lawfully marketed without approval of the U S Food and Drug Administration FDA
and approval for marketing has not been given at the time it is furnished Approval means all forms of
acceptance by the FDA

A medical treatment or procedure or a drug device or biological product is experimental or
investigational if 1 reliable evidence shows that it is the subject of ongoing phase I II or III clinical trials
or under study to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy as
compared with the standard means of treatment or diagnosis or 2 reliable evidence shows that the
consensus of opinion among experts regarding the drug device or biological product or medical treatment
or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose
its toxicity its safety its efficacy or its efficacy as compared with the standard means of treatment or
diagnosis

Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific
literature the written protocol or protocols used by the treating facility or the protocol s of another facility
studying substantially the same drug device or medical treatment or procedure or the written informed
consent used by the treating facility or by another facility studying substantially the same drug device or
medical treatment or procedure

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APWU Health Plan 2000
Section 4 What if we deny your claim or request for pre authorization

What should I do Before you ask us to reconsider your claim you should first check with your provider or facility to be sure
before filing a that the claim was filed correctly For instance did the provider use the correct procedure code for the
disputed claim services performed surgery laboratory test X ray office visit etc Have your provider indicate any complications of any surgical procedures performed Your provider should also include copies of an

operative or procedure report or other documentation that supports your claim

If we deny your request for pre authorization or won't pay your claim you may ask us to reconsider our
decision Your request must

1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time
limit if you show that you were unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Approve your request for pre authorization or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must
make a decision within 30 days after we receive the additional information If we do not receive the
requested information within 60 days we will make our decision based on the information we already
have

When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM
OPM to review a will determine if we correctly applied the terms of our contract when we denied your claim or request for
denial service

What if I have a Call us 1 800 222 APWU and we will expedite our review
serious or life
threatening
condition and
you haven't
responded to my
request for preauthorization

What if you have If we expedite your review due to a serious medical condition and deny your request we will inform OPM
denied my so that they can give your request expedited treatment too Alternatively you can call OPM's health
request for care benefits Contract Division II at 202 606 3818 between 8 a m and 5 p m Serious or life threatening
and my condition conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as
is serious or life soon as possible
threatening

Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial
time limits denial or refusal You may also ask OPM to review your claim if

1 We do not answer your request within 30 days In this case OPM must receive your request within
120 days of the date you asked us to reconsider your claim

2 You provided us with additional information we asked for and we did not answer within 30 days In
this case OPM must receive your request within 120 days of the date we asked you for additional
information

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APWU Health Plan 2000
What do I send Your request must be complete or OPM will return it to you You must send the following information
to OPM 1 A statement about why you believe our decision is wrong based on specific benefit provisions in this

brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents apply to which
claim

Who can make Those who have a legal right to file a disputed claim with OPM are
the request 1 Anyone enrolled in the Plan

2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's
representative They must send a copy of the person's specific written consent with the review
request

Where should I Send your request for review to Office of Personnel Management Office of Insurance Programs
mail my disputed Contracts Division II P O Box 436 Washington D C 20044
claim to OPM

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision
upholds the your only recourse is to sue
Plan's denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year

after the year in which you received the disputed services or supplies

What laws apply Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
if I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute

You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services
supplies or drugs covered by us until you have completed the OPM review procedure described above

Your records Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us to
and the Privacy determine if our denial of your claim is correct The information OPM collects during the review process
Act becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information to support the disputed claim

decision If you file a lawsuit this information will become part of the court record

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APWU Health Plan 2000
Section 5 Benefits

Inpatient Hospital Benefits
What is covered The Plan pays for inpatient hospital services as shown below
Precertification The medical necessity of your hospital admission must be precertified for you to receive full Plan benefits Emergency admissions not precertified must be reported within 48 hours of admission even if you have
been discharged Otherwise the benefits payable will be reduced by 500 See pages 33 and 34 for
details

Waiver This precertification requirement does not apply to persons whose primary coverage is another health insurance policy or when the hospital admission is outside the United States and Puerto Rico Also this
requirement generally does not apply to persons whose primary coverage is Medicare Part A however
see page 33 for exceptions For information on when Medicare is primary see pages 28 29 and 30

Room and board Benefits for hospital room and board and other hospital expenses for a bed patient inpatient in a hospital include
Ward and semiprivate accommodations
Intensive care accommodations when medically appropriate
Isolation care accommodations when medically appropriate to prevent contagion
Lab X ray and pharmacy services
Anesthesia supplies operating and recovery room
Professional ambulance service when medically appropriate
Blood or blood plasma if not donated or replaced

PPO benefit Plan pays room and board and Other charges at 90 of hospital's negotiated rates
Non PPO After a 200 deductible per admission Plan pays room and board and Other charges at 70 of benefit reasonable and customary charges

Private room If a private room is used other than for isolation care the hospital's average charge for semiprivate accommodations will be paid If the hospital only has private rooms the average semiprivate rate for
comparable hospitals in the area will be allowed

Related benefits Pre surgical Outpatient laboratory tests pathology radiology and X rays related to surgery are paid as Other Medical
testing Benefits see pages 17 18 and 19
Professional Charges for professional services of a doctor alternate provider or anesthesiologist even though billed by charges a hospital as part of hospital services are covered only as shown on pages 12 13 14 17 and 19

Take home Appliances medical equipment and medical supplies that are provided for use outside a hospital are items covered as Other Medical Benefits as shown on page 17
Prescription drugs and medicines dispensed for take home use are covered as Prescription Drugs as
shown on pages 20 21 and 22

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APWU Health Plan 2000
Inpatient Hospital Benefits continued
Hospitalization for The Plan pays for room and board and other hospital services for hospitalization in connection with dental
dental work procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient

What is not A hospital admission that the Carrier determines is not medically appropriate i e the medical covered services did not require the acute hospital inpatient overnight setting but could have been provided
in a doctor's office the outpatient department of a hospital or some other less expensive setting
without adversely affecting the patient's condition or the quality of medical care
Custodial care as defined on page 35
Day and evening care centers nursing homes skilled nursing facilities extended care and residential treatment facilities a place for rest or for the aged or any other place which does not meet the

definition of a hospital as shown on page 6
Services of a private duty nurse that would normally be provided by hospital nursing staff
Personal comfort items such as radio television air conditioners beauty and barber services guest meals and beds

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
When no PPO provider is available non PPO benefits apply

Surgical Benefits
What is covered The Plan pays for the following services
PPO benefit After the 250 calendar year deductible 90 of the surgeon's negotiated fee for the inpatient or outpatient surgical procedure

Non PPO After satisfaction of the 250 calendar year deductible 70 of reasonable and customary charges benefit
This Plan will pay charges in or out of a hospital to the extent shown above for
Charges of a surgeon Charges for normal postoperative care by the surgeon s are considered to be part of the surgical charges

Charges of an anesthesiologist
Voluntary sterilization procedures
Routine circumcision of newborn
Breast reconstruction surgery following a mastectomy including surgery to produce a symmetrical appearance on the other breast Benefits will be provided for all stages of breast reconstruction

following a mastectomy including treatment of any physical complications including lymphedemas
and for breast prostheses including surgical bras and replacements see also Other Medical Benefits
on page 17
Recognized surgery for morbid obesity and organic impotence only with prior Plan approval To obtain prior Plan approval call Spectera CARE Programs at 1 800 580 8771

Cosmetic surgery only if necessary for the correction of congenital defects which existed at or from birth limited to conditions listed
on page 35 or
for repair of injuries caused by an accident provided the surgery is completed within two years of
the accidental injury

Multiple surgical When multiple or bilateral surgical procedures that add time or complexity to patient care are performed procedures during the same operative session the Plan pays 50 of the value of the secondary lesser or repeat
procedure s

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APWU Health Plan 2000
Surgical Benefits continued
Incidental Only the value of the major procedure is allowed when an incidental procedure is performed through the same procedures incision or when an independent procedure is carried out as an integral part of the total service

