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APWU Health Plan

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this fee-for-service plan
Section 2. How we change for 2003
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 for
  - Your hospital stay
  - Other services
Section 4. Your costs for covered services
- Copayments
- Your catastrophic protection 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. High Option Benefits
- Overview
- Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
- Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
- Section 5 (c). Services provided by a hospital or other facility, and ambulance services
- Section 5 (d). Emergency services/accidents
- Section 5 (e). Mental health and substance abuse benefits
- Section 5 (f). Prescription drug benefits
- Section 5 (g). Special features
- Section 5 (h). Dental benefits
- Section 5 (i). Non-FEHB benefits available to Plan members
Section 6. Consumer-driven Option Benefits
- Overview
- Section 6 (a). In-network preventive care
- Section 6 (b). Personal Care Account (PCA)
- Section 6 (c). Traditional Health Coverage
- Section 6 (d). Health tools and resources
Section 7. General exclusions -- things we dont cover
Section 8. Filing a claim for covered services
Section 9. The disputed claims process
Section 10. Coordinating benefits with other coverage
- When you have other health coverage
- What is Medicare?
- Medicare managed care plan
- TRICARE AND CHAMPVA
- Workers Compensation
- Medicaid
- When other Government agencies are responsible for your care
- When others are responsible for injuries
Section 11. Definitions of terms we use in this brochure
Section 12. FEHB facts
- Coverage Information
- When you lose benefits
Long Term Care Insurance Is Still Available
Index
Summary of benefits - High Option
Summary of benefits - Consumer-driven Option
2003 Rates

Pages 1--96

Page 1


Dear Federal Employees Health Benefits Program Participant: I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care options best suited for themselves and their families. In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship. The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep health care affordable. Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your family. We suggest you also visit our web site at www.opm.gov/insure.
		Sincerely, Kay Coles James Director

APWU Health Plan http:// www. apwuhp. com
2003
A fee-for-service plan
and A consumer-driven 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
474 Consumer-driven Option -Self Only
475 Consumer-driven Option -Self and Family

For changes in benefits
see page 9.

RI 71-004 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.

By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is
required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how
OPM may use and give out (" disclose") your personal medical information held by OPM.

OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative),
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and
Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim.
For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations),
For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.

By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any
purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM has
already acted based on your permission.

By law, you have the right to:
See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical

information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you authorized

OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address). 3.
3 Page 4 5

Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call
202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following
address:

Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the
Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical
information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

2003 APWU Health Plan 5 Introduction/ Plain Language/ Advisory
Introduction
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 plan is underwritten by the American Postal Workers
Union, AFL-CIO. The address for the APWU Health Plan administrative office is:

APWU Health Plan
P. O. Box 3279 Silver Spring, MD 20918

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family
coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before
January 1, 2003, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are
summarized on page 9. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language 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

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the
agency that employs you or from which you retired.

Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.

Carefully review explanations of benefits (EOBs) that you receive from us. 8.
8 Page 9 10
2003 APWU Health Plan 6 Introduction/ Plain Language/ Advisory
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider 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 1-800/ 222-APWU and explain the situation.
If we do not resolve the issue:

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.

You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.

CALL --THE HEALTH CARE FRAUD HOTLINE
202-418-3300

OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415 9.
9 Page 10 11

2003 APWU Health Plan 7 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 plans offer services through PPO networks. When you use our network providers, you will receive covered
services at reduced cost. APWU Health Plan is solely responsible for the selection of PPO providers in your area. The PPO networks
for the High Option and the Consumer-driven Option are different.

High Option PPO Network: Contact APWU Health Plan at 800/ 222-APWU to request a High Option PPO directory. You can also
go to our web page, which you can reach through the FEHB website, www. opm. gov/ insure. If you need assistance in identifying a
participating provider or to verify their continued participation, 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.

Consumer-driven Option PPO Network: To obtain a PPO directory or if you need assistance identifying a participating provider or
to verify their continued participation, call the Plan's Consumer-driven Option administrator, Definity Health of St. Louis Park, MN,
at 866/ 833-3463 or you can go to their web page, www. definityhealth. com, User ID: APWUHP, Password: HPINFO for a full
nationwide online provider directory.

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 under the High Option at the 70 th percentile and under the Consumer-driven Option at the 80 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 Programs, is the major subcontractor performing hospital precertification, continued stay review and case management for the High Option. The American Accreditation HealthCare Commission/ URAC has accredited them for Health

Utilization Management since 1993.
PreferredOne Administrative Services, Inc. performs hospital precertification, continued stay review and case management for High Option members in the State of Minnesota only. The American Accreditation HealthCare Commission/ URAC has

accredited them for Health Utilization Management since 1993, Health Network w/ Credentialing and Health Plan since 2000.
ValueOptions performs hospital precertification, continued stay review and outpatient prior authorization for mental health/ substance abuse services. The American Accreditation HealthCare Commission/ URAC has accredited them for Health

Utilization Management since 1992. 10.
10 Page 11 12

2003 APWU Health Plan 8 Section 1
The American Postal Workers Union Health Plan is a not-for-profit Voluntary Employee's Beneficiary Association (VEBA) formed in 1972.
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. 11.
11 Page 12 13

2003 APWU Health Plan 9 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Sections 5 and 6 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
A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.

Program information on Medicare is revised.
The Medically Underserved section is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
High Option
Your share of the Postal premium will increase by 3.8% for Self Only or 2.1% for Self & Family.
Your share of the non-Postal premium will increase by 6.6% for Self Only or 6.1% for Self and Family.
We now cover a colonoscopy once every 10 years from age 50 as part of our coverage for colorectal cancer screening.
We now cover one Double Contrast Barium Enema (DCBE) every 5 years from age 50 as part of our coverage for colorectal cancer screening.

We now cover one fasting lipoprotein profile every 5 years for adults 20 or over.
If you are using non-PPO providers, your catastrophic protection out-of-pocket maximum is $8,000 for either a Self Only or a Self and Family enrollment. The limit was previously $6,000.

We now limit benefits for physical, speech and occupational therapy to a maximum of 60 combined visits per calendar year. There was previously no limit to the number of visits.
We now limit home health services to 25 visits for skilled nursing care per calendar year. There was previously no limit to the number of visits.
We have clarified that there is a $5 minimum applicable for brand name drugs obtained from a network pharmacy or network mail order.
We removed the exclusion for coverage of services for illness or injury resulting from an act of war within the United States, its territories or possessions.

New Consumer-driven Option
We have added a new option called Consumer-driven. -You receive a Personal Care Account (PCA) of $1,000 for Self Only or $2,000 for Self and Family which you use first to pay
100% of covered expenses, including some dental/ vision care services, up to specified maximums. Unused PCA benefits may be rolled over to increase your PCA in the following year( s).
-In-network preventive care services are paid at 100% and do not count against your Personal Care Account.
-If you exhaust your PCA, you must pay your Member Responsibility before your Traditional Health Coverage begins
-You receive access to important health tools and resources to help you effectively shop for and manage your health care and
wellness services.
-Please review this brochure, including Consumer-driven Option Benefits in Sections 6( a), 6( b), 6( c) and 6( d) to understand this
new option. If you have any questions about this new option, you may call us at 800/ 222-APWU or call our Consumer- driven
Option administrator, Definity Health, at 866/ 833-3463. 12.
12 Page 13 14

2003 APWU Health Plan 10 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, contact us as follows:

High Option: Call us at 800/ 222-APWU or write to us at P. O. Box 3279, Silver Spring, MD 20918 or through our website: www. apwuhp. com.
Consumer-driven Option: Call Definity Health at 866/ 833-3463 or request replacement cards through the website at www. definityhealth. com.

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 2003, the states are: Alabama, Idaho,
Kentucky, Louisiana, Maine, Mississippi, Missouri, Montana, New Mexico,
North Dakota, South Carolina, South Dakota, Texas, Utah, West Virginia, and
Wyoming.

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. 13.
13 Page 14 15
2003 APWU Health Plan 11 Section 3
Covered facilities (Continued) 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 High Option begins, call our customer
service department immediately at 800/ 222-APWU. For the Consumer-driven Option,
please call Definity Health at 866/ 833-3463.

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. 14.
14 Page 15 16
2003 APWU Health Plan 12 Section 3
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 High Option: 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.
Consumer-driven Option: You, your representative, your doctor, or your hospital must call Definity Health at 866/ 333-4648 at least 48 hours before admission. This

number is 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 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:
High Option: 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.

Consumer-driven Option: 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 Definity Health at 866/ 333-4648.

What happens when you
do not follow the
precertification rules

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. 15.
15 Page 16 17
2003 APWU Health Plan 13 Section 3
-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.
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.

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 (High Option) and some require pre-notification (Consumer-driven Option):
High Option: Call Spectera/ Care at 800/ 580-8771 if you need any of the services listed
below:

Consumer-driven Option: Call Definity Health at 866/ 333-4648 if you need any of the
services listed below:

Prior approval/ pre-notification is required for organ transplantation. Call before your first evaluation as a potential candidate.

Prior approval/ pre-notification is required for surgical procedures which may be cosmetic in nature such as eyelid surgery (blepharoplasty) or varicose vein surgery
(sclerotherapy).
Prior approval/ pre-notification is required for recognized surgery for morbid obesity or for organic impotence.

Prior approval/ pre-notification 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.
Prior approval/ pre-notification is required for durable medical equipment such as wheelchairs, oxygen equipment and supplies, artificial limbs and braces.

Prior approval is also required for mental health and substance abuse benefits, inpatient
or outpatient, in-network or out-of-network. Under the High Option and the Consumer-driven
Option, call ValueOptions at 888/ 700-7965. 16.
16 Page 17 18
2003 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 High Option: A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: Under the High Option, when you see your PPO physician you pay a
copayment of $15 per visit.

Consumer-driven Option: There are no copayments under the Consumer-driven
Option.

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.
High Option
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 from Self and Family to Self Only, or from Self Only to Self and
Family during the year, we will credit the amount of covered expenses already applied
toward the deductible of your old enrollment to the deductible of your new enrollment.
However, if you change from High Option to Consumer-driven Option, or from Consumer-driven Option to High Option, during the year, expenses incurred as of the effective date of

the option change are subject to the benefit provisions of your new option.
Consumer-driven Option: There is no calendar year deductible under the Consumer-driven
Option. Also, there is no separate deductible for mental health and substance
abuse benefits under the Consumer-driven Option.

Coinsurance High Option: Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn't begin until you meet your deductible (High Option) or

your Member Responsibility (Consumer-driven Option).
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. 17.
17 Page 18 19

2003 APWU Health Plan 15 Section 4
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).

Consumer-driven Option: Coinsurance is the percentage of our allowance that you
must pay for your care after you have used up your Personal Care Account (PCA) and
paid your Member Responsibility.

Member Responsibility High Option: Does not apply.

