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Document Outline

Introduction
Plain Language
Inspector General Advisory
Section 1. Facts about this fee-for-service plan
Section 2. How we change for 2002
Section 3. How you get care

Identification cards
Where you get covered care

Covered providers
Covered facilities

What you must do to get covered care
How to Get Approval forƒ

Your hospital stay
Other services

Section 4. Your costs for covered services

Copayments
Deductible
Coinsurance
Differences between our
Your out-of-pocket maximum
When government facilities bill us
If we overpay you
When you are age 65 or over and you do not have Medicare
When you have Medicare

Section 5. Benefits

Overview

(a) Medical services and supplies provided by physicians and other health care professionals
(b) Surgical and anesthesia services provided by physicians and other health care professionals
(c) Services provided by a hospital or other facility, and ambulance services
(d) Emergency services/Accidents
(e) Mental health and substance abuse benefits
(f) Prescription drug benefits
(g) Special features

Flexible benefits option
24-hour nurse line
Wellness benefit
Review and reward program

(h) Dental benefits
(i) Non-FEHB benefits available to Plan members

Section 6. General exclusions -- things we dont cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage

When you have other health coverage
Original Medicare
Medicare managed care plan
TRICARE/Workers' Compensation
Medicaid
When other Government agencies are responsible for your care
When others are responsible for injuries

Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts

Coverage information

No pre-existing condition limitation
Where you can get information about enrolling in the FEHB Program
Types of coverage available for you and your family
When benefits and premiums start
Your medical and claims records are confidential
When you retire

When you lose benefits

When FEHB coverage ends
Spouse equity coverage
Temporary Continuation of Coverage (TCC)
Converting to individual coverage
Getting a Certificate of Group Health Plan Coverage

Long Term Care Insurance Is Coming Later in 2002
Department of Defense/FEHB Demonstration Project
Index
Sunnary of benefits
Rates

Pages 1--72 from APWU Health Plan

Page 1 2

APWU Health Plan http:// www. apwuhp. com
2002 A fee-for-service plan

with preferred provider organizations

Sponsored and administered by: 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.
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 Health Plan upon enrollment in the APWU Health Plan.

Annuitants (retirees) may enroll in this Plan.
Membership dues: $35 per year for an associate membership. APWU will bill new associate
members for the annual dues when it receives notice of enrollment. APWU will also bill continuing associate members for the annual membership. Active and retired Postal Service

employee's membership dues vary by APWU local.
Enrollment codes for this Plan:
471 High Option -Self Only
472 High Option -Self and Family

For changes in benefits
see page 8.

RI 71-004 1
1 Page 2 3

2002 APWU Health Plan 4 Introduction/ Plain Language/ Advisory
Introduction
APWU Health Plan
12345 New Columbia Pike
Silver Spring, MD 20904

This brochure describes the benefits of APWU Health Plan under our contract (CS 1370) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the official
statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure.

If you are enrolled in this Plan, you are 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. You do not have a right to
benefits that were available before January 1, 2002, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2002, and changes are summarized on pages 8. Rates are shown at the end of this brochure.

Plain Language
Teams of Government and health plans' staff worked on all FEHB brochures to make them responsive, accessible, and understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family
member; "we" means APWU Health Plan

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.

Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you
compare plans.

If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may

also write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650 4
4 Page 5 6
2002 APWU Health Plan 5 Introduction/ Plain Language/ Advisory
Inspector General Advisory
Stop health care fraud! Fraud increases the cost of health care for everyone. If you suspect that a physician, pharmacy, or hospital has charged you for services
you did not receive, billed you twice for the same service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 800/ 222-APWU
and explain the situation.

If we do not resolve the issue, call or write

THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415.

Penalties for fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud. Also, the Inspector General may investigate

anyone who uses an ID card if the person tries to obtain services for someone who is not an eligible family member, or is no longer

enrolled in the Plan and tries to obtain benefits. Your agency may also take administrative action against you. 5
5 Page 6 7
2002 APWU Health Plan 6 Section 1
Section 1. Facts about this fee-for-service plan
This Plan is a fee-for-service (FFS) plan. You can choose your own physicians, hospitals, and other health care providers.

We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The type and extent of covered services, and the amount we allow, may be different from other plans. Read brochures
carefully.
We also have Preferred Provider Organizations (PPO):

Our fee-for-service plan offers services through a PPO. When you use our PPO providers, you will receive covered services at reduced cost. Contact us for the names of PPO providers and to verify their continued participation. You
can also go to our web page, which you can reach through the FEHB website, www. opm. gov/ insure. Do not call OPM or your agency for our provider directory.

If you need assistance in identifying a participating provider, call the Plan's PPO administrator for your state: Alliance PPO, Inc. 800/ 342-3289 for providers in the District of Columbia, Maryland, Virginia and West Virginia; Beech
Street 800/ 923-3248 for providers in California, Florida, Georgia, Ohio, Oklahoma, Tennessee, Texas and Washington; MultiPlan 800/ 672-2140 for providers in New Jersey and New York; MedNet 800/ 556-1144 for
providers in Maine; PreferredOne 800/ 451-9597 for providers in Minnesota; V. I. Equicare 340/ 774-5779 for providers in the U. S. Virgin Islands; or First Health 800/ 447-1704 for all other states. For mental conditions/ substance abuse
providers (all states), call ValueOptions toll-free 888/ 700-7965.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every
specialty in all areas. If no PPO provider is available, or you do not use a PPO provider, the standard non-PPO benefits apply.

How we pay providers
PPO Providers: Allowable benefits are based upon charges and discounts which we or our PPO administrators have negotiated with participating providers. PPO provider charges are always within our plan allowance.

Non-PPO providers: We determine our allowance for covered charges by using health care charge data prepared by the Health Insurance Association of America (HIAA) or other credible sources, including our own data, when
necessary. We apply this charge data at the 70 th percentile.
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types
of information that we must make available to you. Some of the required information is listed below.
Spectera/ Care, Inc. is the major subcontractor performing hospital precertification and case management for the Plan and is accredited by American Accreditation HealthCare Commission/ URAC effective May 24, 1997.
PreferredOne Management Company performs hospital precertification and case management for members in the State of Minnesota only and is also URAC accredited effective August 1, 1997.

Value Options performs hospital precertification and outpatient prior authorization for mental health/ substance
abuse and is also URAC accredited effective March 1, 1999. 6
6 Page 7 8

2002 APWU Health Plan 7 Section 1
The following PPO networks are also URAC accredited:
PreferredOne – effective August 1, 1997
MultiPlan – effective August 1, 1998

The American Postal Workers Union Health Plan is a not-for-profit Voluntary Employee's Beneficiary Association (VEBA) formed in 1972 as the result of a merger between four predecessor union plans.

We meet applicable State and Federal licensing and accreditation requirements for fiscal solvency, confidentiality
and transfer of medical records.