Assistant surgeon The Plan will consider 20 of the surgical allowance to be reasonable and customary for all assistant inpatient surgeons combined during the same operative session
outpatient
Second opinion See Other Medical Benefits page 17 voluntary

Anesthesia Plan allowance is based upon CPT code value multiplied by units of time
Organ tissue Transplant surgery means transfer of body organ s from the donor to the recipient allogeneic or a bone transplants and marrow transplant in which the donor and recipient are the same person autologous Donor means a person
donor expenses who undergoes a surgical operation for the purpose of donating a body organ s for transplant surgery Recipient means a person insured by the Plan who undergoes a surgical operation to receive a body organ

transplant
Prior The Plan participates in a National Transplant Program administered by First Health Before your initial approval evaluation as a potential candidate for a transplant procedure you or your doctor must contact First Health
at 1 800 447 1704 and ask to speak to a Transplant Case Manager You will be provided with
information about this program and about transplant preferred providers

The Plan pays reasonable and customary charges for a covered surgical transplant the same as expenses for
any other illness or injury as follows this benefit applies only if recipient is covered by the Plan

PPO All reasonable and customary charges for services performed by a provider specified by the Plan for this benefit benefit whether incurred by the recipient or donor If you participate in the National Transplant Program
you may receive prior approval for travel and lodging costs

Non PPO Pretransplant evaluation organ procurement inpatient hospital surgical and medical expenses for covered benefit transplants whether incurred by the recipient or donor are limited to a maximum of 100,000 for each listed
transplant including multiple organ transplants

What is Benefits will be provided for the following transplants covered Cornea kidney pancreas and liver
Heart and heart lung
Single or double lung transplants for the following end stage pulmonary diseases at an approved center primary fibrosis primary hypertension and emphysema double lung transplant for cystic

fibrosis at an approved center
Benefits for allogeneic bone marrow transplants are limited to patients with leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma aplastic anemia severe combined

immuno deficiency disease or Wiskott Aldrich syndrome
Benefits for autologous bone marrow transplants and autologous peripheral stem cell support are limited to patients with acute leukemia in remission relapsed non Hodgkin's lymphomas responding

to treatment resistant or recurrent neuroblastoma relapsed Hodgkin's disease responding to
treatment testicular cancer mediastinal cancer retroperitoneal cancer ovarian germ cell tumors
epithelial ovarian cancer breast cancer and multiple myeloma
Related medical and hospital expenses of the donor are covered when the recipient is covered by the Plan

What is not Transplants not listed as covered covered Surgical implant of artificial hearts
Services or supplies for or related to surgical transplant procedures for artificial or human organ transplants not listed as specifically covered Related services include administration of high dose

chemotherapy when supported by autologous bone marrow transplant

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APWU Health Plan 2000
Surgical Benefits continued
Oral and This Plan will pay reasonable and customary charges in or out of a hospital to the extent shown on page maxillofacial 12 only for
surgery Extraction of impacted unerupted teeth Alveoplasty partial ostectomy and radical resection of mandible with bone graft unrelated to tooth

structure
Fractures of the jaw and or facial bones and severe malocclusion protruding or retruding mandible or maxilla caused by accidental injury

Correction of cleft palate and severe malocclusion if caused by congenital malformation
Excision of bony cysts of the jaw unrelated to tooth structure
Excision of tori tumors leukoplakia premalignant and malignant lesions and biopsy of hard and soft oral tissues

Reduction of dislocations and excision manipulation arthrocentesis aspiration or injection of temporomandibular joints
Removal of foreign body skin subcutaneous alveolar tissue reaction producing foreign bodies in the musculoskeletal system and salivary stones
Incision excision of salivary glands and ducts
Repair of traumatic wounds
Sinusotomy including repair of oroantral and oromaxillary fistula and or root recovery
Surgical treatment of trigeminal neuralgia
Frenectomy or frenotomy skin graft or vestibuloplasty stomatoplasty unrelated to periodontal disease
Incision and drainage of cellulitis unrelated to tooth structure

To determine whether a procedure is covered it is suggested that prior Carrier approval be obtained by
calling 1 800 222 APWU

Mastectomy Women who undergo mastectomies may at their option have this procedure performed on an inpatient Surgery basis and remain in the hospital up to 48 hours after the procedure

Pre surgical Outpatient laboratory tests pathology radiology and X rays related to surgery are paid as Other Medical testing Benefits see page 17
What is not Cosmetic surgery and other related expenses except as described on page 12 covered Sterilization reversal
Trimming of toenails or removal of corns and calluses except when the patient is under active treatment of metabolic or peripheral vascular disease

Eye surgery such as radial keratotomy when the primary purpose is to correct myopia nearsightedness hyperopia farsightedness or astigmatism blurring
Dental bridges replacement of natural teeth dental orthodontic temporomandibular joint dysfunction appliances and any related expenses
Treatment of periodontal disease and gingival tissues and abscesses
Charges related to orthodontic treatment
Oral implants or transplants of any kind May be eligible for Wellness benefit see page 20

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
When no PPO provider is available non PPO benefits apply

Maternity Benefits
What is covered The Plan pays the same benefits for hospital surgery delivery laboratory tests and other medical expenses as for illness or injury The mother at her option may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if medically necessary

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APWU Health Plan 2000
Maternity Benefits continued
Inpatient hospital
Precertification The medical necessity of your hospital admission must be precertified for you to receive full Plan benefits Unscheduled or emergency admissions not precertified must be reported within 48 hours of admission
even if you have been discharged Newborn confinements that extend beyond the mother's discharge must
also be precertified If any of the above are not done the benefits payable will be reduced by 500 See
pages 33 and 34 for details

Waiver This does not apply when the hospital admission is outside the United States and Puerto Rico

Room and board Benefits for hospital room and board and other hospital expenses for a bed patient inpatient in a hospital
and Other charges include Ward and semiprivate accommodations

Intensive care accommodations when medically appropriate
Isolation care accommodations when medically appropriate to prevent contagion
Lab X ray and pharmacy services
Anesthesia supplies operating and recovery room
Professional ambulance service when medically appropriate
Blood or blood plasma if not donated or replaced

PPO benefit Plan pays room and board and Other charges at 90 of hospital's negotiated rates
Non PPO After a 200 deductible per admission Plan pays room and board and Other charges at 70 of benefit reasonable and customary charges

Private room If a private room is used other than for isolation care the hospital's average charge for semiprivate accommodations will be paid If the hospital only has private rooms the average semiprivate rate for
comparable hospitals in the area will be allowed

Bassinet and Hospital charges for bassinet and nursery care of the child during the mother's hospital confinement are nursery considered expenses of the mother and not expenses of the child Any other expenses incurred by the
child will be considered the child's own and will be allowed only if the child is covered by a Self and
Family enrollment

Outpatient care Outpatient hospital care for surgery delivery including care in freestanding ambulatory facilities including birthing centers is covered as described under Other Medical Benefits on page 18

Obstetrical care Delivery paid under Surgical Benefits as shown on page 12 including prenatal and postpartum care paid as shown on page 17
Administration of anesthesia as shown on page 13
Services of a licensed midwife

Tests Sonograms amniocentesis but not for diagnosing multiple births and other related diagnostic services which are accepted medical practice paid as shown on page 17

Related benefits Contraceptive See Other Medical Benefits on page 17 and Prescription Drugs on page 20
devices and drugs

Diagnosis and Diagnosis and treatment of infertility will be covered up to a maximum Plan benefit of 2,500 per member treatment of per calendar year
infertility

Voluntary See Surgical Benefits on page 12 sterilization

Well child care See Additional Benefits on page 20

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APWU Health Plan 2000
Maternity Benefits continued

For whom Benefits are payable under Self Only enrollments and for family members under Self and Family enrollments