Consumer-driven Option: Your Member Responsibility is your bridge between your
Personal Care Account (PCA) and your Traditional Health Coverage. After you have
exhausted your PCA, you must pay your Member Responsibility before your Traditional
Health Coverage begins. Your Member Responsibility is generally $600 for a Self Only enrollment or $1,200 for a Self and Family enrollment. Your Member Responsibility in

subsequent years may be reduced by rolling over any unused portion of your Personal
Care Account remaining at the end of the calendar year( s).

Differences between our allowance and the bill High Option: 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 11.

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 18.
18 Page 19 20

2003 APWU Health Plan 16 Section 4
Consumer-driven Option:
PPO providers agree to accept our plan allowance so if you use a PPO Provider, you never have to worry about paying the difference between the plan allowance

and the billed amount for covered services. If your covered expenses are being
paid out of your Personal Care Account or if you are receiving in-network covered
preventive services, the plan will pay 100%. If you have exhausted your Personal Care Account, you will be responsible for paying your Member Responsibility and

also coinsurance under the Traditional Health Coverage.
Non PPO Providers: If you use a non-PPO provider, you will have to pay the difference between the plan allowance and the billed amount only if you use up

your Personal Care Account for the year. Note that it usually makes sense to use
PPO providers because it will make your Personal Care Account go much further
since money left in your Personal Care Account can be rolled over to be used in the
next year.

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

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, you pay no coinsurance for
covered services for the remainder of the calendar year.

High Option:
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 $8,000 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
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 12, 13 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 in excess of visit maximums for physical, occupational and speech therapy (see page 25)

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 19.
19 Page 20 21

2003 APWU Health Plan 17 Section 4
Your catastrophic protection
out-of-pocket maximum for
deductibles, coinsurance,
copayments, and Member Responsibility
(continued)

Consumer-driven Option:
If you have exceeded your Personal Care Account and met your Member Responsibility
the following would apply:

In-network benefit: Your out-of-pocket maximum is $4, 500 for either a Self Only or a
Self and Family enrollment if you are using network providers.

Out-of-network benefit: Your out-of-pocket maximum is $9,000 for either a Self Only
or a Self and Family enrollment if your are using out-of-network providers.

Out-of-pocket expenses for the purposes of this benefit are:
The 15% you pay for in-network Inpatient and outpatient hospital charges, Surgical, Medical, Maternity and Emergency services under the Traditional Health Coverage

The 40% you pay for out-of-network Inpatient and outpatient hospital charges, Surgical, Medical, Maternity and Emergency services under the Traditional Health
Coverage
The following cannot be included in the accumulation of out-of-pocket expenses:
Any expenses paid by the Plan under your Personal Care Account
Any expenses paid by the Plan under your In-network Preventive Care benefit
Any expenses you must pay under your Member Responsibility
Expenses in excess of our allowance or maximum benefit limitations or expenses not covered under the Traditional Health Coverage

Expenses for out-of-network mental health or substance abuse care
The 25% you pay for prescription drugs under your Traditional Health Coverage
Dental care or vision care expenses above the limitations provided under your Personal Care Account

Any amounts you pay because benefits have been reduced for non- compliance with this Plan's cost containment requirements (see pages 12, 13, 14 and 15)
Expenses in excess of hospice 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. We will
generally first seek recovery from the provider if we paid the provider directly, or from
the person (covered family member, guardian, custodial parent, etc.) to whom we sent
our payment. 20.
20 Page 21 22
2003 APWU Health Plan 18 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 physician care, 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. 21.
21 Page 22 23

2003 APWU Health Plan 19 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.
High Option: If your physician accepts Medicare assignment, then you pay nothing for covered charges.

Consumer-driven Option: If your physician accepts Medicare assignment, then you pay nothing if you have unused benefits available under your Personal Care
Account to pay the difference between the Medicare approved amount and
Medicare's payment. If your PCA is exhausted, you must pay either this full
difference under your Member Responsibility or the lesser of your coinsurance or
the full difference if your Member Responsibility has been met.
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.

Please see Section 10, Coordinating benefits with other coverage, for more
information about how we coordinate benefits with Medicare. 22.
22 Page 23 24

2003 APWU Health Plan 20 Section 5
HIGH OPTION
Section 5. High Option Benefits --OVERVIEW
(See page 9 for how our benefits changed this year and page 91 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 7; they apply to the benefits in the following subsections. To obtain
claim 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..................................................... 21- 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.................................................. 29-33
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery

Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services .............................................................................. 34-36
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ Skilled nursing care facility
benefits

Hospice care
Ambulance

(d) Emergency services/ Accidents ............................................................................................................................................. 37-38
Accidental injury
Medical emergency
Ambulance

(h) Dental benefits ......................................................................................................................................................................... 44

(i) Non-FEHB benefits available to Plan members ......................................................................................................................... 45
SUMMARY OF BENEFITS -HIGH OPTION................................................................................................................................... 91 23.
23 Page 24 25

2003 APWU Health Plan 21 Section 5( a)
HIGH OPTION
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 10

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 24.
24 Page 25 26
2003 APWU Health Plan 22 Section 5( a)
HIGH OPTION
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
Fasting lipoprotein profile, once every 5 years for adults age 20 or over
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
-Colonoscopy, once every 10 years starting at age 50
-Double Contrast Barium Enema (DCBE), once every 5 years starting at age 50

Routine 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, ages 19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually
Pneumococcal vaccine, age 65 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

Not covered:
Adult immunizations other than those listed above
Office visit associated with preventive care

All charges 25.
25 Page 26 27

2003 APWU Health Plan 23 Section 5( a)
HIGH OPTION
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics up to age 22

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 (No deductible)

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 cover circumcision
of a covered newborn under Surgical benefits. See Surgery benefits (Section 5b).

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
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5( b))
Surgically implanted contraceptives
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 26.
26 Page 27 28

2003 APWU Health Plan 24 Section 5( a)
HIGH OPTION
Infertility services You pay
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

Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed on page 32.

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 27.
27 Page 28 29
2003 APWU Health Plan 25 Section 5( a)
HIGH OPTION
Physical and occupational therapies You pay
Physical therapy and occupational therapy provided by a licensed
registered therapist up to a combined 60 visits per calendar year.

Note: Preauthorization of rehabilitative therapies is required. Call
Spectera/ Care at 800/ 580-8771 for preauthorization.

Note: We only cover physical and occupational 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

Speech therapy
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.

Note: Speech therapy is combined with 60 visits per year for the services
of physical therapy and/ or occupational therapy (see above).

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 28.
28 Page 29 30

2003 APWU Health Plan 26 Section 5( a)
HIGH OPTION
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

Orthopedic and prosthetic devices
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.

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

Durable medical equipment (DME) benefits continued on next page 29.
29 Page 30 31
2003 APWU Health Plan 27 Section 5( a)
HIGH OPTION
Durable medical equipment (DME) (continued) You pay
Under this benefit, we also cover equipment such as:
Hospital beds
Wheelchairs
Ostomy supplies (including supplies purchased at a pharmacy)
Crutches; and
Walkers

Note: Call Spectera/ Care at 800/ 580-8771 as soon as your physician
prescribes this equipment because prior approval is required. 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.

(see above)

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
Services for skilled nursing care up to 25 visits per calendar year, not to
exceed 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 30.
30 Page 31 32

2003 APWU Health Plan 28 Section 5( a)
HIGH OPTION
Chiropractic You pay
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 10

Note: Benefits of certain alternative treatment providers may be covered
in medically underserved areas; see page 10

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 31.
31 Page 32 33

2003 APWU Health Plan 29 Section 5( b)
HIGH OPTION
Section 5 (b). Surgical and anesthesia services provided by physicians
and other health care professionals

I M
P O
R T
A N
T

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

10 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
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Electroconvulsive therapy
Removal of tumors and cysts
Correction of congenital anomalies (see Reconstructive surgery)
Surgical treatment of morbid obesity

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

Surgical procedures benefits continued on next page 32.
32 Page 33 34

2003 APWU Health Plan 30 Section 5( b)
HIGH OPTION
Surgical procedures (continued) You Pay
Insertion of internal prosthetic devices. See Section 5( a) for Orthopedic and prosthetic devices for device coverage information

Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
Surgically implanted contraceptives and intrauterine devices (IUDs)
Treatment of burns
Assistant surgeons -We cover up to 20% of our allowance for the surgeon's charge

(see above)

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

Reconstructive surgery
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

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

Reconstructive surgery benefits continued on next page 33.
33 Page 34 35
2003 APWU Health Plan 31 Section 5( b)
HIGH OPTION
Reconstructive surgery (continued) You Pay
-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.

(see above)

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

Oral and maxillofacial surgery
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

Oral and maxillofacial surgery benefits continued on next page 34.
34 Page 35 36
2003 APWU Health Plan 32 Section 5( b)
HIGH OPTION
Oral and maxillofacial surgery (continued) You pay
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

Organ/ tissue transplants
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.

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

Organ/ tissue transplant benefits continued on next page 35.
35 Page 36 37
2003 APWU Health Plan 33 Section 5( b)
HIGH OPTION
Organ/ tissue transplants (continued) You pay
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

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. 36.
36 Page 37 38

2003 APWU Health Plan 34 Section 5( c)
HIGH OPTION
Section 5 (c). Services provided by a hospital or other facility,
and ambulance services

I M
P O
R T
A N
T

In this Section, unlike Sections 5( a) and 5( b), 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.

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 10

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.

I M
P O
R T
A N
T

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 must 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.

Inpatient hospital benefits continued on next page 37.
37 Page 38 39

2003 APWU Health Plan 35 Section 5( c)
HIGH OPTION
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 38.
38 Page 39 40
2003 APWU Health Plan 36 Section 5( c)
HIGH OPTION
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 maximums
shown

Ambulance
Local professional ambulance service when medically appropriate immediately before or after an inpatient admission 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 39.
39 Page 40 41
2003 APWU Health Plan 37 Section 5( d)
HIGH OPTION
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

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 and are payable only when we determine they are medically necessary.

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 10 about coordinating benefits with other coverage, including with Medicare.

I M
P O
R T
A N
T

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.

If you receive care for your accidental injury within 24 hours, we cover:
Physician services and supplies
Related outpatient hospital services

Note: We pay Hospital benefits if you are admitted.
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: Nothing (No deductible)
Non-PPO: Only the difference between
our allowance and the billed amount (No deductible) 40.
40 Page 41 42
2003 APWU Health Plan 38 Section 5( d)
HIGH OPTION
Medical emergency You Pay
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 within 24 hours of an accidental injury

Air ambulance if medically necessary for transport to the closest appropriate facility for treatment within 24 hours of an accidental
injury
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 41.
41 Page 42 43

2003 APWU Health Plan 39 Section 5( e)
HIGH OPTION
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

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:
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 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 10 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 40.