If you want more information about us, call 800/ 222-APWU, or write to APWU Health Plan, P. O. Box 3279, Silver Spring, MD 20918. You may also contact us by fax at 301/ 622-5712 or visit our website at www. apwuhp. com. 7
7 Page 8 9

2002 APWU Health Plan 8 Section 2
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes

Four states are added to the list of medically underserved areas: Georgia, Montana, North Dakota and Texas.
Louisiana is no longer medically underserved. (Section 3)

We changed the address for sending disputed claims to OPM. (Section 8)
Changes to this Plan

Your share of the Postal premium will increase by 0.1% for Self Only or –5.4% for Self & Family.
Your share of the non-Postal premium will increase by 4.4% for Self Only or 1.7% for Self and Family.
We have eliminated the Point-of-Service (POS) benefit. Last year, a POS benefit was available to members in certain counties in the State of Texas and in the Minneapolis/ St. Paul, Minnesota areas. Plan members enrolled in

the POS benefit will be enrolled in the Plan's PPO benefit beginning January 1.
For prescription drugs, you now pay a $7 copayment for up to a 30-day supply of generic medications obtained from a network pharmacy. Last year, you paid 25% of the cost of generics with a minimum of $5 per

prescription. (Section 5 (f))
For prescription drugs, you now pay a $10 copayment for up to a 90-day supply of generic medications obtained through our mail order program. Last year, you paid 20% of the cost of generics with a minimum of $5 per

prescription. (Section 5 (f))
For PPO in-network services and supplies, you now have a calendar year deductible of $275 per person, $550 per family. If you use non-PPO providers, your calendar year deductible increases to a maximum of $350 per person

($ 700 per family). Whether or not you use PPO providers, your calendar year deductible will not exceed $350 per person ($ 700 per family). Previously, the deductible was $250 per person, $500 per family for both PPO and
non-PPO providers. (Section 4)
The separate in-network calendar year deductible for mental health/ substance abuse treatment has increased to $275 per person, $550 for family. Previously, this deductible was $250 per person, $500 per family.

(Section 5 (e))
We no longer limit total blood cholesterol tests to certain age groups (Section 5 (a))
We now cover certain intestinal transplants. (Section 5 (b))
We changed speech therapy benefits by removing the requirement that services must be required to restore functional speech. (Section 5 (a))

You now pay a $40 copayment (no deductible) for treatment of a medical emergency in a PPO network Urgent Care Center for the facility charge. Previously, you paid 10% after the calendar year deductible. (Section 5 (d))
If you do not use preferred providers, the Plan allowance for surgery, doctor's services, X-ray, lab and therapies
may be lower than last year because the Plan now uses the 70 th percentile of its prevailing charge guides. Last year, the 80 th percentile was used. You may have to pay a larger portion of your bill if you do not use preferred

providers. If you use preferred providers, this change will not affect you since preferred providers always accept the Plan's allowance as their charge for services. (Section 10)

We clarified the Infertility benefits to show that we cover fertility drugs. Last year, these expenses were erroneously listed as non-covered expenses. (Section 5 (a))
We clarified the brochure to better explain that the non-PPO benefits are the standard benefits of this Plan, that PPO benefits apply only when you use a PPO provider, and that when no PPO provider is available, non-PPO
benefits apply. 8
8 Page 9 10
2002 APWU Health Plan 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the

Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at
800/ 222-APWU.

Where you get covered care You can get care from any "covered provider" or "covered facility." How much we pay – and you pay – depends on the type of covered
provider or facility you use. If you use our preferred providers, you will pay less.

Covered providers We consider the following to be covered providers when they perform services within the scope of their license or certification:
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.
Medically underserved areas. Note: We cover any licensed
medical practitioner for any covered service performed within the scope of that license in states OPM determines are "medically

underserved." For 2002, the states are: Alabama, Georgia, Idaho, Kentucky, Mississippi, Missouri, Montana, New Mexico,
North Dakota, South Carolina, South Dakota, Texas, Utah, and Wyoming. 9
9 Page 10 11
2002 APWU Health Plan 10 Section 3
Covered facilities Covered facilities include:
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.

What you must do to get covered care It depends on the kind of care you want to receive. You can go to any provider you want, but we must approve some care in advance.
Transitional care Specialty care: If you have a chronic or disabling condition and
lose access to your specialist because we drop out of the Federal
Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan, or

lose access to your PPO specialist because we terminate our contract
with your specialist for other than cause,

you may be able to continue seeing your specialist and receiving any PPO benefits for up to 90 days after you receive notice of the change.

Contact us or, if we drop out of the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can

continue to see your specialist and any PPO benefits continue until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan
begins, call our customer service department immediately at 800/ 222-APWU. 10
10 Page 11 12
2002 APWU Health Plan 11 Section 3
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92nd day after you become a member of this Plan, whichever
happens first

These provisions apply only to the benefits of the hospitalized person.

How to Get Approval for…

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

on medical necessity.
In most cases, your physician or hospital will take care of precertification. Because you are still responsible for ensuring that we are asked to
precertify your care, you should always ask your physician or hospital whether they have contacted us.

Warning We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically
necessary, we will not pay any benefits.
How to precertify an
admission You, your representative, your doctor, or your hospital must call Spectera/ Care at 800/ 580-8771 at least 48 hours before admission.

In Minnesota, call PreferredOne at 800/ 451-9597 to precertify. These numbers are available 24 hours every day.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious
damage to bodily function, you, your representative, the doctor, or the hospital must telephone the above number 48 hours following the
day of the emergency admission, even if you have been discharged from the hospital.

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 and phone number of admitting doctor
-Name of hospital or facility; and
-Number of planned days of confinement

We will then tell the doctor and/ or hospital the number of approved inpatient days and we will send written confirmation of our decision
to you, your doctor, and the hospital.
Maternity care You do not need to precertify a maternity admission for a routine 11
11 Page 12 13
2002 APWU Health Plan 12 Section 3
delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean
section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you
are discharged, then your physician or the hospital must contact us for precertification of additional days for your baby.

If your hospital stay
needs to be extended: If your hospital stay --including for maternity care --needs to be extended, you, your representative, your doctor or the hospital must ask
us to approve the additional days by calling Spectera/ Care at 800/ 580-8771 or in Minnesota, call PreferredOne at 800/ 451-9597.

What happens when you
do not follow the
precertification rules

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

additional days precertified, then:
-for the part of the admission that was medically necessary, we will pay inpatient benefits, but

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

If no one contacted us, we will decide whether the hospital stay was medically necessary.
-If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty.
-If we determine that it was not medically necessary for you to
be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that

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

supplies and services that are otherwise payable on an outpatient basis.

Exceptions You do not need precertification in these cases:
You are admitted to a hospital outside the United States and Puerto Rico.