What is not Assisted Reproductive Technology ART procedures such as artificial insemination in vitro covered fertilization embryo transfer and GIFT as well as services and supplies related to ART procedures
are not covered
Reversal of voluntary surgical sterilization
Charges related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
When no PPO provider is available non PPO benefits apply

Mental Conditions Substance Abuse Benefits
What is covered The Plan pays for the following Mental conditions substance abuse services
Inpatient care Plan pays for ward or semiprivate accommodations other hospital charges and professional fees In lieu of medically appropriate inpatient care and with prior Plan approval coverage includes treatment at a licensed
day treatment facility which has been accredited by the Joint Commission on Accreditation of Healthcare
Organizations Prior Plan approval may be obtained by calling ValueOptions toll free at
1 888 700 7965

Outpatient care Plan pays for outpatient services by doctors and other covered practitioners for the treatment of mental conditions or substance abuse

PPO After a 250 annual deductible per person the Plan pays benefit Inpatient Care 60 of provider's negotiated fees for up to 45 days per person each calendar year
Outpatient Care 70 of provider's negotiated fees for up to 30 visits per person each calendar year

Non PPO After a 750 annual deductible per person the Plan pays benefit Inpatient Care 50 of reasonable and customary charges up to 30 days per person each calendar year
Outpatient Care 50 of reasonable and customary charges up to 15 visits per person each calendar year

Benefit limitations
Annual The specified limits on covered inpatient days are inclusive of any and all days previously used during the maximum year regardless of whether the days were in a PPO or non PPO facility

The specified limits on covered outpatient visits are inclusive of any and all visits previously used during
the year regardless of whether the visits were with a PPO or non PPO provider

Lifetime The maximum lifetime benefit for inpatient treatment of alcoholism and or drug abuse is one treatment maximum program per member not to exceed a maximum Plan payment of 3,000

Precertification The medical necessity of your admission to a hospital or other facility must be precertified at least 48 Inpatient care hours prior to admission for you to receive full Plan benefits Emergency admissions must be reported
within 48 hours of admission even if you have been discharged Otherwise the benefits will be reduced
by 500 To precertify an admission for mental conditions substance abuse you your representative your
doctor or your hospital must call ValueOptions toll free at 1 888 700 7965

Preauthorization Outpatient care for mental conditions substance abuse requires prior Plan approval Prior approval must Outpatient care be obtained by calling ValueOptions toll free at 1 888 700 7965 prior to seeking care

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APWU Health Plan 2000
Mental Conditions Substance Abuse Benefits continued

What is not Treatment for learning disabilities and mental retardation covered Services rendered or billed by a school or halfway house or a member of its staff
Services and supplies that are not medically appropriate
Phototherapy for treatment of Seasonal Affective Disorder SAD

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
When no PPO provider is available non PPO benefits apply

Other Medical Benefits
What is covered
Outpatient Coverage for home or office visits outpatient consultations and second surgical opinions are covered as physician visits follows

PPO Plan pays in full after a 15 copayment for each covered outpatient visit charge The 250 deductible
benefit does not apply to this benefit

Non PPO After the 250 calendar year deductible the Plan pays 70 of reasonable and customary charges benefit

Chiropractic Benefits are limited to 12 chiropractic visits and or manipulations per person each calendar year treatment
Other services
PPO After the 250 calendar year deductible 90 of provider's negotiated fees
benefit
Non PPO After the 250 calendar year deductible the Plan pays 70 of reasonable and customary charges benefit

Coverage is provided for the following services when prescribed by a doctor
Hospital visits and inpatient consultations
Diagnostic services such as X rays electrocardiograms laboratory tests allergy tests and pre admission testing

Durable medical equipment as defined on page 35 such as a wheelchair kidney machine and oxygen rented or purchased at the Plan's option
Established outpatient cardiac and pulmonary rehabilitation programs
Radiation therapy
Chemotherapy for cancer
Renal dialysis
Necessary supplies and accessories for use in connection with home dialysis hyperalimentation and intravenous therapy

Artificial limbs joints and eyes pacemakers and leg arm neck and back braces but not replacement adjustment or repair of braces unless replacement is necessary due to the growth of a
child
Stump hose for artificial limbs
Internal implants and external breast prostheses and bras for use with external prostheses following mastectomy

Internal implant ocular lenses and or the first contact lenses required to correct an impairment caused by trauma or disease The services of an optometrist are limited to the testing evaluation and
fitting of the first contact lenses required to correct an impairment caused by trauma or disease
Catheters permanent tracheotomy tubes ostomy bags and supplies and accessories required for attachment

Intra uterine devices including the cost of insertion and removal
The Plan recommends that prior approval be obtained for these services and supplies To obtain prior
Carrier approval call Spectera CARE Programs at 1 800 580 8771

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APWU Health Plan 2000
Other Medical Benefits continued
Home health care These benefits must be provided under a treatment plan prescribed by a doctor and require prior and rehabilitative Carrier approval To obtain prior Plan approval call Spectera CARE Programs at 1 800 580 8771
therapy Professional private duty intermittent nursing care performed during home visits by a Registered Nurse R N Licensed Practical Nurse L P N or Licensed Vocational Nurse L V N up to a

maximum Plan payment of 90 per day The patient must have specific needs for which only an
R N L P N or L V N can provide the necessary services
Professional services of a licensed registered therapist performing rehabilitative physical occupational and speech therapy These services may be provided in an outpatient setting or in the

patient's home

Outpatient Outpatient services and supplies of a hospital or free standing ambulatory facility the day of a surgical hospital services procedure including change of cast hemophilia treatment hyperalimentation rabies shots cast or
suture removal oral surgery dental and foot treatment chemotherapy for treatment of cancer and
radiation therapy

Medical emergency Outpatient services and supplies of a hospital or free standing ambulatory facility are covered for treatment within 24 hours after onset of a true medical emergency For Plan purposes a medical
emergency is the sudden and unexpected onset of a serious possibly life threatening condition requiring
immediate care such as loss of consciousness loss of breathing poisoning severe bleeding or chest pain
If you are unsure of the severity of a condition in terms of this benefit the Plan recommends that you first
call its 24 hour nurse advisory service 1 800 755 2200 or your physician

The following conditions are not generally considered medical emergencies for purposes of this Plan
Colds earaches sore throats flu
Nausea and headaches
Maternity term deliveries If you use an emergency room for other than a recognized medical emergency facility fees and supplies

will not be covered

Preventive In addition to coverage of diagnostic X ray laboratory and pathology services and machine diagnostic services tests the following routine screening services are covered as preventive care

Breast cancer Mammograms are covered for women age 35 and older as follows screening From age 35 through 39 one mammogram screening during this five year period
From age 40 through 49 one mammogram screening every one or two consecutive calendar years
From age 50 through 64 one mammogram screening every calendar year
At age 65 and older one mammogram screening every two consecutive calendar years

Cervical cancer Annual coverage of one pap smear for women age 18 and older screening

Colorectal cancer Annual coverage of one fecal occult blood test for members age 40 and older screening From age 50 one screening sigmoidoscopy every five years
Prostate cancer Annual coverage of one PSA Prostate Specific Antigen test for men age 40 and older screening
Nonfasting Covered once annually per covered person from age 19 through 64 years old total blood
cholesterol test

Tetanus Covered once every 10 years per covered member or spouse age 19 years and over For dependent diphtheria Td children through age 22 see Childhood immunizations on page 19
booster

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APWU Health Plan 2000
Other Medical Benefits continued
Influenza and Covered once annually per covered person age 65 years and over Pneumococcal
vaccines

Limited benefits
Childhood Childhood immunizations recommended by the American Academy of Pediatrics are covered for eligible immunizations members under age 22

Smoking cessation After satisfaction of the calendar year deductible the Plan will pay up to 100 for enrollment in one benefit smoking cessation program per member per lifetime