I M
P O
R T
A N
T

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
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

In-network benefits continued on next page 42.
42 Page 43 44

2003 APWU Health Plan 40 Section 5( e)
HIGH OPTION
In-network benefits (continued) You Pay
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

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

2003 APWU Health Plan 41 Section 5( f)
HIGH OPTION
Section 5 (f). Prescription drug benefits
I
M
P
O
R
T
A
N
T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart on the next page.
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 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 10
about coordinating benefits with other coverage, including with Medicare.

I
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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 Medco Health 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 Medco Health Retail Network you may obtain up to a 30-day supply plus one 30-day refill for each
prescription purchased from a Medco Health 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.
-Non-network pharmacy if you do not use your identification card, if you elect to use a non-network pharmacy, or if a Medco Health 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, 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
Medco Health Home Delivery Pharmacy Service 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 44.
44 Page 45 46

2003 APWU Health Plan 42 Section 5( f)
HIGH OPTION
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 Medco Health 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

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
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/ 580-8771

Network Retail: $7 generic/ 25% brand name with a $5 minimum coinsurance
for brand name
Network Retail Medicare:$ 7 generic/ 25% brand name with a $5

minimum coinsurance for brand name
Non-network Retail: 45% of cost
Non-network Retail Medicare: 45% of cost

Network Mail Order: $10 generic/ 20% brand name with a $5 minimum
coinsurance for brand name
Network Mail Order Medicare: $10 generic/ 20% brand name with a $5

minimum coinsurance for 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
2003 APWU Health Plan 43 Section 5( g)
HIGH OPTION
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 2003 and no other benefits for 2003 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, 2004. Wellness claims are paid after March 1, 2004.
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 per calendar year. 46.
46 Page 47 48

2003 APWU Health Plan 44 Section 5( h)
HIGH OPTION
Section 5 (h). Dental benefits

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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 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.
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 10 about coordinating benefits with other coverage, including with Medicare.
Note: We cover hospitalization for dental procedures only when a non-dental physical impairment exists
which makes hospitalization necessary to safeguard the health of the patient. We do not cover the dental
procedure. See Section 5( c) for inpatient hospital benefits.

I
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Accidental injury benefit You pay
We cover restorative services and supplies necessary to repair (but not
replace) sound natural teeth. The need for these services must result
from an accidental injury (a blow or fall) and must be performed within
two years of the accident. See also Section 5( d), Accidental Injury.

Within 24 hours of accident:
PPO: Nothing (No deductible)
Non-PPO: Only the difference between our
allowance and the billed amount (No
deductible)

More than 24 hours after accident:
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount

Dental benefits
Service We pay (scheduled allowance) You pay
Office visits
Restorative care
(fillings)

Simple extractions
Note: Office visits include examinations, prophylaxis

(cleanings), x-rays of all types and
fluoride treatment.

$25 per visit (limit 2 visits per year)
$13 per tooth (single surface)
$18 per tooth (two or more surfaces)

$13 per tooth

All charges in excess of the
scheduled amounts listed to the
left (No deductible) 47.
47 Page 48 49
2003 APWU Health Plan 45 Section 5( i)
HIGH OPTION
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them.
Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

Voluntary
Benefits Plan
Dental Plan

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

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

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

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

Calendar Year Maximum: $1,000 per person for all covered services $500 per person for all eligible Orthodontic services, if Optional Orthodontic

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

TYPE I BENEFITS Preventive Services

Exams X-rays
Cleanings

100%
of the Reasonable and Customary charges
100%
of the Reasonable and Customary charges

TYPE II BENEFITS Basic Services
Fillings Oral Surgery
Extractions

80%
of the Reasonable and Customary charges
(6 month waiting period)

50%
of the Reasonable and Customary charges
(6 month waiting period)

TYPE III BENEFITS
Major Services Crowns
Bridges Dentures
Periodontics

50%
of the Reasonable and Customary charges
(12 month waiting period)

50%
of the Reasonable and Customary charges
(18 month waiting period)

TYPE IV BENEFITS (Optional Coverage)
Orthodontic
50% of the Reasonable and Customary charges
(24 month waiting period)
50% of the Reasonable and Customary charges
(24 month waiting period)
This is a partial summary of the terms, conditions and limitations of the Dental Plan policy #G-224,540. For more information regarding the coverage, rates or to receive an enrollment form, please contact the Voluntary Benefits Plan office by calling

or writing:
Voluntary Benefits Plan
P. O. Box 1471
Waterbury, CT 06721

800/ 422-4492
800/ 237-5536 (In CT)
203/ 754-4410 (T. D. D.)
Benefits on this page are not part of the FEHB contract 48.
48 Page 49 50

2003 APWU Health Plan 46 Section 6
CONSUMER-DRIVEN OPTION
Section 6. Consumer-driven Option Benefits --OVERVIEW
(See page 9 for how our benefits changed this year and page 92 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 7; they apply to the benefits in the following subsections. To obtain
claim forms, claims filing advice, or more information about our benefits, contact us at 1-866/ UDEFINE (1-866/ 833-3463) or at our
website at www. definityhealth. com. User ID: APWUHP, Password: HPINFO

The new Consumer-driven Option focuses on you, the health care consumer, and gives you greater control in how you use
your health care benefits. With this plan, in-network preventive care is covered in full and you can use a Personal Care
Account (PCA) for non-preventive care. If you use up your PCA, the Traditional Health Coverage works like a regular preferred provider organization (PPO) plan. If you don't use up your PCA for the year, you can roll it over to the next year.

The Consumer-driven Option includes four key components:
(a) In-network Preventive Care .............................................................................................................................................. 47-48
This component covers 100% for preventive care for adults and children if you use a network provider. The covered
services include office visits/ exams, immunizations and screenings and are fully described in Section 6( a). They are
based on recommendations by the American Medical Association.

(b) Personal Care Account (PCA) ........................................................................................................................................... 49-50
The plan also provides a Personal Care Account (PCA) for each enrollment. Each year, the plan provides $1,000 for a
Self Only enrollment or $2,000 for a Self and Family enrollment. The PCA covers 100% for your covered medical
expenses, which include dental and vision care.

If you have an unused PCA balance at the end of the year, you can rollover that balance so you can use them in the future.
The Personal Care Account is described in Section 6( b).

Note that the In-network Preventive Care benefits paid under Section 6( a) do NOT count against your Personal Care
Account (PCA).

(c) Traditional Health Coverage ............................................................................................................................................. 51-70
After you have used up your Personal Care Account (PCA) and paid your Member Responsibility, the plan starts paying
benefits under the Traditional Health Coverage described in Section 6( c). The plan generally pays 85% of the cost for
in-network care and 60% of the plan allowance for out-of-network care.

Covered services include:
Medical services and supplies
Surgical and anesthesia services
Hospital services, other facilities and ambulance
Emergency services/ Accidents
Mental health and substance abuse benefits
Prescription drug benefits

(d) Health tools and resources ...................................................................................................................................................... 71
Section 6( d) describes the health tools and resources available to you under the Consumer-driven Option to help you
improve the quality of your health care and manage your expenses. There is also care support and a 24-hour nurse
advisory service.

Non-FEHB benefits available to Plan members............................................................................................................................ 45

SUMMARY OF BENEFITS CONSUMER-DRIVEN OPTION................................................................................................... 92 49.
49 Page 50 51

2003 APWU Health Plan 47 Section 6( a)
CONSUMER-DRIVEN OPTION
Section 6 (a). In-network preventive care
I M
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Here are some important things you should keep in mind about these in-network preventive
care benefits:
Under the Consumer-driven Option, the plan pays 100% for the preventive care services listed in this Section as long as you use a network (PPO) provider.

For preventive care not listed in this Section or for preventive care from a non-network provider, please see Section 6( b) Personal Care Account (PCA).
For all other covered expenses, please see Section 6( b) Personal Care Account and Section 6( c) Traditional Health Coverage.
Note that the in- network preventive care paid under this Section does NOT count against or use up your Personal Care Account (PCA).
Under the Consumer-driven Option, there is no calendar year deductible.
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.

I M
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Benefit Description You Pay
NOTE: There is no calendar year deductible under the Consumer-driven Option.
Preventive care, adult
One annual routine office visit and examination per person after age 18 Nothing

Routine immunizations:
Tetanus-diphtheria (Td) Booster once every 10 years
Influenza Vaccination (flu shot) annually
Pneumococcal Vaccination (Pneumovax) one dose for persons 65 and over

Nothing

Routine screenings:
Total Blood Cholesterol, once annually
Fasting lipoprotein profile, once every 5 years for adults age 20 or over
Chlamydial infection
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
Pap Smear and Routine Pelvic Exam annually
Colorectal Cancer Screenings, member has the choice of the following:
-Fecal occult blood test (FOBT) annually and flexible sigmoidoscopy once every 5 years, both beginning at age 50; or

-Colonoscopy once every 10 years beginning at age 50; or
-Double contrast barium enema (DCBE) once every five years starting at age 50

Digital rectal examination (DRE) and prostate specific antigen (PSA) test annually starting at age 45

Nothing 50.
50 Page 51 52
2003 APWU Health Plan 48 Section 6( a)
CONSUMER-DRIVEN OPTION
Preventive care, children You Pay
Routine office visits, examinations and laboratory tests as follows:
Six visits the first year (to age 1)
Three visits the second year (age 1-2)
Annual visits from age 2 through age 18

Nothing

Routine immunizations:
Two doses of Hepatitis A
Three doses of Hepatitis B
Six doses of Diphtheria, Tetanus, Pertussis (DtaP)
Four doses of Haemophilus Influenza type b
Four doses of Polio
Four doses of Pneumococcal Conjugate
Two doses of Varicella
Two doses of Measles, Mumps, Rubella

Nothing

Routine screenings:
Lead level testing, one between ages 9 to 12 months and one between 12 and 24 months

Vision screening at ages 3, 4, 5, 6, 8, 10, 12, 15, and 18
Hearing screening at ages 4, 5, 6, 8, 10, 12, 15, and 18
Pap smear and routine pelvic exam annually beginning at age 18 or the onset of sexual activity, whichever comes first.

Nothing 51.
51 Page 52 53

2003 APWU Health Plan 49 Section 6( b)
CONSUMER-DRIVEN OPTION
Section 6 (b). Personal Care Account (PCA)
I M
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A N
T

Here are some important things you should keep in mind about your Personal Care Account:
All eligible health care expenses (except in-network preventive care) are paid first from your Personal Care Account (PCA). Traditional Health Coverage (Section 6( c)) will only start once

your Personal Care Account is exhausted.
Note that in-network preventive care covered under Section 6( a) does NOT count against your PCA.