You have another group health insurance policy that is the primary payer for the hospital stay.
Your Medicare Part A is the primary payer for the hospital stay.
Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will

become the primary payer and you do need precertification.
Other services Some services require prior approval:
Prior approval is required for organ transplantation. Before your first evaluation as a potential candidate, contact Spectera/ Care at

800/ 580-5771 and ask to speak to the transplant case manager.
Prior approval is required for surgical procedures which may be cosmetic in nature such as eyelid surgery (blepharoplasty) or

varicose vein surgery (sclerotherapy). Call Spectera/ Care at 800/ 580-8771 before the surgery is done. 12
12 Page 13 14
2002 APWU Health Plan 13 Section 3
Prior approval is required for recognized surgery for morbid obesity or for organic impotence. Call Spectera/ Care at 800/ 580-8771
before the surgery is done.
Prior approval is required for home health care such as nursing visits, infusion therapy, growth hormone therapy (GHT),

rehabilitative therapy (physical, occupational or speech therapy) and pulmonary rehabilitation programs. Call Spectera/ Care at
800/ 580-8771.
Prior approval is recommended for durable medical equipment such as wheelchairs, oxygen equipment and supplies, artificial limbs and

braces. Call Spectera/ Care at 800/ 580-8771.
Prior approval is required for mental health and substance abuse benefits, inpatient or outpatient, in-network or out-of-network. Call

ValueOptions at 888/ 700-7965. 13
13 Page 14 15
2002 APWU Health Plan 14 Section 4
Section 4. Your costs for covered services
This is what you will pay out-of-pocket for your covered care:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your PPO physician you pay a copayment of $15 per visit.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for
them. Copayments do not count toward any deductible.

If you use PPO providers, the calendar year deductible is $275 per person. Under a family enrollment, the deductible is satisfied for
all family members when the combined covered expenses applied to the calendar year deductible for family members reach $550. If
you use non-PPO providers, your calendar year deductible increases to a maximum of $350 per person ($ 700 per family).
Whether or not you use PPO providers, your calendar year deductible will not exceed $350 per person ($ 700 per family).

We also have a separate deductible for mental health and substance
abuse benefits. The in-network deductible is $275 per person. Under a family enrollment, this deductible is satisfied for all family

members when the combined in-network covered expenses applied to this deductible for all family members reach $550. The out-of-network
deductible is $750 per person each calendar year with no family maximum.

Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective
date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan

And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of
your old option to the deductible of your new option.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn't begin until you meet your deductible.

Example: You pay 30% of our allowance for office visits to a non-PPO physician.
Note: If your provider routinely waives (does not require you to pay) your copayments, deductibles, or coinsurance, the provider is misstating
the fee and may be violating the law. In this case, when we calculate our share, we will reduce the provider's fee by the amount waived.

For example, if your physician ordinarily charges $100 for a service but routinely waives your 30% coinsurance, the actual charge is $70. We
will pay $49 (70% of the actual charge of $70).
Differences between our allowance and the bill Our "Plan allowance" is the amount we use to calculate our payment for covered services. Fee-for-service plans arrive at their allowances in

different ways, so their allowances vary. For more information about how we determine our Plan allowance, see the definition of Plan
allowance in Section 10. 14
14 Page 15 16
2002 APWU Health Plan 15 Section 4
Often, the provider's bill is more than a fee-for-service plan's allowance. Whether or not you have to pay the difference between our allowance
and the bill will depend on the provider you use.
PPO providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered
charges consists only of your deductible and coinsurance or copayment. Here is an example about coinsurance: You see a PPO
physician who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance.
That is, you pay just --10% of our $100 allowance ($ 10). Because of the agreement, your PPO physician will not bill you for the $50
difference between our allowance and his bill.
Non-PPO providers, on the other hand, have no agreement to limit
what they will bill you. When you use a non-PPO provider, you will pay your deductible and coinsurance --plus any difference between

our allowance and charges on the bill. Here is an example: You see a non-PPO physician who charges $150 and our allowance is again
$100. Because you've met your deductible, you are responsible for your coinsurance, so you pay 30% of our $100 allowance ($ 30).
Plus, because there is no agreement between the non-PPO physician and us, he can bill you for the $50 difference between our allowance
and his bill.
The following table illustrates the examples of how much you have to pay out-of-pocket for services from a PPO physician vs. a non-PPO
physician. The table uses our example of a service for which the physician charges $150 and our allowance is $100. The table shows the
amount you pay if you have met your calendar year deductible.

EXAMPLE PPO physician Non-PPO physician
Physician's charge $150 $150
Our allowance We set it at: 100 We set it at: 100
We pay 90% of our allowance: 90 70% of our allowance: 70
You owe: Coinsurance 10% of our allowance: 10 30% of our allowance: 30
+Difference up to charge? No: 0 Yes: 50
TOTAL YOU PAY $10 $80

Your catastrophic protection
out-of-pocket maximum for deductibles, coinsurance, and

copayments

There is a limit to the amount you must pay out-of-pocket for coinsurance for the year for certain charges. When you have reached this
limit, and your calendar year deductible has been met, you pay no coinsurance for covered services for the remainder of the calendar year.

PPO benefit: Your out-of-pocket maximum is $4,000 for either a Self Only or a Self and Family enrollment if you are using PPO providers.
Non-PPO benefit: Your out-of-pocket maximum is $6,000 for either a Self Only or a Self and Family enrollment if you are using non-PPO
providers.
Out-of-pocket expenses for the purposes of this benefit are:
The 10% you pay for PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services

The 30% you pay for non-PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services; and
The copayment of $15 for outpatient visits to PPO physicians 15
15 Page 16 17

2002 APWU Health Plan 16 Section 4
The following cannot be included in the accumulation of out-of-pocket expenses :
Expenses in excess of our allowance or maximum benefit limitations
Expenses for out-of-network mental health or 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 11 and 14)
Covered expenses applied to the $275 or $350 calendar year deductibles

Covered expenses applied to the $275 deductible for in -network
mental health or substance abuse care 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 27); and
Expenses in excess of hospice care and preventive care maximums

Carryover If you enrolled in our Plan during Open Season and your effective date is
after January 1, your previous plan will be responsible for any medical care you received before your coverage in our Plan began. The old plan

will pay your covered costs under this year's benefits since benefit changes start on January 1. If you did not meet your out-of-pocket
maximum under your old plan last year, your covered out-of-pocket expenses will be applied to that maximum. If you did meet that
maximum, your old plan's catastrophic protection benefit will continue to apply until your effective date in our Plan.

When government facilities
bill us

Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service are entitled to seek

reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing
laws allow.

If we overpay you We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to
offset overpayments. 16
16 Page 17 18
2002 APWU Health Plan 17 Section 4
When you are age 65 or over and you do not have Medicare
Under the FEHB law, we must limit our payments for those benefits you would be entitled to if you had Medicare. Your physician and hospital must follow Medicare rules and cannot bill you for more than they could bill you if you
had Medicare. The following chart has more information about the limits.

If you…
are age 65 or over, and
do not have Medicare Part A, Part B, or both; and
have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former
spouse; and

are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)

Then, for your inpatient hospital care,
the law requires us to base our payment on an amount --the "equivalent Medicare amount" --set by Medicare's rules for what Medicare would pay, not on the actual charge;

you are responsible for your applicable deductibles, coinsurance, or copayments you owe under this Plan;
you are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation of benefits (EOB) form that we send you; and

the law prohibits a hospital from collecting more than the Medicare equivalent amount.
And, for your physiciancare, the law requires us to base our payment and your coinsurance on…
an amount set by Medicare and called the "Medicare approved amount," or
the actual charge if it is lower than the Medicare approved amount.