What is not Routine physical examinations routine eye examinations and immunizations covered Eyeglasses contact lenses except as shown above eye exercises and visual training
Hearing aids and examinations for them
Professional fees for automated lab tests
Weight reduction control and treatment of obesity except as shown on page 12
Orthopedic shoes foot appliances or any related expenses elastic stockings corsets lumbosacral neck or joint supports trusses air purifiers whirlpool equipment sun and heat lamps light boxes

heating pads exercise devices stair glides and elevators
Drugs and medicines that can be purchased without a doctor's prescription even if a doctor has prescribed them or recommended their use

Nursing services and rehabilitative therapy without prior Plan approval
Speech therapy for developmental delay
Services of nurses aides or home health aides
Administration of high dose chemotherapy when supported by non covered autologous bone marrow transplants

Maintenance therapies May be eligible for Wellness benefit see page 20

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
When no PPO provider is available non PPO benefits apply

Additional Benefits The additional benefits described on this page and on page 20 are not subject to any deductibles

Accidental injury The Plan pays as follows for outpatient first aid treatment within 24 hours after an accidental injury an injury resulting from a violent external force There is no deductible for first aid treatment for an
accidental injury rendered within 24 hours after the injury

PPO 100 of provider's negotiated fees
benefit
Non PPO 100 of reasonable and customary charges benefit

24 hour nurse The Plan offers a 24 hour nurse advisory service for your use This program is strictly voluntary and advisory confidential You may call toll free at 1 800 755 2200 and reach registered nurses to discuss an existing
medical concern or to receive information about numerous health care issues

Hospice care The Plan pays reasonable and customary charges for hospice care provided by a hospice program subject to the following annual limits
Maximum annual outpatient benefit 3,000
Maximum annual inpatient benefit 2,000
Maximum bereavement benefit per family unit during any one calendar year 200 Conditions 1 Patient's doctor certifies terminal illness and life expectancy of six months or less and 2

the hospice in or outpatient services must be ordered by the patient's doctor and charged for by an
approved hospice program

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APWU Health Plan 2000
Additional Benefits continued

Preventive benefits The Plan pays for the following preventive benefits see also Preventive services under Other Medical Benefits on pages 18 and 19

Well child care The Plan pays for physical examinations and laboratory tests for children through age 12 covered by a Self and Family enrollment The Plan also pays for one eye exam for amblyopia lazy eye and
strabismus eye muscle imbalance per covered child between the ages of 2 through 6 Benefits
provided are as follows

PPO 100 for children ages birth through 12 benefit
Non PPO 100 of reasonable and customary charges not to exceed Plan maximum of 250 per child per year for benefit children birth through age 3 For children ages 4 through 12 the Plan pays a maximum benefit of 150
per child per calendar year

Childhood The Plan will cover childhood immunizations recommended by the American Academy of Pediatrics for immunizations dependent children under age 22 as follows

PPO 100 of provider's negotiated fees benefit
Non PPO 100 of reasonable and customary charges benefit

Wellness The Plan reimburses up to 250 per Self Only enrollment and 350 per Self and Family enrollment per benefit calendar year for non covered expenses such as vision care eyeglasses hearing aids if received in 2000
and no other benefits for 2000 have been paid If the Plan paid claims of less than 350 for a Self and
Family enrollment the difference up to 350 will be paid See page 27 for additional claims
information

Review and Upon receipt of a corrected hospital billing from the member the Plan will credit 20 of any hospital reward program charge over 20 for covered services and supplies that were not actually provided to a covered person
The maximum amount payable under this program is 100 per person per calendar year

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
When no PPO provider is available non PPO benefits apply

Prescription Drug Benefits
What is covered You may purchase the following medications and supplies prescribed by a doctor from either a pharmacy or by mail
Drugs and medicines including those for smoking cessation for use at home that are obtainable only upon a doctor's prescription and listed in official formularies

Insulin and reagent strips for known diabetics
Needles and syringes for the administration of covered medications
Full range of FDA approved drugs prescriptions and devices for birth control
Approved drugs for organic impotence subject to prior Plan approval and limitations on dosage and quantity

What is Medication that does not require a prescription under Federal law even if your doctor prescribes it or not covered a prescription is required under your State law
Vitamins minerals nutritional supplements and enteral formulas liquid food supplements
Medical supplies such as dressings and antiseptics
Drugs and supplies for cosmetic purposes

20 22
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APWU Health Plan 2000
Prescription Drug Benefits continued

From a pharmacy
Plan After the 50 per person calendar year drug deductible maximum 100 per family the Plan pays 80
pharmacy of covered charges

You may obtain up to a 30 day supply plus one 30 day refill for each prescription purchased from a Plan
pharmacy After one 30 day refill you must obtain a new prescription and submit it to the Mail Order
Program Failure to do so will result in benefits payable at the non Plan pharmacy benefit level and the
waiver below will not apply Refills for maintenance medications are not considered new prescriptions
except when the doctor changes the strength or 180 days have elapsed since the previous purchase

Call 1 800 841 2734 to locate a Plan network pharmacy in your area
To use a Plan pharmacy you must present an APWU PAID prescription identification card which the Plan will provide you

You will be required to pay only your deductible and coinsurance for the drugs
Do not submit a claim to the Plan The Plan pharmacy will automatically submit your claim for you

Waiver If you have Medicare Parts A and B as your primary payer and you use a Plan pharmacy the Plan will waive the deductible and the coinsurance for purchase of generic drugs For purchase of brand name
drugs only the deductible will be waived This waiver does not apply beyond the first 30 day supply and
the first 30 day refill of each prescription

Non Plan If you do not use your identification card if you elect to use a non network pharmacy or if a Plan pharmacy pharmacy is not available you will need to file a claim and the Plan will reimburse you for covered
expenses as follows

After the 50 per person calendar year deductible maximum 100 per family the Plan pays 60 of
covered charges for up to a 30 day supply and unlimited refills

Waiver If you have Medicare Parts A and B as your primary payer the Plan will waive the deductible applicable to prescription drugs

To claim Use a Prescription Drug Claim Form to claim benefits for prescription drugs and supplies you purchased benefits from a non Plan pharmacy You may obtain forms by calling 1 800 222 APWU Your claim must
include receipts that show the prescription number National Drug Code NDC number name of drug
prescribing doctor's name date and charge Follow the instructions on the claim form and mail to
APWU Health Plan
Post Office Box 967
Silver Spring MD 20910

By mail If you are currently taking a prescription medication on a regular basis the Mail order drug program can help you save money on the cost of your prescriptions and refills Your doctor may prescribe up to a 90
day supply Merck Medco Rx Services which is a licensed pharmacy will fill your prescription within
two weeks of receipt of a prescription received by mail or within two business days of a prescription
initiated by physicians over the telephone

The Plan pays 100 after a 7 copayment for covered generic drugs and medicines and a 25
copayment for covered brand name drugs when purchased through the Plan's Mail order drug program

If you have Medicare Parts A and B as your primary payer the Plan pays 100 after a 5 copayment for
covered generic drugs and a 15 copayment for brand name drugs when purchased through the Plan's
Mail order drug program

Charges for Mail order drugs are not subject to any deductible

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APWU Health Plan 2000
Prescription Drug Benefits continued
To claim Contact the Plan for an order kit and the address of the Mail order drug program To use the program benefits 1 Complete the Patient Profile Questionnaire and complete the information on the back of the
pre addressed envelope
2 Enclose your prescription and mail to Merck Medco who will fill your prescription and mail it to
you
3 Merck Medco will file your claim with the Plan then bill you for any outstanding balance Do not
submit a claim to the Plan for mail order drugs
4 Forms necessary for refills and future prescription orders will be provided each time you receive a
supply of medication from the program
If you have any questions about the Mail order drug program or about a particular drug or prescription
you may call toll free 1 800 841 2734