The Personal Care Account provides full coverage for both in-network and out-of-network providers. However your Personal Care Account will generally go much further when you use
network providers because network providers agree to discount their fees.
You have flexibility about how to spend your PCA, and the Plan provides you with the resources to manage your PCA. You can track your PCA on your personal private website, by telephone at

866/ 333-4648 (toll-free), or with quarterly statements mailed directly to you at home.
If you join this Plan during Open Season, you receive the full PCA ($ 1,000 per Self Only or $2,000 per Self and Family enrollment) as of your effective date of coverage. If you join at any

other time during the year, your PCA for your first year will be prorated at a rate of $83 per
month for Self Only or $167 per month for Self and Family for each full month of coverage
remaining in that calendar year.
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.

Under the Consumer-driven Option, there is no calendar year deductible.
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 confirm which services require precertification.

I M
P O
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T

Benefit Description You Pay
NOTE: There is no calendar year deductible under the Consumer-driven Option.
A Personal Care Account (PCA) is provided by the plan for each enrollment.
Each year the plan adds to your account:

$1,000 per year for a Self Only enrollment or
$2,000 per year for a Self and Family enrollment

The Personal Care Account covers eligible expenses at 100%. For example,
if you are ill and go to a network doctor for a $60 visit, the doctor will submit your claim and the cost of the visit will be deducted automatically

from your PCA; you pay nothing.
Balance in PCA for Self Only $1,000
Less: Cost of visit -60
Remaining Balance in PCA $ 940

In-network and Out-of-Network: Nothing
up to $1,000 for a Self Only enrollment or
$2,000 for a Self and Family enrollment 52.
52 Page 53 54

2003 APWU Health Plan 50 Section 6( b)
CONSUMER-DRIVEN OPTION
Benefit Description You Pay
There are two types of eligible expense covered by your PCA.
Basic PCA Expenses are the same medical, surgical, hospital, emergency, mental health and substance abuse, and prescription drug
services and supplies covered under the Traditional Health Coverage
(see Section 6( c) for details).

Extra PCA Expenses include:
-Dental and/ or vision services up to a maximum of $400 per Self Only enrollment or $800 per Self and Family enrollment each

calendar year, including:
-Vision exam performed by an optometrist or ophthalmologist -
Eyeglasses and contact lenses
-Dental treatment (including examinations, cleanings, fillings, restorative treatment, endodontics, and periodontics

-Costs for in-network preventive care services not included under Section 6( a) In- network Preventive Care benefits
-Costs for out-of- network preventive care including amounts in excess of the Plan allowance, limited to services shown as covered
under Section 6( a)
-Amounts in excess of the Plan allowance for services received out-of-network and covered under Basic PCA Expenses

Note: Both Basic and Extra PCA Expenses are covered at 100% as long as you have not used up your Personal Care Account.
Note: Extra PCA Expenses payable under your PCA will not count toward your Member Responsibility.
To make the most of your Personal Care Account, you should:
Use the network providers wherever possible; Use generic prescriptions wherever possible; and

Only use your PCA for Extra PCA Expenses if you expect to have an unused balance in your PCA at the end of the calendar year.

(see above)

Not covered:
Orthodontia Dental treatment for cosmetic purposes

Out-of-network preventive care services not included under Section 6( a) Services or supplies shown as not covered under Traditional Health
Coverage (see Section 6( c)) and not included under Extra PCA Expenses above

All charges

PCA Rollover
Any unused, remaining balance in your PCA at the end of the calendar year may be rolled over to subsequent years up to a
maximum rollover of $4,000 per Self Only enrollment or $6,000 per Self and Family enrollment, thereby increasing your PCA
in the following year( s). 53.
53 Page 54 55

2003 APWU Health Plan 51 Section 6( c)
CONSUMER-DRIVEN OPTION
Section 6 (c). Traditional Health Coverage
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.

In-network preventive care is covered at 100% under Section 6( a) and does not count against your Personal Care Account.
Your Personal Care Account must be used first for eligible health care expenses.
If your Personal Care Account has been exhausted, you must pay your Member Responsibility before your Traditional Health Coverage may begin. Your Member Responsibility applies to all

benefits in this section
The Consumer-driven Option provides coverage for both in-network and out-of-network providers. The out-of-network benefits are the standard benefits under the Traditional Health

Coverage. In-network benefits apply only when you use a provider from the large, national
network. When a network provider is not available, out-of-network benefits apply.
If you join at any time during the year other than Open Season, your Member Responsibility for your first year will be prorated at a rate of $50 per month for Self Only or $100 per month for

Self and Family for each full month of coverage remaining in that calendar year.
When you use a network 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 network providers. If they are not, they will be paid by this Plan as
out-of-network providers under the Traditional Health Coverage.
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

10 about coordinating benefits with other coverage, including with Medicare.
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 confirm which services require precertification.

I M
P O
R T
A N
T

Benefit Description You Pay
NOTE: There is no calendar year deductible under the Consumer-driven Option.
Member Responsibility before Traditional Health
Coverage begins

If your Personal Care Account has been exhausted, you are responsible to
pay your Member Responsibility before your Traditional Health Coverage
begins.

Traditional Health Coverage benefits begin after covered eligible expenses
total $1,600 for Self Only or $3,200 for Self and Family (the combination of eligible expenses paid out of your PCA and Member Responsibility) each

calendar year.
Note: You must use any available PCA benefits, including any amounts
rolled over from previous years, before Traditional Health Coverage begins.

In-network/ Out-of-network: $600 per Self
Only enrollment or $1,200 per Self and
Family enrollment 54.
54 Page 55 56
2003 APWU Health Plan 52 Section 6( c)
CONSUMER-DRIVEN OPTION
Member responsibility before Traditional Health Coverage begins
(continued)
You pay

In year one, therefore, the member responsibility is $600 for Self Only and
$1,200 for Self and Family enrollment.

Self Only Self and Family
Basic PCA Expenses paid by PCA $1,000 $2,000
Member Responsibility paid by you $ 600 $1,200 _______________________________________________________ _______________________________________________________

Traditional Health Coverage starts after $1,600 $3,200
Any PCA dollars that you rollover at the end of the year will reduce your
Member Responsibility next year.

In future years, the amount of your Member Responsibility may be lower if
you rollover PCA dollars at the end of the year. For example, if you rollover
$300 at the end of the year:

Self Only Self and Family
PCA for year 2
Rollover from year 1
$1,000
+ 300
$1,300

$2,000
+ 300
$2,300

Member Responsibility paid by you + 300 + 900 _______________________________________________________ _______________________________________________________

Traditional Health Coverage starts
when eligible expenses total $1,600 $3,200

If you decide to use your PCA for Extra PCA Expenses, you may increase your Member Responsibility. For example, if you buy eyeglasses for $150
and later have an accident that leads to a hospital stay, you will have to pay
your Member Responsibility plus "make up" the $150 dollars you spent on
Extra PCA Expenses.

(see above) 55.
55 Page 56 57

2003 APWU Health Plan 53 Section 6( c)
CONSUMER-DRIVEN OPTION
Traditional Health Coverage You Pay
NOTE: The services listed below are Covered Expenses under Traditional Health Coverage
Medical services and supplies provided by physicians and
other health care professionals

Diagnostic and treatment services

Professional services of physicians
In physician's office
At home
In an urgent care center
During a hospital stay
Initial examination of a newborn child covered under a family enrollment

In a skilled nursing facility
Second surgical opinion

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
and any difference between our allowance
and the billed amount

Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
and any difference between our allowance
and the billed amount

Note: If your network provider uses an out-of-
network lab or radiologist, we will pay
out-of-network benefits for any lab and
X-ray charges.

Not covered: Professional fees for automated lab tests All charges
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.

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
and any difference between our allowance
and the billed amount

Maternity care benefits continued on next page 56.
56 Page 57 58
2003 APWU Health Plan 54 Section 6( c)
CONSUMER-DRIVEN OPTION
Medical services and supplies provided by physicians and other health care professionals
(continued)
You Pay

Maternity care (continued)
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover the
initial examination of the infant and other care of an infant who
requires non-routine treatment if we cover the infant under a Self
and Family enrollment. We cover circumcision of a covered
newborn under Surgical benefits. See Surgery benefits below.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits and Surgery benefits

below.

(see above)

Not covered: Amniocentesis if for diagnosing multiple births All charges
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures below)
Surgically implanted contraceptives
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms

Note: We cover oral contraceptives under the prescription drug benefit.

In-network: 15% of the Plan allowance
Out-of-network: 40% 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. In-network: 15% of the Plan allowance and
any amount over $2,500

Out-of-network: 40% of the Plan allowance
and 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 57.
57 Page 58 59

2003 APWU Health Plan 55 Section 6( c)
CONSUMER-DRIVEN OPTION
Medical services and supplies provided by physicians and other health care professionals
(continued)
You Pay

Allergy care
Testing and treatment, including materials (such as allergy serum)
Allergy injections
In-network: 15% of the Plan allowance
Out-of-network: 40% 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

Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed on page 32.

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 are
pre-notified of the treatment. Call Definity Health at 866/ 333-4648 for pre-notification. Definity Health will ask you to submit information that

establishes that GHT is medically necessary. You should pre-notify
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

In-network: 15% of the Plan allowance
Out-of-network: 40% 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 up to a combined 60 visits per calendar year.

Note: Pre-notification of rehabilitative therapies is required. Call
Definity Health at 866/ 333-4648 for pre-notification.

Note: We only cover physical and occupational 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

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
and any difference between our allowance
and the billed amount

Physical and occupational therapies benefits continued on next page 58.
58 Page 59 60

2003 APWU Health Plan 56 Section 6( c)
CONSUMER-DRIVEN OPTION
Medical services and supplies provided by physicians and other health care professionals
(continued)
You Pay

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

All charges

Speech therapy
Speech therapy where medically necessary and provided by a licensed
therapist

Note: Pre-notification of speech therapy is required. Call Definity
Health at 866/ 333-4648 for pre-notification.

Note: Speech therapy is combined with 60 visits per year for the services
of physical therapy and/ or occupational therapy (see above).

In-network: 15% of the Plan allowance
Out-of-network: 40% 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 In-network: 15% of the Plan allowance
Out-of-network: 40% 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 page 48 -Preventive care, children, for eye exams for children

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
and any difference between our allowance and the billed amount

Not covered:
Eyeglasses or contact lenses and examinations for them except under PCA

Eye exercises and visual training
Radial keratotomy and other refractive surgery

All charges 59.
59 Page 60 61
2003 APWU Health Plan 57 Section 6( c)
CONSUMER-DRIVEN OPTION
Medical services and supplies provided by physicians and other health care professionals
(continued)
You Pay

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

In-network: 15% of the Plan allowance
Out-of-network: 40% 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

Orthopedic and prosthetic devices
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 Surgical benefits below for coverage of the
surgery to insert the device.

Note: We recommend pre-notification of orthopedic and prosthetic
devices. Call Definity Health at 866/ 333-4648 for pre-notification.