If your physician… Then you are responsible for…

Participates with Medicare or accepts Medicare assignment for the claim and
is a member of our PPO network,
your deductibles, coinsurance, and copayments;

Participates with Medicare and is not in our PPO network, your deductibles, coinsurance, copayments, and any balance up to the Medicare approved
amount;
Does not participate with Medicare, your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare

approved amount

It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are permitted to collect only up to the Medicare approved amount.

Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the
charges. If you have paid more than allowed, ask for a refund. If you need further assistance, call us. 17
17 Page 18 19

2002 APWU Health Plan 18 Section 4
When you have the Original
Medicare Plan (Part A, Part B, or both)

We limit our payment to an amount that supplements the benefits that Medicare would pay under Medicare Part A (Hospital insurance) and

Medicare Part B (Medical insurance), regardless of whether Medicare pays. Note: We pay our 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 covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend
on whether your physician accepts Medicare assignment for the claim.
If your physician accepts Medicare assignment, then you pay nothing for covered charges .

If your physician does not accept Medicare assignment, then you pay the difference between our payment combined with Medicare's
payment and the charge.
Note: The physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its payment
on, called the "limiting charge." The Medicare Summary Notice (MSN) that Medicare will send you will have more information about the
limiting charge. If your physician tries to collect more than allowed by law, ask the physician to reduce the charges. If the physician does not,
report the physician to your Medicare carrier who sent you the MSN form. Call us if you need further assistance.

When you have a Medicare private contract with a
physician

A physician may ask you to sign a private contract agreeing that you can be billed directly for services Medicare ordinarily covers. Should you
sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the
amount we would have paid after Medicare's payment.
Please see Section 9, Coordinating benefits with other coverage, for more information about how we coordinate benefits with Medicare. 18
18 Page 19 20

2002 APWU Health Plan 19 Section 5
Section 5. Benefits --OVERVIEW
(See page 8 for how our benefits changed this year and pages 70 and 71 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in
mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claims forms, claims filing advice, or more information

about our benefits, contact us at 800/ 222-APWU or at our website at www. apwuhp. com
(a) Medical services and supplies provided by physicians and other health care professionals ......................... 20-28

Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapy
Speech therapy

Hearing services (testing, treatment, and
supplies) Vision services (testing, treatment, and

supplies) Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ....................... 29-34
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery

Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services......................................................... 35-37
Inpatient hospital
Outpatient hospital or ambulatory
surgical center Extended care benefits/ Skilled nursing

care facility benefits

Hospice care
Ambulance

(d) Emergency services/ Accidents ................................................................................................................................... 38-39
Medical emergency
Accidental injury
Ambulance

(h) Dental benefits..................................................................................................................................................................... 47

(i) Non-FEHB benefits available to Plan members ............................................................................................................ 48
SUMMARY OF BENEFITS ....................................................................................................................................................... 70 19
19 Page 20 21

2002 APWU Health Plan 20 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians
and other health care professionals

I M
P O
R T
A N
T

Here are some important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

medically necessary.
The calendar year deductible is: PPO -$275 per person ($ 550 per family); Non-PPO -$350 per person ($ 700 per family). The calendar year deductible applies to almost

all benefits in this Section. We added "( No deductible)" to show when the calendar year deductible does not apply.

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.
When you use a PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emergency room physicians,

anesthesiologists, and pathologists, may not all be preferred providers. If they are not, they will be paid by this Plan as non-PPO providers.

Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including

with Medicare.

I M
P O
R T
A N
T

Benefit Description You Pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)" when it does not apply.
Diagnostic and treatment services
Professional services of physicians
In physician's office
PPO: $15 copayment (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our

allowance and the billed amount
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Initial examination of a newborn child covered under a family enrollment

Second surgical opinion
At home

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our

allowance and the billed amount

Not covered: Routine physical checkups and related tests All charges 20
20 Page 21 22
2002 APWU Health Plan 21 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and the billed amount

Note: If your PPO provider uses a non-PPO lab or radiologist, we will
pay non-PPO benefits for any lab and X-ray charges.

Not covered: Professional fees for automated lab tests All charges
Preventive care, adult
Routine screenings, limited to:
Total Blood Cholesterol – once annually
Chlamydial infection
Colorectal Cancer Screening, including
-Fecal occult blood test, once annually, ages 40 and older

-Sigmoidoscopy, screening – every five years starting at age 50
Prostate Specific Antigen (PSA test) – one annually for
men age 40 and older

Routine pap test, one annually, women age 18 and older

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and the billed amount

Routine mammogram – covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and the billed amount

Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – once every 10 years,
ages19 and over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference

between our allowance and the billed amount 21
21 Page 22 23

2002 APWU Health Plan 22 Section 5( a)
Preventive care, adult – Continued You pay
Not covered:
Adult immunizations other than those listed above
Office visit associated with preventive care

All charges

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics through age 22 PPO: Nothing (No deductible)
Non-PPO: Any difference between the Plan allowance and the billed

charge (No deductible)
Examinations, limited to:
-Well-child care charges for physical examinations and laboratory tests through age 12

-Examination for amblyopia and strabismus-limited to one screening examination (age 2 through 6)

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

charge and any amount above $250 per child (ages 0 through 3) each
year and any amount above $150 per child (ages 4 through 12) each year
(No deductible)
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see
pages 12 and 13 for other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a
regular delivery and 96 hours after a cesarean delivery. We will cover an extended stay if medically necessary, but you,

your representative, your doctor, or your hospital must precertify.

We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will
cover other care of an infant who requires non-routine treatment if we cover the infant under a Self and Family
enrollment.
We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital Benefits

(Section 5c) and Surgery Benefits (Section 5b).

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference

between our allowance and the billed amount

Not covered: Amniocentesis if for diagnosing multiple births All charges 22
22 Page 23 24
2002 APWU Health Plan 23 Section 5( a)
Family planning You pay
A broad range of voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference

between our allowance and the billed amount

Not covered: Reversal of voluntary surgical sterilization and
genetic counseling
All charges

Infertility services
Diagnosis and treatment of infertility, except as shown in Not covered. PPO: 10% of the Plan allowance and any amount over $2,500

Non-PPO: 30% of the Plan allowance, any difference between
our allowance and the billed amount and any amount over $2,500

Not covered:
Infertility services after voluntary sterilization
Assisted reproductive technology (ART) procedures, such as:

-artificial insemination (all procedures)
-in vitro fertilization
-embryo transfer and GIFT
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)
Services and supplies related to ART procedures

Cost of donor sperm
Cost of donor egg

All charges

Allergy care
Testing and treatment, including materials (such as allergy serum)

Allergy injections
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference

between our allowance and the billed amount

Not covered: Provocative food testing and sublingual allergy
desensitization
All charges 23
23 Page 24 25

2002 APWU Health Plan 24 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on

page 34.
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.