Purchasing mail Use of the Mail order drug program for overseas delivery is restricted to delivery to APO boxes The order drugs prescribing doctor must be licensed to prescribe drugs in the United States
overseas

Drugs from Prescription drugs and antigens for treatment of allergies provided to you by a doctor or facility are other sources covered as Prescription Drugs as shown on page 21

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
When no PPO provider is available non PPO benefits apply

Dental Benefits
What is covered The services listed under the dental benefits are a complete list of covered services for which the Plan pays the following

Routine dental Diagnostic and preventive services up to 25 a visit up to two 2 visits each year including care examinations prophylaxis cleaning X rays of all types and fluoride treatment
Restorative dentistry fillings one surface 13 two or more surfaces 18
Simple extractions 13 per tooth
Restorative care

Restorative care There is no limit to the number of fillings or simple extractions in a calendar year

ADA code Amalgam restorations including polishing
2110 Amalgam one surface 13
2120 Amalgam two surfaces 18
2130 Amalgam three surfaces 18
2131 Amalgam four surfaces 18
2140 Amalgam one surface 13
2150 Amalgam two surfaces 18
2160 Amalgam three surfaces 18
2161 Amalgam four surfaces 18

Silicate restoration
2210 Silicate cement per restoration 13

Acrylic or plastic or composite resin
2330 Acrylic or plastic or composite resin one surface 13
2331 Acrylic or plastic or composite resin two surfaces 18
2332 Acrylic or plastic or composite resin three surfaces 18
2335 Acrylic or plastic or composite resin involving incisal angle or four or more
surfaces 18

Acrylic or plastic or composite resin
2380 Resin one surface posterior primary 13
2381 Resin two surfaces posterior primary 18
2382 Resin three or more surfaces posterior primary 18
2385 Resin one surface posterior permanent 13
2386 Resin two surfaces posterior permanent 18
2387 Resin three or more surfaces posterior permanent 18

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APWU Health Plan 2000
Dental Benefits continued
Gold foil restorations
2410 Gold foil one surface 13
2420 Gold foil two surfaces 18
2430 Gold foil three surfaces 18

Gold inlay restorations
2510 Gold inlay one surface 13
2520 Gold inlay two surfaces 18
2530 Gold inlay three surfaces 18

Porcelain restorations
2610 Porcelain inlay one surface 13
2620 Porcelain inlay two surfaces 18
2630 Porcelain inlay three surfaces 18
2650 Inlay Composite Resin one surface 13
2651 Inlay Composite Resin two surfaces 18
2652 Inlay Composite Resin three or more surfaces 18

Extractions ADA code Simple extractions includes local anesthesia and post operative care 7110 Single tooth 13

7120 Each additional tooth 13
7210 Surgical extractions each 13

Related benefits
Accidental The Plan will pay for covered expenses to the same extent as expenses for any other illness or injury for injury necessary repair of accidental injury to natural teeth due to a blow or fall including dental X rays

to natural teeth provided the treatment is performed within two years of the accident and while the patient is still covered by the Plan

Oral and For covered oral surgery see page 14 maxillofacial
surgery
What is not Services not shown as covered under this benefit covered Dental bridges replacement of natural teeth dental orthodontic temporomandibular joint dysfunction

appliances and any related expenses
Treatment of periodontal disease and gingival tissues and abscesses
Charges related to orthodontic treatment
Oral implants or transplants of any kind

23 25
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APWU Health Plan 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available
to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the FEHB premium and
any charges for these services do not count toward any FEHB deductibles out of pocket maximum co pay charges etc These benefits are
not subject to the FEHB disputed claims review procedure

Voluntary The Voluntary Benefits Plan Dental program is an optional program with an additional premium that supplements the
Benefits dental benefits in your APWU Health Plan coverage All participants of the APWU Health Plan who enroll in the
Plan Dental Voluntary Benefits Plan Dental Plan through this offer will receive a discount in the regular premiums for that
Plan program To enroll in this additional coverage complete and sign the Voluntary Benefits Plan Dental Plan enrollment
form which you can obtain from your APWU Health Plan representative or by calling the Voluntary Benefits Plan
office at the toll free number listed below Please specify that you are an APWU Health Plan participant

Availability The Voluntary Benefits Plan Dental Plan is available to all Active Retired Associate and Transitional Employee
APWU Members in all States and Territories of the United States

Coverage This optional dental plan is an indemnity insurance plan underwritten by the Reliance Insurance Company You may
Description use any dentist you choose Covered services are reimbursed as a percentage of the Usual and Customary charges
for that service in the state where the charge is incurred Once you have satisfied the continuous coverage limitations
of the program there are no further waiting periods as long as you remain continuously insured under the plan Both
you and your eligible dependents spouse and unmarried children to age 19 full time students to age 25 can be
insured under this plan

Coverage Calendar Year Deductible 50 per person Type I benefits
Schedule 100 per person Type II and Type III benefits combined

Calendar Year Maximum 1,000 per person for all covered services
500 per person for all eligible Orthodontic services if Optional Orthodontic Coverage
is selected

Lifetime Maximum 1,000 for Orthodontic services if Optional Orthodontic Coverage is selected
BENEFIT SCHEDULE After the Annual Deductible this plan will pay
HIGH OPTION PLAN LOW OPTION PLAN

TYPE I BENEFITS
Preventive Services 100 100
Exams of the Usual and Customary of the Usual and Customary
X rays charges charges
Cleanings
TYPE II BENEFITS
Basic Services 80 50
Fillings of the Usual and Customary of the Usual and Customary
Oral Surgery charges after 6 months of continuous coverage charges after 6 months of continuous coverage
Extractions
TYPE III BENEFITS
Major Services 50 50
Crowns of the Usual and Customary of the Usual and Customary
Bridges charges after 12 months of continuous coverage charges after 18 months of continuous coverage
Dentures
Periodontics
TYPE IV BENEFITS 50 50
Optional Coverage of the Usual and Customary of the Usual and Customary
Orthodontic charges after 24 months of continuous coverage charges after 24 months of continuous coverage
This is a partial summary of the terms conditions and limitations of the Dental Plan policy NVO 0144842 For more information
regarding the coverage rates or to receive an enrollment form please contact the Voluntary Benefits Plan office by calling or writing

Voluntary Benefits Plan 1 800 442 4492
P O Box 1471 1 800 237 5536 In CT
Waterbury CT 06721 1 203 754 4410 T D D

Benefits on this page are not part of the FEHB contract

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APWU Health Plan 2000
Section 6 How to file a claim

How to Claim Benefits
Claim forms If you do not receive your identification card s within 60 days after the effective date of your enrollment identification cards call the Carrier at 1 800 222 APWU for TDD use 1 800 622 2511 to report the delay In the
and questions meantime use your copy of the SF 2809 enrollment form or your annuitant confirmation letter from OPM as proof of enrollment when you obtain services This is also the number to call for claim forms or
advice on filing claims

If you made your open season change by using Employee Express and have not received your new ID
card by the effective date of your enrollment call the Employee Express HELP number to request a
confirmation letter Use that letter to confirm your new coverage with providers

If you have a question concerning Plan benefits contact the Carrier at 1 800 222 APWU or you may
write to the Carrier at PO Box 3279 Silver Spring MD 20918 You may also contact the Carrier by fax
at 301 622 5712 at its website at http www apwuhp com or by email at custser apwuhp com

How to file Claims filed by your doctor that include an assignment of benefits to the doctor are to be filed on the form claims HCFA 1500 Health Insurance Claim Form Claims submitted by enrollees may be submitted on the
HCFA 1500 or a claim form that includes the information shown below Bills and receipts should be
itemized and show
Name of patient and relationship to enrollee
Plan identification number of the enrollee
Name address and taxpayer identification number of person or firm providing the service or supply
Dates that services or supplies were furnished
Type of each service or supply and the charge
Diagnosis