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
and any difference between our allowance
and the billed amount

All charges 60.
60 Page 61 62
2003 APWU Health Plan 58 Section 6( c)
CONSUMER-DRIVEN OPTION
Medical services and supplies provided by physicians and other health care professionals
(continued)
You Pay

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
Ostomy supplies (including supplies purchased at a pharmacy)
Crutches; and
Walkers Note: Call Definity Health at 866/ 333-4648 as soon as your physician

prescribes this equipment because pre-notification is required.

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
and any difference between our allowance
and the billed amount

All charges 61.
61 Page 62 63
2003 APWU Health Plan 59 Section 6( c)
CONSUMER-DRIVEN OPTION
Medical services and supplies provided by physicians and other health care professionals
(continued)
You Pay

Home health services
Services for skilled nursing care up to 25 visits per calendar year, not to exceed 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 Definity Health
at 866/ 333-4648 for pre-notification.

In-network: 15% of the Plan allowance; all charges after we pay $90 per day
Out-of-network: 40% of the Plan allowance
and any difference between our allowance
and the billed amount; 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
Services of nurses aides or home health aides

All charges

Chiropractic
Chiropractic treatment limited to 12 visits and/ or manipulations per year. In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
and any difference between our allowance
and the billed amount 62.
62 Page 63 64

2003 APWU Health Plan 60 Section 6( c)
CONSUMER-DRIVEN OPTION
Medical services and supplies provided by physicians and other health care professionals
(continued)
You Pay

Alternative treatments
Acupuncture by a doctor of medicine or osteopathy In-network: 15% of the Plan allowance
Out-of-network: 40% 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 10

Note: Benefits of certain alternative treatment providers may be covered
in medically underserved areas; see page 10

All charges

Educational classes and programs
Coverage is limited to:
Smoking Cessation Up to $100 for one smoking cessation program per member per lifetime.
In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
and any difference between our allowance
and the billed amount

Surgical and anesthesia services provided by physicians
and other health care professionals
You Pay

Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
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 Orthopedic and prosthetic devices above for device coverage information)

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance and any difference between our allowance

and the billed amount

Surgical procedures benefits continued on next page 63.
63 Page 64 65
2003 APWU Health Plan 61 Section 6( c)
CONSUMER-DRIVEN OPTION
Surgical and anesthesia services provided by physicians and other health care professionals
(continued)
You Pay

Surgical procedures (continued)
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:
-In-network: 85% of the Plan allowance or
-Out-of-network: 60% of the Plan allowance

For the secondary procedure( s):
-In-network: 85% of one-half of the Plan allowance or
-Out-of-network: 60% of one-half of the Plan allowance

In-network: 15% of the Plan allowance for the primary procedure and 15% of one-half
of the Plan allowance for the secondary
procedure( s)

Out-of-network: 40% of the Plan allowance
for the primary procedure and 40% of one-half
of the Plan allowance for the secondary
procedure( s); and any difference between
our payment and the billed amount

necessary
Radial keratotomy and other refractive surgery

All charges

Reconstructive surgery
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

-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)

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance and
any difference between our allowance and the
billed amount

Reconstructive surgery benefits continued on next page 64.
64 Page 65 66
2003 APWU Health Plan 62 Section 6( c)
CONSUMER-DRIVEN OPTION
Surgical and anesthesia services provided by physicians and other health care professionals
(continued)
You Pay

Reconstructive surgery (continued)
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.

(see above)

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

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

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 866/ 333-4648 to determine whether a
procedure is covered.

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance and
any difference between our allowance and the
billed amount

Oral and maxillofacial surgery benefits continued on next page 65.
65 Page 66 67
2003 APWU Health Plan 63 Section 6( c)
CONSUMER-DRIVEN OPTION
Surgical and anesthesia services provided by physicians and other health care professionals
(continued)
You Pay

Oral and maxillofacial surgery (continued)
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva and alveolar bone)

All charges

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

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 Definity Health at 866/ 333-4648
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.

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
and any difference between our allowance
and the billed amount and any amount over
$100,000

Organ/ tissue transplant benefits continued on next page 66.
66 Page 67 68
2003 APWU Health Plan 64 Section 6( c)
CONSUMER-DRIVEN OPTION
Surgical and anesthesia services provided by physicians and other health care professionals
(continued)
You Pay

Organ/ tissue transplants (continued)
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.

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance and any difference between our allowance and the

billed amount and any amount over $100,000

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 In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance and
any difference between our allowance and the
billed amount

Note: If your network provider uses an out-of-network
anesthesiologist, we will pay out-of-network
benefits for any anesthesia charges.

Services provided by a hospital or other facility, and
ambulance services
You Pay

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 must 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 out-of-network 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.

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
and any difference between our allowance
and the billed amount

Note: If you use a network provider and a
network facility, we may still pay out-of-network
benefits on any services received
from a radiologist, pathologist, or anesthesiologist who is not a network

provider.

Inpatient hospital benefits continued on next page 67.
67 Page 68 69
2003 APWU Health Plan 65 Section 6( c)
CONSUMER-DRIVEN OPTION
Services provided by a hospital or other facility, and ambulance services
(continued)
You Pay

Inpatient hospital (continued)
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 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.

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
and any difference between our allowance
and the billed amount

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

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 68.
68 Page 69 70
2003 APWU Health Plan 66 Section 6( c)
CONSUMER-DRIVEN OPTION
Services provided by a hospital or other facility, and ambulance services
(continued)
You Pay

Outpatient hospital or ambulatory surgical center
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.

In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
and any difference between our allowance
and the billed amount

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 maximums
shown

Ambulance
Local professional ambulance service when medically appropriate immediately before or after an inpatient admission In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
and any difference between our allowance and the billed amount

Not covered:
Ambulance service used for routine transport
All charges 69.
69 Page 70 71
2003 APWU Health Plan 67 Section 6( c)
CONSUMER-DRIVEN OPTION
Emergency services/ accidents You Pay
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.

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

Accidental injury
If you receive care for your accidental injury within 24 hours, we cover:
Physician services and supplies
Related outpatient hospital services

In-network: 15% of the Plan allowance
Out-of-network: 15% of the Plan allowance and
any difference between our allowance and the
billed amount

Medical emergency
Outpatient facility charges in an Urgent Care Center
Outpatient medical or surgical services and supplies, other than an Urgent Care Center
In-network: 15% of the Plan allowance

Out-of-network: 15% of the Plan allowance
and any difference between our allowance
and the billed amount

Ambulance
Professional ambulance service within 24 hours of an accidental injury or medical emergency
Air ambulance if medically necessary for transport to the closest appropriate facility for treatment within 24 hours of an accidental
injury
Note: See Hospital benefits above for non-emergency service.

In-network: 15% of the Plan allowance
Out-of-network: 15% of the Plan allowance and any difference between our allowance

and the billed amount 70.
70 Page 71 72

2003 APWU Health Plan 68 Section 6( c)
CONSUMER-DRIVEN OPTION
Mental health and substance abuse benefits You Pay
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.

15% of the Plan allowance

Diagnostic tests 15% of the Plan allowance
Inpatient services provided by a hospital or other facility
Services in approved partial hospitalization setting
15% of the Plan allowance

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
40% 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
40% of charges for up to 30 days per calendar
year; all charges after 30 days

Out-of-network benefits continued on next page 71.
71 Page 72 73

2003 APWU Health Plan 69 Section 6( c)
CONSUMER-DRIVEN OPTION
Mental health and substance abuse benefits (continued) You Pay
Out-of-network benefits (continued)
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

40% of charges for one treatment program up
to $3,000; all charges over $3,000 per lifetime

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

See these sections of the brochure for more valuable information about these benefits:
Section 4, Your costs for covered services, for information about catastrophic protection for these benefits.
Section 8, Filing a claim for covered services, for information about submitting out-of-network claims. 72.
72 Page 73 74
2003 APWU Health Plan 70 Section 6( c)
CONSUMER-DRIVEN OPTION
Prescription drug benefits You Pay
Covered medications and supplies
Each new enrollee will receive a description of our prescription drug
program administered by Medco Health, a combined prescription
drug/ Plan identification card, a mail order form/ patient profile and a
reply envelope.

You may purchase the following medications and supplies prescribed by
a physician from either a network 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

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
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

Note: If you do not use your identification card at a network pharmacy,
or if you use a non-network pharmacy, the Plan provides no benefit and
you must pay the full cost of your purchases. Non-network retail drugs
will be covered under the in-network benefit only if necessary and
prescribed for sudden illness while traveling outside of the United States
(including Puerto Rico).

Network Retail: 25% of charge with a minimum of $8 per prescription
Network Retail Medicare: 25% of charge with a minimum of $8 per
prescription
Network Mail Order: 25% of charge with a minimum of $8 per prescription

Network Mail Order Medicare: 25% of charge with a minimum of $8 per
prescription

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
Non-network retail drugs (unless for a sudden illness while traveling outside the United States or Puerto Rico)

All charges 73.
73 Page 74 75
2003 APWU Health Plan 71 Section 6( d)
CONSUMER-DRIVEN OPTION
Section 6 (d). Health tools and resources
Special features Description
Online tools and resources Your personal, private website accessible by Internet or telephone (866/ 333-4648) featuring:

Your Personal Care Account balance and activity (also mailed quarterly)
Your complete claims payment history
A consumer health encyclopedia and interactive services
Online health risk assessment to help determine your risk for certain conditions and steps to manage them

Consumer choice
information

Each member is provided access by Internet or telephone (866/ 333-4648) to information
which you may use to support your important health and wellness decisions, including:

Online provider directory with complete national network and provider information (i. e., address, telephone, specialty, practice hours, languages spoken)

Network provider discounted pricing for comparative shopping
Pricing information for prescription drugs
General cost information for surgical and diagnostic procedures and for comparison of different treatment options

Provider quality information
Health calculators on medical and wellness topics

Care support A 24-hour nurse advisory service for your use. This program is strictly voluntary and confidential. You may call toll-free at 866/ 333-4648 to discuss an existing medical
concern or to receive information about numerous health care and self-care issues. This
also includes health coaching with a registered nurse when you want to discuss
significant medical decisions. TTY/ TDD callers, please call the National Relay Center
at 800/ 855-2880 and ask for 866/ 333-4648.