Note: We only cover IV/ Infusion therapy and GHT when we preauthorize the treatment. Call Spectera/ Care at 800/ 580-8771
for preauthorization. Spectera/ Care will ask you to submit information that establishes that GHT is medically necessary.
You should ask for preauthorization before you begin treatment. If you do not ask or if we determine GHT is not medically
necessary, we will not cover GHT or related services and supplies. See Services requiring our prior approval in Section
3.
Respiratory and inhalation therapies

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference

between our allowance and the billed amount

Physical and occupational therapies
Physical therapy and occupational therapy provided by a licensed registered therapist.

Note: Preauthorization of rehabilitative therapies is required. Call Spectera/ Care at 800/ 580-8771 for preauthorization.
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to
illness or injury and when a physician:
1) Orders the care
2) Identifies the specific professional skills the patient requires and the medical necessity for skilled services; and

3) Indicates the length of time the services are needed

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference

between our allowance and the billed amount

Not covered:
Maintenance therapies
Exercise programs
Physical and occupational therapies without preauthorization

All charges 24
24 Page 25 26
2002 APWU Health Plan 25 Section 5( a)
Speech therapy You pay
Speech therapy where medically necessary and provided by a licensed therapist

Note: Preauthorization of speech therapy is required. Call Spectera/ Care at 800/ 580-8771 for preauthorization.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference

between our allowance and the billed amount

Hearing services (testing, treatment, and supplies)
Audiologist to diagnose a hearing problem PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference

between our allowance and the billed amount

Not covered:
Hearing aids, testing and examinations for them
All charges

Vision services (testing, treatment, and supplies)
Internal (implant) ocular lenses and/ or the first contact lenses required to correct an impairment caused by accident

or illness. 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 accident or illness.

Note: See Preventive care, children for eye exams for children

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference

between our allowance and the billed amount

Not covered:
Eyeglasses or contact lenses and examinations for them
Eye exercises and visual training
Radial keratotomy and other refractive surgery

All charges

Foot care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes

See Orthopedic and prosthetic devices for information on podiatric shoe inserts
PPO: $15 copayment for the office visit (No deductible) plus 10% of the
Plan allowance for other services performed during the visit

Non-PPO: 30% of the Plan allowance and any difference
between our allowance and the billed amount

Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions

of the foot, except as stated above

Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot
(unless the treatment is by open cutting surgery)

All charges 25
25 Page 26 27
2002 APWU Health Plan 26 Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras,
including necessary replacements following a mastectomy

Leg, arm, neck and back braces
Internal prosthetic devices, such as artificial joints,
pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: See Section

5( b) for coverage of the surgery to insert the device.

Note: We recommend preauthorization of orthopedic and prosthetic devices. Call Spectera/ Care at 800/ 580-8771 for
preauthorization.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference

between our allowance and the billed amount

Not covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

All charges

Durable medical equipment (DME)
Durable medical equipment (DME) is equipment and supplies that:
1) Are prescribed by your attending physician (i. e., the physician who is treating your illness or injury)

2) Are medically necessary
3) Are primarily and customarily used only for a medical purpose
4) Are generally useful only to a person with an illness or injury
5) Are designed for prolonged use; and
6) Serve a specific therapeutic purpose in the treatment of an illness or injury

We cover rental or purchase, at our option, including repair and adjustment, of durable medical equipment, such as oxygen and
dialysis equipment. Under this benefit, we also cover equipment such as:

Hospital beds
Wheelchairs
Crutches; and
Walkers

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference

between our allowance and the billed amount 26
26 Page 27 28
2002 APWU Health Plan 27 Section 5( a)
Durable medical equipment (DME) -Continued You pay
Note: Call Spectera/ Care at 800/ 580-8771 as soon as your physician prescribes this equipment. We arrange with a health
care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when
you call.
Not covered:
Whirlpool equipment
Sun and heat lamps
Light boxes
Heating pads
Exercise devices
Stair glides
Elevators
Air Purifiers
Computer "story boards", "light talkers", or other communication aids for communication-impaired

individuals

All charges

Home health services You pay
Services for skilled nursing care up to a maximum plan payment of $90 per day when preauthorized and:

A registered nurse (R. N.), licensed practical nurse (L. P. N.) or licensed vocational nurse (L. V. N.) provides the services
The attending physician orders the care
The physician identifies the specific professional skills required by the patient and the medical necessity for skilled

services; and
The physician indicates the length of time the services are needed

Note: Skilled nursing care must be preauthorized. Call Spectera/ Care at 800/ 580-8771 for preauthorization.

PPO: 10%; all charges after we pay $90 per day
Non-PPO: 30%; all charges after we pay $90 per day

Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient's family

Home care primarily for personal assistance that does not include a medical component and is not diagnostic,
therapeutic, or rehabilitative
Nursing services without preauthorization
Services of nurses aides or home health aides

All charges 27
27 Page 28 29

2002 APWU Health Plan 28 Section 5( a)
Chiropractic
Chiropractic treatment limited to 12 visits and/ or manipulations per year. PPO: $15 copayment (No deductible)
Non-PPO: 30% of the Plan allowance and any difference

between our allowance and the billed amount

Alternative treatments
Acupuncture – by a doctor of medicine or osteopathy PPO: $15 copayment (No deductible) Non-PPO: 30% of the Plan
allowance and any difference between our allowance and the billed
amount
Not covered:
Services of any provider not listed as covered; see Covered providers on page 9

Note: Benefits of certain alternative treatment providers may be covered in medically underserved areas; see page 9

All charges

Educational classes and programs
Coverage is limited to:
Smoking Cessation – Up to $100 for one smoking cessation program per member per lifetime.
PPO: Nothing
Non-PPO: Nothing 28
28 Page 29 30

2002 APWU Health Plan 29 Section 5( b)
Section 5( b). Surgical and anesthesia services provided by physicians
and other health care professionals

I M
P O
R T
A N
T

medically necessary.
The calendar year deductible is: PPO -$275 per person ($ 550 per family); Non-PPO -$350 per person ($ 700 per family). The calendar year deductible applies

to almost all benefits in this Section. We added "( No deductible)" to show when the calendar year deductible does not apply.

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.

When you use a PPO hospital, keep in mind that the professionals who provide
services to you in the hospital, such as radiologists, emergency room physicians, anesthesiologists, and pathologists, may not all be preferred providers. If they

are not, they will be paid by this Plan as non-PPO providers.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members

who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges
associated with the facility (i. e. hospital, surgical center, etc.).
YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in

Section 3 to be sure which services require precertification.
Precertification/ preauthorization is required for:
-Organ transplantations
-Procedures which might be cosmetic in nature, such as eyelid surgery or
varicose vein surgery

-Surgery for morbid obesity, or
-Surgery for organic impotence

I M
P O
R T
A N
T

Benefit Description You Pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)"
when it does not apply.