In addition
A copy of the explanation of benefits EOB from any primary payer such as Medicare must be sent with your claim

Bills for private duty nurses must show that the nurse is a registered licensed practical or licensed vocational nurse
Claims for rental or purchase of durable medical equipment private duty nursing and physical occupational and speech therapy require a written statement from the doctor specifying the medical
necessity for the service or supply and the length of time needed
Claims for prescription drugs that are not obtained from a Plan pharmacy or through the Mail order program must include receipts that include the prescription number the National Drug Code NDC

number name of drug prescribing doctor's name date and charge
Claims for overseas foreign services should include an English translation Charges should be converted to U S dollars using the exchange rate applicable at the time the expense was incurred

Cancelled checks cash register receipts or balance due statements are not acceptable
After completing a claim form and attaching proper documentation send claims to
APWU Health Plan
Post Office Box 967
Silver Spring MD 20910
Phone 1 800 580 8771 for hospital precertification see page 33
Phone 1 800 222 APWU benefits verifications
Phone 1 301 622 1700 other business
FAX 1 301 622 5712 not for filing of claims
TDD line for hearing impaired 1 800 622 2511 TDD equipment required

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APWU Health Plan 2000
How to Claim Benefits continued
Wellness Claims The Plan notifies members in November of each year if they are eligible for the Wellness benefit Submit Wellness claims after January 1 2001 Wellness claims are paid after March 1 2001 If after Wellness
benefits have been paid subsequent claims are received for hospital medical or dental expenses
payments made under the Wellness benefit will be deducted from allowable charges

Records Keep a separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to each person Save copies of all medical bills including those
you accumulate to satisfy a deductible In most instances they will serve as evidence of your claim The
Carrier will not provide duplicate or year end statements

Submit claims Claims must be submitted within two years of the date you incur the expense The Plan encourages timely promptly submission because failure to file within the two year limit will invalidate your claim unless timely filing
was prevented by administrative operations of Government or legal incapacity provided the claim was
submitted as soon as reasonably possible Once benefits have been paid there is a three year limitation on
the reissuance of uncashed checks

Overseas claims See How to file claims page 25 and Records above
Direct payment You or your spouse may authorize direct payment to the provider by completing the assignment of benefits to hospital or payment section of the claim form or the provider's own assignment form Otherwise payment will be
provider of care made to you The Plan reserves the right to make payment of benefits directly to you

When more Reply promptly when the Carrier requests information in connection with a claim If you do not respond information the Carrier may delay processing or limit the benefits available
is needed

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APWU Health Plan 2000
Section 7 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless we
determine it is medically necessary to prevent diagnose or treat your illness or condition The fact that one of our covered providers has
prescribed recommended or approved a service or supply does not make it medically necessary or eligible for coverage under this Plan

We do not Services drugs or supplies that are not medically necessary
cover the Services not required according to accepted standards of medical dental or psychiatric practice in the
following United States Experimental or investigational procedures treatments drugs or devices

Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or

incest
Procedures services drugs and supplies related to sex transformations sexual dysfunction or sexual inadequacy except for organic impotence as shown on pages 15 and 20

Services or supplies you receive from a provider or facility barred from the FEHB Program
Expenses you incurred while you were not enrolled in this Plan
Services drugs and supplies for which no charge would be made if the covered individual had no health insurance coverage

Services drugs and supplies furnished without charge except as described on page 31 while in active military service or required for illness or injury sustained on or after the effective date of
enrollment 1 as a result of an act of war within the United States its territories or possessions or 2
during combat
Services drugs and supplies furnished by immediate relatives or household members such as spouse parent child brother or sister by blood marriage or adoption

Services and supplies furnished or billed by a noncovered facility except that medically necessary prescription drugs and physical speech and occupational therapy rendered by a qualified professional
therapist on an outpatient basis are covered subject to plan limits
Services supplies and drugs not specifically listed as covered
Services supplies and drugs furnished or billed by someone other than a covered provider as defined on page 7

Any portion of a provider's fee or charge ordinarily due from the enrollee but that has been waived If a provider routinely waives does not require the enrollee to pay a deductible copay or coinsurance
the Carrier will calculate the actual provider fee or charge by reducing the fee or charge by the
amount waived
Charges the enrollee or Plan has no legal obligation to pay such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and or B see pages 31 and 32 doctor

charges exceeding the amount specified by the Department of Health and Human Services when
benefits are payable under Medicare limiting charge see page 32 or State premium taxes however
applied
Biofeedback nonmedical self care or self help training such as recreational educational or milieu therapy and

Charges that the Plan determines to be in excess of the reasonable and customary charge

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APWU Health Plan 2000
Section 8 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you may
need to file a Medicare claim form

If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with
us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you
later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in
the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration SSA
office or call SSA at 1 800 638 6833

This Plan and Medicare
Coordinating The following information applies only to enrollees and covered family members who are entitled to
benefits benefits from both this Plan and Medicare You must disclose information about Medicare coverage including your enrollment in a Medicare prepaid plan to this Carrier this applies whether or not you file a

claim under Medicare You must also give this Carrier authorization to obtain information about benefits
or services denied or paid by Medicare when they request it It is also important that you inform the
Carrier about other coverage you may have as this coverage may affect the primary secondary status of this
Plan and Medicare

This Plan covers most of the same kinds of expenses as Medicare Part A hospital insurance and Part B
medical insurance except that Medicare does not cover prescription drugs

The following rules apply to enrollees and their family members who are entitled to benefits from both an
FEHB plan and Medicare

This Plan is 1 You are age 65 or over have Medicare Part A or Parts A and B and are employed by the Federal
primary if Government 2 Your covered spouse is age 65 or over and has Medicare Part A or Parts A and B and you are

employed by the Federal Government
3 The patient you or a covered family member is within the first 30 months of eligibility to receive
Medicare Part A benefits due to End Stage Renal Disease ESRD except when Medicare based on
age or disability was the patient's primary payer on the day before he or she became eligible for
Medicare Part A due to ESRD or
4 The patient you or a covered family member is under age 65 and eligible for Medicare solely on the
basis of disability and you are employed by the Federal Government

For purposes of this section employed by the Federal Government means that you are eligible for FEHB
coverage based on your current employment and that you do not hold an appointment described under
Rule 6 of the following Medicare is primary section

Medicare is 1 You are an annuitant age 65 or over covered by Medicare Part A or Parts A and B and are not
primary if employed by the Federal Government 2 Your covered spouse is age 65 or over and has Medicare Part A or Parts A and B and you are not

employed by the Federal Government

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APWU Health Plan 2000
Medicare is 3 You are age 65 or over and a you are a Federal judge who retired under title 28 U S C b you are
primary if a Tax Court judge who retired under Section 7447 of title 26 U S C or c you are the covered
continued spouse of a retired judge described in a or b 4 You are an annuitant not employed by the Federal Government and either you or a covered family

member who may or may not be employed by the Federal Government is under age 65 and eligible
for Medicare on the basis of disability
5 You are enrolled in Part B only regardless of your employment status
6 You are age 65 or over and employed by the Federal Government in an appointment that excludes
similarly appointed nonretired employees from FEHB coverage and have Medicare Part A or Parts
A and B
7 You are a former Federal employee receiving workers compensation and the Office of Workers
Compensation has determined that you are unable to return to duty
8 The patient you or a covered family member has completed the 30 month ESRD coordination
period and is still eligible for Medicare due to ESRD or
9 The patient you or a covered family member becomes eligible for Medicare due to ESRD after
Medicare assumed primary payer status for the patient under rules 1 through 7 above

When Medicare is When Medicare is primary all or part of your Plan deductibles and coinsurance will be waived for
Primary services and supplies covered by this Plan as follows

Inpatient hospital benefits If you are enrolled in Medicare Part A the Plan will waive the deductible and
coinsurance