Identification and notification of potential patient safety issues (e. g., drug interactions).
Individual support with a health care professional for numerous medical conditions
including maternity, asthma, diabetes, congestive heart failure, and more. 74.
74 Page 75 76

2003 APWU Health Plan 72 Section 7
Section 7. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless we determine it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition.
We do not cover the following:
Services, drugs, or supplies you receive while you are not enrolled in this Plan
Services, drugs, or supplies that are not medically necessary
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice
Experimental or investigational procedures, treatments, drugs or devices
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest

Services, drugs, or supplies related to sex transformations, sexual dysfunction or sexual inadequacy except for organic impotence as shown on pages 29, 42, 60 and 70
Services, drugs, or supplies for weight reduction/ control or treatment of obesity except as shown under Surgical benefits, Sections 5( b) and 6( c)
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program
Services, drugs and supplies for which no charge would be made if the covered individual had no health insurance coverage
Computer "story boards", "light talkers", or other communication aids for communication-impaired individuals
Services, drugs, or supplies you receive without charge while in active military service.
Services, drugs and supplies furnished by immediate relatives or household members, such as spouse, parent, child, brother, or sister by blood, marriage, or adoption

Services and supplies furnished or billed by a noncovered facility, except that medically necessary prescription drugs and physical, speech and occupational therapy rendered by a qualified professional therapist on an outpatient basis are covered subject
to plan limits
Services, supplies and drugs not specifically listed as covered
Services, supplies and drugs furnished or billed by someone other than a covered provider as defined on page 10
Any portion of a provider's fee or charge ordinarily due from the enrollee but that has been waived. If a provider routinely waives (does not require the enrollee to pay) a deductible, copay or coinsurance, we will calculate the actual provider fee or

charge by reducing the fee or charge by the amount waived
Charges which you or we have no legal obligation to pay, such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and/ or B (see pages 18 and 19), doctor charges exceeding the amount specified by the Department

of Health and Human Services when benefits are payable under Medicare (limiting charge) (see page 19), or State premium taxes
however applied
Biofeedback; nonmedical self care or self help training, such as recreational, educational, or milieu therapy; or
Charges that we determine to be in excess of the Plan allowance. 75.
75 Page 76 77

2003 APWU Health Plan 73 Section 8
Section 8. Filing a claim for covered services
How to claim benefits High Option: to obtain claim forms or other claims filing advice or answers about our benefits, contact us at 800/ 222-APWU, or at our website at www. apwuhp. com.
Consumer-driven Option: contact Definity Health at 866/ 333-4638 or visit their
website at www. definityhealth. com. User ID: APWUHP Password: HPINFO

In most cases, providers and facilities file claims for you. Your physician must file on
the form HCFA-1500, Health Insurance Claim Form. Your facility will file on the UB-92
form. For claims questions and assistance, call us at 800/ 222-APWU.

When you must file a claim, such as when you use non-PPO providers, for services you
receive overseas or when another group health plan is primary, submit it on the HCFA-1500
or a claim form that includes the information shown below. Bills and receipts
should be itemized and show:

Name of patient and relationship to enrollee
Plan identification number of the enrollee
Name, address and taxpayer identification number of person or firm providing the
service or supply
Dates that services or supplies were furnished
Diagnosis
Type of each service or supply; and
The charge for each service or supply

Note: Canceled checks, cash register receipts, or balance due statements are not
acceptable substitutes for itemized bills.

In addition:
You must send a copy of the explanation of benefits (EOB) from any primary payer (such as the Medicare Summary Notice (MSN)) with your claim

Bills for home nursing care must show that the nurse is a registered nurse, licensed practical nurse or licensed vocational nurse
Claims for rental or purchase of durable medical equipment; private duty nursing; and physical, occupational, and speech therapy require a written
statement from the physician specifying the medical necessity for the service or
supply and the length of time needed
Claims for prescription drugs and supplies that are not obtained from a network pharmacy or through the Mail Service Prescription Drug Program must include

receipts that include the prescription number, the National Drug Code (NDC)
number, name of drug or supply, prescribing physician's name, date, and charge
You should provide an English translation and currency conversion rate at the time of services for claims for overseas (foreign) services

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

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless
timely filing was prevented by administrative operations of Government or legal
incapacity, provided the claim was submitted as soon as reasonably possible. Once
we pay benefits, there is a three-year limitation on the reissuance of uncashed checks. 76.
76 Page 77 78
2003 APWU Health Plan 74 Section 8
Overseas claims For covered services you receive in hospitals outside the United States and Puerto Rico and performed by physicians outside the United States, send a completed Claim
Form and the itemized bills to the following address. Also send any written inquiries
concerning the processing of overseas claims to:

-High Option: APWU Health Plan, P. O. Box 967, Silver Spring, MD 20910.
-Consumer-driven Option: Definity Health at the claims address shown on the back of your Definity Health ID card.

When we need more
information

Please reply promptly when we ask for additional information. We may delay
processing or deny your claim if you do not respond. 77.
77 Page 78 79
2003 APWU Health Plan 75 Section 9
Section 9. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or
request for services, drugs, or supplies including a request for preauthorization/ prior approval:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your High Option request to us at: APWU Health Plan, P. O. Box 3279, Silver Spring, MD 20918 or send your
Consumer-driven Option request to: Definity Health, Attn: Appeals, 1600 Utica Ave., So., Suite 900, St. Louis Park,
MN 55416; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this
brochure; and
(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical
records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or (c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request --go
to step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We
will base our decision on the information we already have.

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Health Benefits Contracts Division II,
1900 E Street, NW, Washington, D. C. 20415-3620

Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms

Copies of all letters you sent to us about the claim
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons
beyond your control. 78.
78 Page 79 80
2003 APWU Health Plan 76 Section 9
The disputed claims process (continued)
5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against
OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or
supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not
be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This
information will become part of the court record.

You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits,
and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to
uphold or overturn our decision. You may recover only the amount of benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if
not treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval under the High Option, then call
us at 800/ 222-APWU or under the Consumer-driven Option, call 866/ 333-4648 and we will expedite our review; or

(b) We denied your initial request for care or preauthorization/ prior approval, then:

If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division II at 202/ 606-3818 between 8 a. m. and 5 p. m. eastern time. 79.
79 Page 80 81
2003 APWU Health Plan 77 Section 10
Section 10. Coordinating benefits with other coverage
When you have other health
coverage

You must tell us if you or a covered family member have coverage under another group
health plan or have automobile insurance that pays health care expenses without regard to fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits in full as the
primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National
Association of Insurance Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary
plan pays, we will pay what is left of our allowance, up to our regular benefit. We will
not pay more than our allowance. When we are secondary payer, we will not waive
specified visit limits.

What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older
Some people with disabilities, under 65 years of age
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis
or a transplant)

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you

should be able to qualify for premium-free Part A insurance. (Someone who was a
Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise, if
you are age 65 or older, you may be able to buy it. Contact 800/ MEDICARE
(800/ 633-4227) for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement

check.
If you are eligible for Medicare, you may have choices in how you get your health care.
Medicare+ Choice is the term used to describe the various health plan choices available to
Medicare beneficiaries. The information in the next few pages shows how we coordinate
benefits with Medicare, depending on the type of Medicare+ Choice plan you have.

The Original Medicare Plan (Part A or Part B) The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people

get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist,
or hospital that accepts Medicare. The Original Medicare Plan pays its share and you
pay your share. Some things are not covered under Original Medicare, like prescription
drugs.

When you are enrolled in Original Medicare, along with this Plan, you still need to
follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan: You probably will never
have to file a claim form when you have both our Plan and the Original Medicare Plan: 80.
80 Page 81 82

2003 APWU Health Plan 78 Section 10
The Original Medicare Plan (Part A or Part B)
(Continued)
When we are the primary payer, we process the claim first. In this case, we do not waive any out-of-pocket costs
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then
provide secondary benefits for covered charges. You will not need to do anything.
To find out if you need to do something to file your claim, call us at 800/ 222-APWU
or contact us at our website at www. apwuhp. com

We waive some costs if the Original Medicare Plan is your primary payer.
Under the High Option, we will waive some out-of-pocket costs as follows:
Inpatient hospital service. If you are enrolled in Medicare Part A, the Plan will waive the deductible, copayment and coinsurance

Medical services and supplies provided by physicians and other health care professionals. If you are enrolled in Medicare Part B, we will waive the
deductible and coinsurance
Under the Consumer-driven Option, when Original Medicare (either Medicare Part A
or Medicare Part B) is the primary payer, we will not waive any out-of-pocket costs. 81.
81 Page 82 83
2003 APWU Health Plan 79 Section 10
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family
member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and
Original Medicare This Plan

1) Are an active employee with the Federal government (including when you or a family member are eligible for Medicare solely because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office which of these applies to you.)

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court judge who retired under Section 7447 of title 26, U. S. C. (or if your covered spouse is
this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, (for Part B
services)

(for other
services)

6) Are a former Federal employee receiving Workers' Compensation and the Office of Workers' Compensation Programs has determined that you are

unable to return to duty,

(except for claims
related to Workers'
Compensation.)

B. When you --or a covered family member --have Medicare based on end
stage renal disease (ESRD) and

1) Are within the first 30 months of eligibility to receive Part A benefits solely
because of ESRD,

2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD,

3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision,
C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or

b) Are an active employee .

c) Are a former spouse of an annuitant
d) Are a former spouse of an active employee 82.
82 Page 83 84

2003 APWU Health Plan 80 Section 10
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health care choices (like
HMOs) in some areas of the country. In most Medicare managed care plans, you can
only go to doctors, specialists, or hospitals that are part of the plan. Medicare
managed care plans provide all the benefits that Original Medicare covers. Some
cover extras, like prescriptions drugs. To learn more about enrolling in a Medicare
managed care plan, contact Medicare at 800/ MEDICARE (800/ 633-4227) or at
www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are available to
you:

This Plan and another plan's Medicare managed care plan: You may enroll in
another plan's Medicare managed care plan and also remain enrolled in our FEHB
plan. We will still provide benefits when your Medicare managed care plan is
primary, even out of the managed care plan's network and/ or service area, but we will
not waive any of our copayments, coinsurance, or deductibles. If you enroll in a
Medicare managed care plan, tell us. We will need to know whether you are in the
Original Medicare Plan or in a Medicare managed care plan so we can correctly
coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are
an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a
Medicare managed care plan, eliminating your FEHB premium. (OPM does not
contribute to your Medicare managed care plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want

to re-enroll in the FEHB Program, generally you may do so only at the next Open
Season unless you involuntarily lose coverage or move out of the Medicare managed
care plan's service area.

Private contract with your physician A physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. 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
Original Medicare's payment.

If you do not enroll in Medicare Part A or
Part B
If you do not have one or both Parts of Medicare, you can still be covered under the
FEHB Program. We will not require you to enroll in Medicare Part B and, if you
can't get premium-free Part A, we will not ask you to enroll in it.

TRICARE AND CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and their eligible dependents. If
TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or
CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an
annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any
applicable plan premiums.) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose

coverage under the program. 83.
83 Page 84 85
2003 APWU Health Plan 81 Section 10
Workers' Compensation We do not cover services that:
You need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency

determines they must provide; or
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or

similar laws
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care.

Medicaid When you have this Plan and Medicaid, we pay first.