Surgical procedures

A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our

allowance and the billed amount 29
29 Page 30 31

2002 APWU Health Plan 30 Section 5( b)
Surgical procedures -Continued You Pay
Normal pre -and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures

(see above)

Biopsy procedures
Electroconvulsive therapy
Removal of tumors and cysts
Correction of congenital anomalies (see Reconstructive surgery)

Surgical treatment of morbid obesity
Insertion of internal prosthetic devices. See Section 5( a) for Orthopedic and prosthetic devices for device coverage

information
Voluntary sterilization, Norplant (a surgically implanted contraceptive), and intrauterine devices (IUDs)

Treatment of burns
Assistant surgeons -We cover up to 20% of our
allowance for the surgeon's charge

When multiple or bilateral surgical procedures performed during the same operative session add time or complexity to
patient care, our benefits are:
For the primary procedure:
-PPO: 90% of the Plan allowance or

-Non-PPO: 70% of the Plan allowance
For the secondary procedure( s):
-PPO: 90% of one-half of the Plan allowance or

-Non-PPO: 70% of one-half of the Plan allowance
Note: Multiple or bilateral surgical procedures performed through the same incision are "incidental" to the primary

surgery. That is, the procedure would not add time or complexity to patient care. We do not pay extra for incidental
procedures.

PPO: 10% of the Plan allowance for the primary procedure and 10% of one-half of
the Plan allowance for the secondary procedure( s)

Non-PPO: 30% of the Plan allowance for the primary procedure and 30% of one-half
of the Plan allowance for the secondary procedure( s); and any difference between
our payment and the billed amount

Not covered:
Cosmetic surgery and other related expenses if not preauthorized

Reversal of voluntary sterilization
Services of a standby surgeon, except during angioplasty or other high risk procedures when we determine

standbys are medically necessary
Radial keratotomy and other refractive surgery

All charges 30
30 Page 31 32

2002 APWU Health Plan 31 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness
if:

-The condition produced a major effect on the member's appearance and

-The condition can reasonably be expected to be
corrected by such surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or

norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks
(including port wine stains); and webbed fingers and toes.

All stages of breast reconstruction surgery following a mastectomy, such as:
-Surgery to produce a symmetrical appearance on the other breast
-Treatment of any physical complications, such as
lymphedemas

-Breast prostheses ; and surgical bras and replacements (see Prosthetic devices for coverage)

Note: We pay for internal breast prostheses as hospital benefits.
Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the
hospital up to 48 hours after the procedure.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount

Not covered:
Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve

physical appearance through change in bodily form, except repair of accidental injury if repair is initiated
within two years of the accident
Surgeries related to sex transformation, sexual dysfunction or sexual inadequacy except if preauthorized

for organic impotence

All charges 31
31 Page 32 33
2002 APWU Health Plan 32 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft plate or severe functional malocclusion

Removal of stones from salivary ducts
Excision of leukoplakia or malignancies
Excision of cysts and incision of abscesses when done as independent procedures

Other surgical procedures that do not involve the teeth or their
supporting structures

Extraction of impacted (unerupted) teeth
Alveoplasty, partial ostectomy and radical resection of
mandible with bone graft unrelated to tooth structure

Excision of bony cysts of the jaw unrelated to tooth structure
Excision of tori, tumors, and premalignant 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
Note: We suggest you call us at 800/ 222-APWU to determine whether a procedure is covered.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount

Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva and

alveolar bone)
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

All charges 32
32 Page 33 34
2002 APWU Health Plan 33 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single – only for the following end-stage pulmonary diseases: pulmonary fibrosis, primary pulmonary

hypertension, or emphysema; Double – only for patients with cystic fibrosis

Pancreas
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

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

Intestinal transplants (small intestine) and the small
intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas only for

those patients with irreversible intestinal failure who have failed TPN (total parenteral nutrition)

The Plan uses specific Plan-designated organ/ tissue transplant facilities. Before your initial evaluation as a potential candidate
for a transplant procedure, you or your doctor must contact Spectera/ Care at 800/ 580-8771 and ask to speak to a Transplant
Case Manager. You will be provided with information about transplant preferred providers. If you choose a Plan-designated
transplant facility, you may receive prior approval for travel and lodging costs.

Limited Benefits – If you don't use a Plan-designated transplant facility, benefits for pretransplant evaluation, organ procurement,
inpatient hospital, surgical and medical expenses for covered transplants , whether incurred by the recipient or donor, are limited
to a maximum of $100,000 for each listed transplant, including multiple organ transplants.

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

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and

the billed amount and any amount over $100,000 33
33 Page 34 35
2002 APWU Health Plan 34 Section 5( b)
Organ/ tissue transplants – Continued You pay
Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

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

Transplants not listed as covered

All charges

Anesthesia
Professional services for administration of anesthesia PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our

allowance and the billed amount
Note: If your PPO provider uses a non-PPO anesthesiologist, we will pay non-PPO
benefits for any anesthesia charges. 34
34 Page 35 36

2002 APWU Health Plan 35 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility,
and ambulance services

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medically necessary.
Unlike Sections 5( a) and 5( b), in this Section 5( c) the calendar year deductible applies to only a few benefits. In that case, we added "( calendar year deductible

applies)." The calendar year deductible is; PPO -$275 per person ($ 550 per family); Non-PPO -$350 per person ($ 700 per family).

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.

not, they will be paid by this Plan as non-PPO providers.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or

over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare .

The amounts listed below are for the charges billed by the facility (i. e. hospital or surgical center) or ambulance service for your surgery or care. Any costs associated
with the professional charge (i. e. physicians, etc.) are in Sections 5( a) or (b).
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to

the precertification information shown in Section 3 to be sure which services require precertification.

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Benefit Description You Pay
NOTE: The calendar year deductible applies ONLY when we say below: "( calendar year deductible applies)".
Inpatient hospital

Room and board, such as:
Ward, semiprivate, or intensive care accommodations
General nursing care
Meals and special diets

Note: We only cover a private room when you mu st be isolated to prevent contagion. Otherwise, we will pay the hospital's
average charge for semiprivate accommodations. If the hospital only has private rooms, we base our payment on the average
semiprivate rate of comparable hospitals in the area.
Note: When the non-PPO hospital bills a flat rate, we prorate the charges to determine how to pay them, as follows: 30%

room and board and 70% other charges.

PPO: 10% of the covered charges
Non-PPO: $200 per admission and 30% of the covered charges

Note: If you use a PPO provider and a PPO facility, we may still pay non-PPO
benefits if you receive treatment from a radiologist, pathologist, or
anesthesiologist who is not a PPO provider. 35
35 Page 36 37

2002 APWU Health Plan 36 Section 5( c)
Inpatient hospital – Continued You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays Blood or blood plasma, if not donated or replaced

Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services

Note: We cover appliances, medical equipment and medical supplies provided for take-home use under Section 5( a). We cover
prescription drugs and medicines dispensed for take- home use under Section 5( f).

Note: We base payment on whether the facility or a health care professional bills for the services or supplies. For example, when the
hospital bills for its nurse anesthetists' services, we pay Hospital benefits and when the anesthesiologist bills, we pay Surgery benefits.