Surgical Benefits If you are enrolled in Medicare Part B the Plan will waive the deductible and
coinsurance

Mental conditions substance abuse benefits If you are enrolled in Medicare Part A the Plan will waive
the coinsurance applicable to inpatient hospital charges for services covered by Medicare Part A and this
Plan If you are enrolled in Medicare Part B the Plan will waive the deductible and coinsurance for
doctors inpatient services and outpatient care

Other Medical Benefits If you are enrolled in Medicare Part B the Plan will waive the deductible and
coinsurance

Prescription Drugs If you are enrolled in Medicare Parts A and B where Medicare is the primary payer
the Plan will waive the coinsurance and deductible applicable to generic prescription drugs but will
waive only the deductible for brand name drugs obtained from a Plan pharmacy for up to a 30 day supply
plus one 30 day refill for each prescription For subsequent refills from a Plan pharmacy or for all
purchases from a Non Plan pharmacy only the deductible is waived 40 coinsurance applies

When Medicare is the primary payer this Plan will limit its payment to an amount that supplements the
benefits that would be payable by Medicare regardless of whether or not Medicare benefits are paid
However the Plan will pay its regular benefits for emergency services to an institutional provider such as
a hospital that does not participate with Medicare and is not reimbursed by Medicare

If you are enrolled in Medicare you may be asked by a physician to sign a private contract agreeing that
you can be billed directly for services that would ordinarily be covered by Medicare Should you sign
such an agreement Medicare will not pay any portion of the charges and you may receive less or no
payment for those services under this Plan

When you also When you are enrolled in a Medicare prepaid plan while you are a member of this Plan you may continue
enroll in a to obtain benefits from this Plan If you submit claims for services covered by this Plan that you receive
Medicare prepaid from providers that are not in the Medicare plan's network the Plan will not waive any deductibles or coinsurance when paying these claims
plan

Medicare's If you are covered by Medicare Part B and it is primary you should be aware that your out of pocket costs
payment and this for services covered by both this Plan and Medicare Part B will depend on whether your doctor accepts
Plan Medicare assignment for the claim

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APWU Health Plan 2000
Medicare's Doctors who participate with Medicare accept assignment that is they have agreed not to bill you for
payment and this more than the Medicare approved amount for covered services Some doctors who do not participate with
Plan continued Medicare accept assignment on certain claims If you use a doctor who accepts Medicare assignment for the claim the doctor is permitted to bill you after the Plan has paid only when the Medicare and Plan

payments combined do not total the Medicare approved amount

Doctors who do not participate with Medicare are not required to accept direct payment or assignment
from Medicare Although they can bill you for more than the amount Medicare would pay Medicare law
the Social Security Act 42 U S C sets a limit on how much you are obligated to pay This amount
called the limiting charge is 115 percent of the Medicare approved amount Under this law if you use a
doctor who does not accept assignment for the claim the doctor is permitted to bill you after the Plan has
paid only if the Medicare and Plan payments combined do not total the limiting charge Neither you nor
your FEHB Plan is liable for any amount in excess of the Medicare limiting charge for charges of a doctor
who does not participate with Medicare The Medicare Summary Notice MSN form will have more
information about this limit

If your doctor does not participate with Medicare asks you to pay more than the limiting charge and he or
she is under contract with this Plan call the Plan If your doctor is not a Plan doctor ask the doctor to
reduce the charge or report him or her to the Medicare carrier that sent you the Medicare MSN form In
any case a doctor who does not participate with Medicare is not entitled to payment of more than 115
percent of the Medicare approved amount

How to claim In most cases when services are covered by both Medicare and this Plan Medicare is the primary payer if
benefits you are an annuitant and this Plan is the primary payer if you are an employee When Medicare is the primary payer your claims should first be submitted to Medicare After Medicare has paid its benefits the

Carrier will consider the balance of any covered expenses The Carrier has contracted with most
Medicare Part B claims processors to receive electronic copies of your claims after Medicare has paid
their benefits thus eliminating the necessity for you to submit your Part B claims to this Plan If you
completed and returned to this Plan the Authorization Form sent you you are included in this program
You may call the Carrier at 1 800 222 APWU to obtain information about your status in this program or
to obtain an Authorization Form If your claims are not being electronically filed you must submit the
MSN form from Medicare and duplicates of all bills along with a completed claim form The Carrier will
not process your claim without knowing whether you have Medicare and if you do without receiving the
Medicare MSN

Other group insurance coverage
When anyone has coverage with us and with another group health plan it is called double coverage You
must tell us if you or a family member has double coverage You must also send us documents about
other insurance if we ask for them

When you have double coverage one plan is the primary payer it pays benefits first The other plan is
secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines

If we pay second we will determine how much of the charge we will pay for After the first plan pays we
will pay either what is left of the reasonable charge or our regular benefit whichever is less We will not
pay more than the reasonable charge

Remember Even if you do not file a claim with your other plan you must still tell us that you have double
coverage

Automobile insurance Double coverage also applies when you are entitled to the payment of medical and hospital costs under automobile insurance including no fault that pays without regard to fault In such case your automobile
insurance will pay first and we will pay second We will pay either what is left of the reasonable charge or
our regular benefit whichever is less We will not pay more than the reasonable charge

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APWU Health Plan 2000
When others are
responsible for
injuries

Liability Subrogation applies when you are sick or injured as a result of the act or omission of another person or
insurance and party
third party If you or your dependent sustains an injury or illness caused by a third party the Plan will pay benefits for
actions the injury or illness subject to the conditions that you and your dependents 1 agree to the Plan being subrogated to any recovery or right of recovery you or your dependents have including the right to bring

suit in your name 2 will not take any action which would prejudice the Plan's subrogation rights and 3
will cooperate in doing what is reasonably necessary to assist the Plan in any recovery The Plan will be
subrogated only to the extent of Plan benefits paid because of that injury

This provision means that the Plan must be reimbursed in full for benefits paid in an amount not to exceed
the amount you recover or if you do not bring suit or recover that the Plan to the extent of benefits paid
has a right to bring suit in the name s of the injured party or parties Under this provision all recoveries
whether by lawsuit settlement or otherwise no matter how described or designated must be used to
reimburse the Plan in full for benefits paid This provision does not allow the Plan's share of the recovery
to be reduced because you or your covered dependent do not receive the full amount of damages claimed
or for your attorney's fees and costs unless the Plan agrees in writing to a reduction

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage

Workers We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must provide

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your
benefits

Medicaid We pay first if both Medicaid and this Plan cover you

Other Government We do not cover services and supplies that a local State or Federal Government agency directly or
Agencies indirectly pays for

Overpayments The Carrier will make reasonable diligent efforts to recover benefit payments made erroneously but in good faith and may apply subsequent benefits otherwise payable to offset any overpayments

Limit on your costs The information in the following paragraphs applies to you when 1 you are not covered by either
if you are age 65 or Medicare Part A hospital insurance or Part B medical insurance or both 2 are enrolled in this Plan as
older and don't have an annuitant or as a former spouse or family member covered by the family enrollment of an annuitant or former spouse and 3 you are not employed in a position which confers FEHB coverage
Medicare

Inpatient If you are not covered by Medicare Part A are age 65 or older or become age 65 while receiving inpatient
hospital hospital services and you receive care in a Medicare participating hospital the law
care 5 U S C 8904 b requires the Plan to base its payment on an amount equivalent to the amount Medicare would have allowed if you had Medicare Part A This amount is called the equivalent Medicare amount

After the Plan pays the law prohibits the hospital from charging you for covered services after you have
paid any deductibles coinsurance or copayments you owe under the Plan Any coinsurance you owe will
be based on the equivalent Medicare amount not the actual charge You and the Plan together are not
legally obligated to pay the hospital more than the equivalent Medicare amount