When other Government
agencies are responsible
for your care

We do not cover services and supplies when a local, State, or Federal Government
agency directly or indirectly pays for them.

When others are responsible
for injuries

If you or your dependent's injury or illness is caused by another person or entity, the Health Plan will pay benefits for that injury or illness according to the terms of the

Brochure in effect at the time services are provided. If the Health Plan pays any
benefits for that injury or illness, when you or your dependent receive money or have
a right to receive money from any source, including underinsured and uninsured
automobile coverage, as a result of this injury or illness, you or your dependent must
reimburse the Health Plan for any expenses we paid for that injury or illness. The
amount owed to the Health Plan will not be reduced for attorney's fees or costs nor
because you or your dependent was not fully compensated for the injury or illness,
unless the Plan agrees in writing to a reduction.

If you do not seek damages you must agree to let us try. This includes the right of
the Plan to sue the responsible person or entity in your or your dependent's name.
This is called subrogation. You must inform the Plan promptly if your or your dependent's injury or illness is caused by another person. If you file a claim for

compensation, you must notify the Plan of the status of all stages of your claim and
you must tell us about any recoveries you obtain, whether in or out of court. We may
seek a lien on the proceeds of your claim in order to reimburse ourselves to the full
amount of benefits we have paid or will pay. You must agree that you will not do
anything that would prevent the Plan from being reimbursed for the benefits it paid
and will cooperate in doing what is reasonably necessary to assist the plan in
recovering the benefits it paid because of that injury or illness. All money recovered
and in whatever manner it is recovered, and regardless of how it is designated, must
first be used to reimburse the Plan before it is distributed in any form. We may
reduce subsequent benefit payments if we are not reimbursed for the benefits we paid if you or your dependent receives a recovery.

We may request that you assign to us (1) your right to bring an action or (2) your
right to the proceeds of a claim for your injury. We may delay processing of your
claims until you provide the assignment. The Plan's right to full reimbursement
applies even if the Plan has paid benefits before we know of the accident or illness,
and before we have asked you to sign a Reimbursement Agreement.

If you need more information, contact us for our subrogation procedures. 84.
84 Page 85 86

2003 APWU Health Plan 82 Section 11
Section 11. Definitions of terms we use in this brochure
Accidental injury An injury resulting from a violent external force.
Admission The period from entry (admission) into a hospital or other covered facility until discharge. In counting days of inpatient care, the date of entry and the date of
discharge are counted as the same day.

Assignment Your authorization for us to pay benefits directly to the provider. We reserve the right to pay you directly for all covered services.

Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the
same year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See page 14.

Consumer-driven option A fee-for-service option under the FEHB that offers you greater control over choices of your health care expenditures. You decide what health care services will be
reimbursed under the health plan funded Personal Care Account (PCA) . Unused
funds from the PCA will roll over at the end of the year. If you spend the entire
PCA fund before the end of the year, then you must satisfy a member responsibility before
benefits are payable under the traditional type of insurance covered by your
Plan. You decide whether to use in-network or out-of-network providers to reach
the maximum fund allowed under your PCA.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 14.

Covered services Services we provide benefits for, as described in this brochure.
Custodial care Treatment or services, regardless of who recommends them or where they are provided, that could be rendered safely and reasonably by a person not medically skilled, or that
are designed mainly to help the patient with daily living activities. These activities
include, but are not limited to:

Personal care such as help in: walking; getting in and out of bed; bathing; eating by spoon, tube or gastrostomy; exercising; dressing

Homemaking, such as preparing meals or special diets
Moving the patient
Acting as a companion or sitter
Supervising medication that can usually be self administered; or
Treatment or services that any person may be able to perform with minimal instruction, including but not limited to recording temperature, pulse, and

respirations, or administration and monitoring of feeding systems
We determine which services are custodial care. Custodial care that lasts 90 days or
more is sometimes known as long term care.

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 those services. See
page 14. 85.
85 Page 86 87
2003 APWU Health Plan 83 Section 11
Experimental or
investigational services

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

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

as compared with the standard means of treatment or diagnosis.
Reliable evidence shall mean only published reports and articles in the authoritative
medical and scientific literature; the written protocol or protocols used by the treating
facility or the protocol( s) of another facility studying substantially the same drug,
device, or medical treatment or procedure; or the written informed consent used by the
treating facility or by another facility studying substantially the same drug, device, or
medical treatment or procedure.

Determination of experimental/ investigational status may require review by a specialty
appropriate board-certified health care provider or appropriate government publications
such as those of the National Institute of Health, National Cancer Institute, Food and Drug Administration, Agency of Health Care Policy & Research, and the National

Library of Medicine.
Group health coverage Health care coverage that a member is eligible for because of employment by, membership in, or connection with, a particular organization or group that provides
payment for hospital, medical, or other health care services or supplies, or that pays a
specific amount for each day or period of hospitalization if that specified amount
exceeds $200 per day, including extension of any of these benefits through COBRA.

Home health care agency An agency which meets all of the following:
Is primarily engaged in providing, and is duly licensed or certified to provide, skilled nursing care and therapeutic services

Has policies established by a professional group associated with the agency or organization. This professional group must include at least one registered nurse
(R. N.) to direct the services provided and it must provide for full-time supervision
of each service by a physician or registered nurse
Maintains a complete medical record on each individual; and
Has a full-time administrator

Hospice care program A coordinated program of home and inpatient palliative and 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.

Maintenance therapy Includes but is not limited to physical, occupational, or speech therapy where continued therapy is not expected to result in significant restoration of a bodily
function but is utilized to maintain the current status. 86.
86 Page 87 88

2003 APWU Health Plan 84 Section 11
Medically necessary Services, drugs, supplies or equipment provided by a hospital or covered provider of health care services that we determine:
Are appropriate to diagnose or treat the patient's condition, illness or injury
Are consistent with standards of good medical practice in the United States
Are not primarily for the personal comfort or convenience of the patient, the family, or the provider

Are not a part of or associated with the scholastic education or vocational training of the patient; and
In the case of inpatient care, cannot be provided safely on an outpatient basis
The fact that a covered provider has prescribed, recommended, or approved a service, supply, drug or equipment does not, in itself, make it medically necessary.

Member Responsibility Under the Consumer-driven Option, your Member Responsibility is the amount you must pay, if you have exhausted your Personal Care Account, before your
Traditional Health Coverage begins. See page 15.
Personal Care Account Under the Consumer-driven Option, your Personal Care Account (PCA is an established benefit amount which is available for you to use first to pay for covered
hospital, medical, dental and vision care expenses. You determine how your PCA
will be spent and any unused amount at the end of the year may be rolled over to
increase your available PCA in the subsequent year( s).

Plan allowance Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their allowances
in different ways. We determine our allowance as follows:
For PPO providers, our allowance is based on negotiated rates. PPO providers
always accept the Plan's allowance as their charge for covered services.

For non-PPO providers, we base the Plan allowance on the lesser of the provider's
actual charge or the reasonable and customary charge for the service you received.
We determine the reasonable and customary allowance by using health care charges
guides which compare charges of other providers for similar services in the same
geographical area. For surgery, doctor's services, X-ray, lab and therapies (physical,
speech and occupational), we use guides prepared by the Health Insurance
Association of America (HIAA) and apply these guides under the High Option at the
70 th percentile and under the Consumer-driven Option at the 80 th percentile. We
update these charges guides at least once each year. If HIAA information is not available, we will use other credible sources including our own data.

For more information, see Differences between our allowance and the bill in
Section 4.

Rollover Any unused, remaining balance in your PCA at the end of the calendar year may be rolled over to subsequent years up to a maximum rollover of $4,000 per Self Only
enrollment or $6,000 per Self and Family enrollment, thereby increasing your PCA
in the following year( s). You must use any available PCA benefits, including any
amounts rolled over from previous years, before Traditional Health Coverage
begins.

Rehabilitative care Treatment that reasonably can be expected to restore and/ or substantially restore a bodily function that was impaired as a result of trauma or disease.

Us/ We Us and we refer to APWU Health Plan.
You You refers to the enrollee and each covered family member. 87.
87 Page 88 89

2003 APWU Health Plan 85 Section 12
Section 12. FEHB facts
No pre-existing condition
limitation

We will not refuse to cover the treatment of a condition that you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information
about enrolling in the
FEHB Program

See www. opm. gov/ insure. Also, your employing or retirement office can answer
your questions, and give you a Guide to Federal Employees Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision

about your FEHB coverage. These materials tell you:
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire

When your enrollment ends; and
When the next Open Season for enrollment begins

We don't determine who is eligible for coverage and, in most cases, cannot change
your enrollment status without information from your employing or retirement office.

Types of coverage available
for you and your family

Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, and your unmarried dependent children under age 22, including any foster

children or stepchildren your employing or retirement office authorizes coverage for.
Under certain circumstances, you may also continue coverage for a disabled child 22
years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family enrollment
if you marry, give birth, or add a child to your family. You may change your
enrollment 31 days before to 60 days after that event. The Self and Family
enrollment begins on the first day of the pay period in which the child is born or
becomes an eligible family member. When you change to Self and Family because
you marry, the change is effective on the first day of the pay period that begins after
your employing office receives your enrollment form; benefits will not be available to your spouse until you marry.

Your employing or retirement office will not notify you when a family member is no
longer eligible to receive health benefits, nor will we. Please tell us immediately
when you add or remove family members from your coverage for any reason,
including divorce, or when your child under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another FEHB plan.

Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage in the
Federal Employees Health Benefits (FEHB) Program, if you are an employee subject
to a court or administrative order requiring you to provide health benefits for your
child( ren).

If this law applies to you, you must enroll for Self and Family coverage in a health
plan that provides full benefits in the area where your children live or provide
documentation to your employing office that you have obtained other health benefits
coverage for your children. If you do not do so, your employing office will enroll you
involuntarily as follows:
If you have no FEHB coverage, your employing office will enroll you for Self 88.
88 Page 89 90

2003 APWU Health Plan 86 Section 12
and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's
Basic Option;

If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your

enrollment to Self and Family in the same option of the same plan; or
If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the

Blue Cross and Blue Shield Service Benefit Plan's Basic Option.
As long as the court/ administrative order is in effect, and you have at least one child
identified in the order who is still eligible under the FEHB Program, you cannot
cancel your enrollment, change to Self Only, or change to a plan that doesn't serve the area in which your children live, unless you provide documentation that you have

other coverage for the children. If the court/ administrative order is still in effect when
you retire, and you have at least one child still eligible for FEHB coverage, you must
continue your FEHB coverage into retirement (if eligible) and cannot make any
changes after retirement. Contact your employing office for further information.

When benefits and
premiums start

The benefits in this brochure are effective on January 1. If you joined this Plan during
Open Season, your coverage begins on the first day of your first pay period that starts
on or after January 1. Annuitants' coverage and premiums begin on January 1. If you
joined at any other time during the year, your employing office will tell you the
effective date of coverage.