(see above)

Not covered:
Any part of a hospital admission that is not medically necessary (see definition), such as when you do not need

acute hospital inpatient (overnight) care, but could receive
care in some other setting without adversely affecting your condition or the quality of your medical care. Note: In this

event, we pay benefits for services and supplies other than
room and board and in-hospital physician care at the level they would have been covered if provided in an alternative

setting
Custodial care; see definition
Non-covered facilities, such as nursing homes, skilled nursing facilities, residential treatment facilities, day and

evening care centers, and schools
Personal comfort items such as radio, television, air conditioners, beauty and barber services, guest meals and

beds
Services of a private duty nurse that would normally be provided by hospital nursing staff

All charges 36
36 Page 37 38
2002 APWU Health Plan 37 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other
biologicals

Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts , and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment.
We do not cover the dental procedures.

Note: We cover outpatient services and supplies of a hospital or free-standing ambulatory facility the day of a surgical procedure
(including change of cast), hemophilia treatment, hyperalimentation, rabies shots, cast or suture removal, oral
surgery, foot treatment, chemotherapy for treatment of cancer, and radiation therapy.

PPO: 10% of the Plan allowance (calendar year deductible applies)
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and the billed amount (calendar year deductible
applies)

Extended care benefits/ Skilled nursing care facility benefits
No benefit All charges
Hospice care
Hospice is a coordinated program of home and inpatient supportive care for the terminally ill patient and the patient's

family provided by a medically supervised specialized team under the direction of a duly licensed or certified Hospice Care
Program.
We pay $3,000 annually for outpatient services and $2,000 annually for inpatient services.

We pay a $200 annual bereavement benefit per family unit.

Any amount over the annual maximu ms shown

Ambulance
Local professional ambulance service when medically appropriate PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our

allowance and the billed amount
Not covered:
Ambulance service used for routine transport
All charges 37
37 Page 38 39

2002 APWU Health Plan 38 Section 5( d)
Section 5 (d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

The calendar year deductible is: PPO -$275 per person ($ 550 per family); Non-PPO
-$350 per person ($ 700 per family). The calendar year deductible applies to almost all benefits in this Section. We added "( No deductible)" to show when the

calendar year deductible does not apply.
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.
When you use a PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emergency room physicians,

anesthesiologists, and pathologists, may not all be preferred providers. If they are not, they will be paid by this Plan as non-PPO providers.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who
are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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What is an accidental injury?
An accidental injury is a bodily injury sustained solely through violent, external, and accidental means, such as broken bones, animal bites, and poisonings.

What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some

problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life -threatening, such as heart attacks,
strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action. 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 (800/ 755-2200) or your physician.

Note: If you use an emergency room for other than a recognized medical emergency, facility fees and supplies will not be covered.

Benefit Description You Pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)" when it does not apply.
Accidental injury
If you receive care for your accidental injury within 24 hours, we cover:

Physician services and supplies
PPO: Nothing (No deductible)
Non-PPO: Only the difference between our allowance and the billed amount

(No deductible) 38
38 Page 39 40

2002 APWU Health Plan 39 Section 5( d)
Accidental injury– Continued You Pay
Related outpatient hospital services
Note: We pay Hospital benefits if you are admitted.
(see above)

If you receive care for your accidental injury after 24 hours, we cover:
Physician services and supplies
Note: We pay Hospital benefits if you are admitted.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our

allowance and the billed amount

Medical emergency
Outpatient facility charges in an Urgent Care Center PPO: $40 copayment (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our

allowance and the billed amount
Outpatient medical or surgical services and supplies, other than an Urgent Care Center PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our

allowance and the billed amount
Ambulance
Professional ambulance service
Air ambulance if medically necessary for transport to the
closest appropriate facility for treatment

Note: See Section 5( c) for non-emergency service.

PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our

allowance and the billed amount 39
39 Page 40 41

2002 APWU Health Plan 40 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
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You may choose to get care In-Network or Out-of-Network. When you receive In-Network care, you must get our approval for services and follow a treatment plan we
approve. If you do, cost-sharing and limitations for In -Network mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses
and conditions.
Here are some important things to keep in mind about these benefits:

All benefits are subject to the definitions, limitations, and exclusions in this
brochure.

The Mental health and substance abuse benefits have a separate calendar year deductible. The In-network deductible is $275 per person, $550 per family.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES . See the instructions after the benefits descriptions below.

In-Network mental health and substance abuse benefits are below, then Out-of-Network benefits begin on page 41.

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Benefit Description You Pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)" when it does not apply.
In-Network benefits
All diagnostic and treatment services contained in a treatment plan that we approve. The treatment plan may include

services, drugs, and supplies described elsewhere in this brochure.

Note: In-Network benefits are payable only when we determine the care is clinically appropriate to treat your condition and only
when you receive the care as part of a treatment plan that we approve.

Your cost sharing responsibilities are no greater than for other illness or conditions.

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, licensed
social workers, or licensed intensive outpatient treatment centers

Medication management

$15 per visit (No deductible)

Diagnostic tests 10% of the Plan allowance
In-Network benefits-Continued on next page 40
40 Page 41 42

2002 APWU Health Plan 41 Section 5( e)
In-Network benefits – Continued You pay
Inpatient services provided by a hospital or other facility
Services in approved partial hospitalization setting
10% of the covered charges (No deductible)

Not covered: Services we have not approved
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will

generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges

Preauthorization To be eligible to receive these enhanced mental health and substance abuse benefits you must obtain a treatment plan and follow all of the
following network authorization processes:
Inpatient careYou must get preauthorization of hospital stays; failure to do so will result in a minimum $500 penalty. Please

refer to the precertification information shown in Section 3. To obtain preauthorization of an admission for mental conditions or
substance abuse, call ValueOptions at 888/ 700-7965
Outpatient careYou must get preauthorization of outpatient
care for mental conditions or substance abuse. Preauthorization must be obtained by calling ValueOptions at 888/ 700-7965

We do not make available provider directories for mental health or substance abuse providers. ValueOptions will provide you
with a choice of network providers when you call to preauthorize your care

Out-of-Network benefits
Professional outpatient care to treat mental conditions and substance abuse After a $750 mental conditions/ substance abuse calendar year deductible, 50% of our
allowance for up to 15 visits; all charges after 15 visits

Inpatient care to treat mental conditions includes ward or semiprivate accommodations and other hospital charges After a $750 mental conditions/ substance abuse calendar year deductible, 50% of
charges for up to 30 days per calendar year; all charges after 30 days

Inpatient care to treat substance abuse includes room and board and ancillary charges for confinements in a treatment facility
for rehabilitative treatment of alcoholism or substance abuse
After a $750 mental conditions/ substance abuse calendar year deductible, 50% of
charges for one treatment program up to $3,000; all charges over $3,000 per
lifetime 41
41 Page 42 43

2002 APWU Health Plan 42 Section 5( e)
Out-of-Network benefits -Continued You Pay
Not covered out-of-network:
Treatment for learning disabilities and mental retardation
Services rendered or billed by a school or halfway house or a member of its staff

Phototherapy for treatment of Seasonal Affective Disorder (SAD)

All charges

Lifetime maximum Out-of-Network inpatient care for the treatment of alcoholism and drug abuse is limited to one treatment program per lifetime not to exceed
$3,000.