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APWU Health Plan 2000
Inpatient The Carrier's explanation of benefits EOB will tell you how much the hospital can charge you in addition
hospital to what the Plan paid If you are billed more than the hospital is allowed to charge ask the hospital to
care continued reduce the bill If you have already paid more than you have to pay ask for a refund If you cannot get a reduction or refund or are not sure how much you owe call the Plan at 1 800 222 APWU for assistance

Physician Claims for physician services provided for retired FEHB members age 65 and older who do not have
services Medicare Part B are also processed in accordance with 5 U S C 8904 b This law mandates the use of Medicare Part B limits for covered physician services for those members who are not covered by

Medicare Part B
The Plan is required to base its payment on the Medicare approved amount which is the Medicare fee
schedule for the service or the actual charge whichever is lower If your doctor is a member of the
Plan's preferred provider organization PPO and participates with Medicare the Plan will base its
payment on the lower of these two amounts and you are responsible only for any deductible and the PPO
copayment or coinsurance

If you go to a PPO doctor who does not participate with Medicare you are responsible for any deductible
and the copayment or coinsurance In addition unless the doctor's agreement with the Carrier specifies
otherwise you must pay the difference between the Medicare approved amount and the limiting charge
115 of the Medicare approved amount

If your physician is not a Plan PPO doctor that participates with Medicare the Plan will base its regular
benefit payment on the Medicare approved amount For instance under this Plan's surgery benefit the
Plan will pay 70 of the Medicare approved amount You will only be responsible for any deductible and
coinsurance equal to 30 of the Medicare approved amount

If your physician does not participate with Medicare the Plan will still base its payment on the Medicareapproved
amount However in most cases you will be responsible for any deductible the coinsurance or
copayment amount and any balance up to the limiting charge amount 115 of the Medicare approved
amount

Since a physician who participates with Medicare is only permitted to bill you up to the Medicare fee
schedule amount even if you do not have Medicare Part B it is generally to your financial advantage to use
a physician who participates with Medicare

The Carrier's explanation of benefits EOB will tell you how much the physician can charge you in
addition to what the Plan paid If you are billed more than the physician is allowed to charge ask the
physician to reduce the bill If you have already paid more than you have to pay ask for a refund If you
cannot get a reduction or refund or are not sure how much you owe call the Plan at 1 800 222 APWU for
assistance

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APWU Health Plan 2000
Section 9 Fee for Service facts

Precertification Precertify Precertification is not a guarantee of benefit payments Precertification of an inpatient admission is a
before predetermination that based on the information given the admission meets the medical necessity
admission requirements of the Plan It is your responsibility to ensure that precertification is obtained If precertification is not obtained and benefits are otherwise payable benefits for the admission will be

reduced by 500

To precertify a scheduled admission
You your representative your doctor or your hospital must call Spectera CARE Programs at least 48 hours prior to admission The toll free number is 1 800 580 8771 and may be reached 24 hours

every day In Minnesota call PreferredOne at 1 800 451 9597 to precertify To precertify an
admission for mental conditions substance abuse see page 16
Provide the following information enrollee's name and Plan identification number patient's name birth date and phone number reason for hospitalization proposed treatment or surgery name of

hospital or facility name and phone number of admitting doctor
The doctor and or hospital will be notified telephonically of the number of days of confinement approved
initially for the care Written confirmation of the Carrier's certification decision will be sent to the patient
provider and facility If the length of stay needs to be extended follow the procedures below

Need additional The CARE nurse reviewer will be in contact with the facility and or physician throughout your
days hospitalization If any additional days are required CARE will obtain clinical information to determine if these days are medically necessary

If the admission is precertified but you remain confined beyond the number of days certified as medically
necessary the Plan will not pay for charges incurred on any extra days that are determined to not be
medically necessary by the Carrier during the claim review

You don't need Medicare Part A or another group health insurance policy is the primary payer for the hospital
to certify an confinement see pages 28 and 29 Precertification is required however for members with
admission when Medicare Part A prior to the 60th day of a Medicare benefit period when Medicare hospital benefits are exhausted prior to using lifetime reserve days or if being admitted to a Department of Veterans

Affairs or Department of Defense hospital
You are confined in a hospital outside the United States and Puerto Rico

Maternity or When there is an unscheduled maternity admission or an emergency admission due to a condition that puts
emergency the patient's life in danger or could cause serious damage to bodily function you your representative the
admissions doctor or the hospital must telephone the applicable number listed above within 48 hours of admission even if the patient has been discharged from the hospital Otherwise inpatient benefits otherwise payable

for the admission will be reduced by 500

Newborn confinements that extend beyond the mother's discharge date must also be certified You your
representative the doctor or hospital must request certification for the newborn's continued confinement
within 48 hours of delivery birth

Other An early determination of need for confinement precertification of the medical necessity of inpatient
considerations admission is binding on the Carrier unless the Carrier is misled by the information given to it After the claim is received the Carrier will first determine whether the admission was precertified and then provide

benefits according to all of the terms of this brochure

If you do not If precertification is not obtained at least 48 hours before admission to the hospital or within 48 hours of a
precertify maternity or emergency admission or in the case of a newborn the mother's discharge a medical necessity determination will be made at the time the claim is filed If the Carrier determines that the

hospitalization was not medically necessary the inpatient hospital benefits will not be paid However
medical supplies and services determined to be medically necessary and otherwise payable on an
outpatient basis will be paid under applicable outpatient benefits

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APWU Health Plan 2000
If you do not If the claim review determines that the admission was medically necessary any benefits payable according
precertify continued to all of the terms of this brochure will be reduced by 500 for failing to have the admission precertified

If the admission is determined to be medically necessary but part of the length of stay was found not to be
medically necessary inpatient hospital benefits will not be paid for the portion of the confinement that was
not medically necessary However medical services and supplies determined to be medically necessary
and otherwise payable on an outpatient basis will be paid under applicable outpatient benefits

Protection Against Catastrophic Costs
Catastrophic For certain services with coinsurance the Plan pays 100 of reasonable and customary charges for the
protection remainder of the calendar year after the calendar year deductible is met when out of pocket expenses for coinsurance in that calendar year exceed 3,500 for a Self Only enrollment or 3,500 for a Self and

Family enrollment Whether or not you use Preferred providers the 250 individual deductible or the
500 family deductible must be satisfied before the Plan will pay benefits at 100

Preferred When your eligible out of pocket expenses from using Preferred providers exceed 2,000 for a Self Only
Providers enrollment or 2,000 for a Self and Family enrollment the Plan pays 100 of covered expenses for Preferred providers for the remainder of the calendar year

Out of pocket Out of pocket expenses for the purposes of this benefit are
expenses The 10 you pay for PPO Inpatient hospital charges Surgical Maternity and Other Medical Benefits

The 30 you pay for non PPO Inpatient hospital charges Surgical Maternity and Other Medical Benefits and

The copayment of 15 for outpatient visits to PPO physicians see page 17
The following cannot be included in the accumulation of out of pocket expenses
Expenses in excess of reasonable and customary charges or maximum benefit limitations
Expenses for mental conditions substance abuse or dental care
Any amounts you pay because benefits have been reduced for non compliance with this Plan's cost containment requirements see pages 4 6 33 and 34

Covered expenses applied to the 250 calendar year deductible
The 200 per admission deductible for non PPO Inpatient hospital charges
Expenses for prescription drugs
Expenses incurred in excess of the 90 per day provided under home nursing care see page 18 and
Expenses in excess of hospice care and preventive care maximums

Carryover 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 old plan if they are for care
you got in January before the effective date of your coverage in this Plan If you have already met the
covered out of pocket maximum expense level in full your old plan's catastrophic protection benefit will
continue to apply until the effective date If you have not met this expense level in full your old 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 The old plan will pay these covered expenses according to this year's benefits benefit
changes are effective on January 1

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APWU Health Plan 2000
Definitions
Accidental injury An injury resulting from a violent external force

Admission The period from entry admission into a hospital or other