Precertification Inpatient care – You must get preauthorization of hospital stays; failure to do so will result in a minimum $500 penalty. Please refer
to the precertification information shown in Section 3. To obtain preauthorization of an admission for mental conditions or substance
abuse, call ValueOptions at 888/ 700-7965
Outpatient care – You must get preauthorization of outpatient care for mental conditions or substance abuse. Preauthorization must be

obtained by calling ValueOptions at 888/ 700-7965
See these sections of the brochure for more valuable information about these benefits:
Section 3, How you get care, for information about catastrophic protection for these benefits.
Section 7, Filing a claim for covered services, for information about submitting out-of-network claims. 42
42 Page 43 44

2002 APWU Health Plan 43 Section 5( f)
Section 5 (f). Prescription drug benefits
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart on page 45.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

The calendar year deductible does not apply to prescription drug benefits.
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.

Be sure to read Section 4, Your costs for covered services, for valuable information about how
cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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There are important features you should be aware of. These include:
Who can write your prescription. Any covered provider licensed to prescribe drugs may write your
prescription.

Where can you obtain them. You can fill the prescription at a PAID network pharmacy, a non-network pharmacy, or by mail. We pay our highest level of benefits for mail order and you should use

the mail order program to obtain your maintenance medications.
We use a formulary. Our formulary is open and voluntary. A formulary is a list of medications we have selected based on their clinical effectiveness and lower cost. By asking your doctor to prescribe

formulary medications, you can help reduce your costs while maintaining high-quality care. Use of a formulary drug is voluntary; there is no financial penalty if your physician does not prescribe a
formulary drug.
Brand/ Generic Drugs

Why use generic drugs? A generic drug is a chemical equivalent of a corresponding name brand
drug. The US Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand name drugs. Generic drugs

are less expensive than brand drugs, therefore, you may reduce your out-of-pocket-expenses by choosing to use a generic drug.

A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally -approved generic drug is
available, and your physician has not received a preauthorization, you have to pay the difference in cost between the name brand drug and the generic, in addition to your coinsurance. However, if
your doctor obtains preauthorization because it is medically necessary that a brand name drug be dispensed, you will not be required to pay this cost difference. Your doctor may seek
preauthorization by calling 800/ 841-5409.
These are the dispensing limitations.
-The PAID Retail Network –you may obtain up to a 30-day supply plus one 30-day refill for each prescription purchased from a PAID network pharmacy. After one 30-day refill, you must obtain a
new prescription and submit it to the mail order program. If you do not, we will pay the non-network pharmacy benefit level. To receive maximum savings you must present your card at the
time of each purchase, and your enrollment information must be current and correct. In most cases, you simply present the card together with the prescription to the pharmacist. Refills cannot be
obtained until 75% of the drug has been used. 43
43 Page 44 45

2002 APWU Health Plan 44 Section 5( f)
-Non-network pharmacy – if you do not use your identification card, if you elect to use a non-network pharmacy, or if a PAID network pharmacy is not available, you will need to file a claim
and we will pay at the non-network retail pharmacy benefit level
-Mail order – through this program, you may receive up to a 90-day supply of maintenance medications for drugs which require a prescription, ostomy supplies, diabetic supplies and insulin,

syringes and needles for covered injectable medications, and oral contraceptives. Some medications may not be available in a 90-day supply from Merck-Medco Home Delivery Pharmacy
even though the prescription is for 90 days.
-Refills for maintenance medications are not considered new prescriptions except when the doctor changes the strength or 180 days has elapsed since the previous purchase. Refill orders submitted

too early after the last one was filled are held until the right amount of time has passed. As part of the administration of the prescription drug program, we reserve the right to maximize your quality
of care as it relates to the utilization of pharmacies.
-You may fill your prescription at any pharmacy participating in the PAID TelePaid system. For the
names of participating pharmacies, call 800/ 841-2734.

Certain controlled substances and several other prescribed medications may be subject to other dispensing limitations, such as quantities dispensed, and to the judgment of the pharmacist.

When you have to file a claim. Use a Prescription Drug Claim Form to claim benefits for prescription drugs and supplies purchased from a non-network pharmacy. You may obtain forms by calling
800/ 222-APWU or from our website at www. apwuhp. com. Your claim must include receipts that show the prescription number, the National Drug Code (NDC) number, name of the drug, prescribing
physician's name, date of purchase and charge for the drug. Mail the claim form and receipt( s) to:
APWU Health Plan P. O. Box 967
Silver Spring, MD 20910
Prescription drug benefits begin on next page. 44
44 Page 45 46
2002 APWU Health Plan 45 Section 5( f)
Benefit Description You Pay
NOTE: The calendar year deductible does not apply to this section.
Covered medications and supplies

Each new enrollee will receive a description of our prescription drug program, a combined prescription drug/ Plan identification

card, a mail order form/ patient profile and a preaddressed reply envelope.

You may purchase the following medications and supplies prescribed by a physician 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
Drugs and medicines (including those administered during a non-covered admission or in a non-covered facility) that

by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not
covered
Insulin and reagent strips for known diabetics
Needles and syringes for the administration of covered medications

Ostomy Supplies
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

Viagra, Retin A and Growth Hormones must have prior approval from Spectera/ Care at 800/ 581-8771

Network Retail: $7 generic/ 25%
brand name

Network Retail Medicare:$ 7 generic/ 25% brand name

Non-Network Retail: 45% of cost
Non-Network Retail Medicare : 45% of cost
Network Mail Order: $10 generic/ 20% brand name
Network Mail Order Medicare :
$10 generic/ 20% brand name

Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, minerals, nutritional supplements, and enteral formulas (liquid food supplements)

Medical supplies such as dressings and antiseptics
Nonprescription medicines

All charges 45
45 Page 46 47
2002 APWU Health Plan 46 Section 5( g)
Section 5 (g). Special features
Special features Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.

We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly
alternative benefit
Alternative benefits are subject to our ongoing review
By approving an alternative benefit, we cannot guarantee you will get it in the future

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract
benefits
Our decision to offer or withdraw alternative benefits is not
subject to OPM review under the disputed claims process

24 hour nurse line We offer a 24-hour nurse service for your use. This program is strictly voluntary and confidential. You may call toll-free at
800/ 755-2200 and reach registered nurses to discuss an existing medical concern or to receive information about numerous health
care issues.

Services for deaf and hearing impaired We offer a toll-free TDD line for customer service. The number is 800/ 622-2511. TDD equipment is required.

Wellness benefit We reimburse you up to $250 per Self Only enrollment and $350 per Self and Family enrollment per calendar year for non-covered
expenses such as vision care, eyeglasses , hearing aids, if received in 2002 and no other benefits for 2002 have been paid. If we paid

claims of less than $350 for a Self and Family enrollment, the difference up to $350 will be paid.

We will notify you in November if you are eligible for the Wellness benefit. Submit Wellness claims after January 1, 2003. Wellness
claims are paid after March 1, 2003. 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.

Review and reward program If you send us a corrected hospital billing, we will credit 20% of any hospital 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 pe