Under the Consumer-driven Option, if you joined this Plan during Open Season, you receive the full Personal Care Account (PCA) as of your effective date of coverage. If

you joined at any other time during the year, your PCA and your Member
Responsibility for your first year will be prorated for each full month of coverage
remaining in that calendar year.

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal
service. If you do not meet this requirement, you may be eligible for other forms of
coverage, such as Temporary Continuation of Coverage (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.

You may be eligible for spouse equity coverage or Temporary Continuation of
Coverage.

Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse's enrollment. This is the case even when the court

has ordered your former spouse to supply health coverage to you. But, you may be
eligible for your own FEHB coverage under the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a

divorce, contact your ex-spouse's employing or retirement office to get RI 70-5, the
Guide to Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, or other information about your coverage
choices. You can also download the guide from OPM's website, www. opm. gov/ insure. 89.
89 Page 90 91

2003 APWU Health Plan 87 Section 12
Temporary Continuation of Coverage (TCC) If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage
(TCC). For example, you can receive TCC if you are not able to continue your FEHB
enrollment after you retire, if you lose your Federal job, if you are a covered
dependent child and you turn 22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the
Guide to Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, from your employing or retirement office or
from www. opm. gov/ insure. It explains what you have to do to enroll.

Converting to individual coverage You may convert to a non-FEHB individual policy if:
Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);

You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal service, your employing office will notify you of your right to
convert. You must apply in writing to us within 31 days after you receive this notice.
However, if you are a family member who is losing coverage, the employing or
retirement office will not notify you. You must apply in writing to us within 31 days
after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you
will not have to answer questions about your health, and we will not impose a waiting period or limit your coverage due to pre-existing conditions.

Getting a Certificate of Group Health Plan
Coverage
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal
law that offers limited Federal protections for health coverage availability and continuity
to people who lose employer group coverage. If you leave the FEHB Program, we will
give you a Certificate of Group Health Plan Coverage that indicates how long you have
been enrolled with us. You can use this certificate when getting health insurance or other
health care coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this Plan. If
you have been enrolled with us for less than 12 months, but were previously enrolled in
other FEHB plans, you may also request a certificate from those plans.

For more information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC) under the FEHB Program. See also the FEHB website
(www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked
questions. These highlight HIPAA rules, such as the requirement that Federal employees
must exhaust any TCC eligibility as one condition for guaranteed access to individual
health coverage under HIPAA, and have information about Federal and State agencies
you can contact for more information. 90.
90 Page 91 92

2003 APWU Health Plan 88 Long Term Care Insurance
Long Term Care Insurance Is Still Available
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002.
If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open Season.
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.

FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care," long term care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide help you may need due to a
severe cognitive impairment such as Alzheimer's disease.
You Can Also Apply Later, But
Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open Season ends, but they will have to answer more health-related questions.
For annuitants and other qualified relatives, the number of health-related questions that you need to answer is the same during and after the Open Season.

You Must Act to Receive an Application
Unlike other benefit programs, YOU have to take action you won't receive an application automatically. You must request one through the toll-free number or website listed below.
Open Season ends December 31, 2002 act NOW so you won't miss the abbreviated underwriting available to employees and their spouses, and the July 1 "age freeze"!

Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired: 1-800-843-
3557) or visiting www. ltcfeds. com to get more information and to request an application. 91.
91 Page 92 93
2003 APWU Health Plan 89 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

Accidental injury .. .. 31, 37, 44, 62, 67,
82
Acupuncture............................. 28, 60
Allergy care.............................. 24, 55
Allogeneic bone marrow transplant. ... ............................................. 32, 63

Alternative treatments............... 28, 60
Ambulance .............. 34, 36, 38, 66, 67
Anesthesia .................... 33, 36, 64, 66
Artificial limbs ................... 13, 26, 57
Autologous bone marrow transplant
...................... 24, 32, 33, 55, 63, 64
Autologous peripheral stem cell
support.................................. 32, 63 Biopsies........................
29, 31, 60, 62
Blood and blood plasma... .. 35, 36, 65, 66

Breast prosthesis.... .. 26, 31, 57, 61, 62 Casts
........................................ 36, 66
Catastrophic protection ............. 16, 17
CHAMPVA................................... 80
Changes for 2003............................. 9
Chemotherapy .. .24, 33, 36, 55, 64, 66
Chiropractic........................ 10, 28, 59
Cholesterol tests............................. 22
Coinsurance..... .. 14, 15, 16, 18, 78, 82
Colorectal cancer screening............ 22 Congenital anomalies.. .. 29, 30, 60, 61

Contraceptive devices and drugs .... 23,
30, 42, 54, 60, 70
Coordination of benefits... .. 77, 78, 79,
80, 81
Copayment .. 14, 16, 21, 26, 28, 78, 82
Covered charges ....................... 19, 78
Covered providers.......................... 10
Crutches ................................... 27, 58 Deductible..
14, 15, 16, 21, 29, 34, 37,
39, 40, 42, 44, 47, 49, 50, 51, 70, 78,
82 Definitions.......................... 82, 83, 84

Dental care ................... 32, 44, 45, 63
Diagnostic services ..... .. 22, 36, 53, 66
Disputed claims review ............. 75, 76
Doctor ........................................... 10
Donor expenses (transplants)... .. 33, 64
Dressings...................... 36, 42, 66, 70
Durable medical equipment.... .. 13, 26,
27, 58, 73 Educational
classes and programs
............................................. 28, 60 Effective date of enrollment ........... 10

Emergency .............. 12, 19, 37, 38, 67

Enteral formulas....................... 42, 70
Experimental or investigational.. 72, 83
Eyeglasses .......................... 25, 43, 56 Family
planning....................... 23, 54
Fecal occult blood test.................... 22 Flexible benefits option ............ 43, 71

Foot care.................................. 26, 57
Freestanding ambulatory facilities . 10,
36, 66 General
exclusions......................... 72 Hearing
services ................. 25, 43, 56
Home health services .......... 13, 27, 59
Home nursing care.. 13, 16, 27, 59, 73
Hospice care ................. 16, 36, 66, 83
Hospital.. 10, 11, 12, 13, 18, 19, 21, 23,
29, 31, 33, 34, 35, 36, 37, 40, 43, 53, 62, 64, 65, 66, 67, 68, 69, 78, 82, 84

Immunizations......................... 22, 23
Infertility ................................. 24, 54
Inhospital physician care.......... 21, 53
Inpatient hospital benefits... 13, 16, 34,
35, 64, 65
Insulin ..................................... 42, 70 Laboratory
and pathological services
................. 22, 23, 35, 36, 53, 65, 66
Long Term Care............................. 88 Magnetic
reasonance imagings (MRIs) ............................................. 22, 53

Mail order prescription drugs.... 41, 42,
70
Mammograms.......................... 22, 47
Maternity benefits 12, 23, 53, 54
Medicaid........................................ 81
Medical emergency............. 37, 38, 67
Medically necessary... .. 12, 13, 21, 26,
29, 34, 35, 38, 44, 58, 65, 67, 72, 84
Medically underserved areas..... 10, 28,
60
Medicare..... 13, 18, 19, 29, 34, 37, 39, 41, 42, 44, 70, 77, 78, 79, 80

Member responsibility.. 14, 15, 16, 17,
51, 52, 82, 84, 86
Mental health .......... 13, 39, 40, 68, 69 Newborn
care................ 21, 23, 53, 54
Non-FEHB benefits........................ 45
Nurse.. ... 10, 13, 27, 35, 59, 65, 73, 83
Licensed Practical Nurse... 10, 27,
59, 73
Licensed Vocational Nurse... 10, 27,
59, 73 Nurse Anesthestist...................... 10

Nurse Midwife ........................... 10

Nurse Practitioner ....................... 10
Registered Nurse . 10, 27, 59, 73, 83
Nursing school administered clinic . 10 Obstetrical
care ........................ 23, 53
Occupational therapy.. .. 10, 13, 25, 55, 73, 83

Office visits........................ 21, 26, 44
Oral and maxillofacial surgery.. 31, 32,
62, 63
Organic impotence .. 13, 29, 42, 70, 72
Orthopedic devices ................... 26, 57
Out-of-pocket expenses ............ 16, 17
Overseas claims........................ 73, 74
Oxygen ...... .. 13, 26, 35, 36, 58, 65, 66 Pap
test .................................... 22, 53
Personal Care Account (PCA) .. 15, 17, 49, 51, 71, 82, 84, 86

Physical and occupational therapies
........................................ 25, 55, 56
Physical examination...................... 23
Physical therapy.. 10, 13, 25, 55, 73, 83
Physician..... 12, 14, 18, 19, 21, 25, 27,
29, 35, 37, 41, 42, 53, 55, 59, 65, 67,
70, 73, 80, 83
Precertification.. 12, 13, 34, 40, 68, 69
Preferred Provider Organizations
(PPO) ........................................... 7 Prescription drugs... 16, 35, 41, 42, 70,

72, 73
Preventive care, adult.. . 22, 27, 30, 31,
32, 33, 35, 40, 61, 62, 63, 64, 65, 76
Preventive care, children................. 23
Prior approval.... 13, 24, 32, 55, 63, 75,
76
Prostate cancer screening................ 22
Prosthetic devices. .. 26, 30, 31, 57, 60,
61
Psychologist ................................... 10 Radiation
therapy.......... 24, 36, 55, 66 Reagent strips........................... 42, 70

Renal dialysis........................... 24, 55
Review and reward program ........... 43
Rollover ............................. 50, 52, 84
Room and board............ 34, 35, 64, 65 Second
surgical opinion............ 21, 53
Sigmoidoscopy............................... 22
Skilled nursing facility care.. ... 11, 21,
35, 36, 53, 65, 66
Smoking cessation.................... 42, 70
Social worker ................................. 10 Speech therapy.............. 10, 13, 73, 83

Index -continued on next page 92.
92 Page 93 94
2003 APWU Health Plan 90 Index
Index (continued)
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

Substance abuse...... 10, 13, 16, 39, 40,
68, 69
Surgery.. 13, 25, 29, 30, 31, 32, 33, 34,
36, 38, 56, 60, 61, 62, 63, 64, 66, 67
Anesthesia. ... 29, 33, 35, 36, 64, 65,
66
Assistant surgeon .................. 30, 60 Multiple procedures .............. 30, 61

Oral ............... 31, 32, 36, 62, 63, 66
Outpatient ........... 10, 36, 38, 66, 67
Reconstructive .......... 30, 31, 61, 62
Syringes................................... 42, 70 Temporary
continuation of coverage
............................................. 86, 87
Transplants ...... .. 24, 32, 33, 55, 63, 64 Treatment therapies.................. 24, 55

TRICARE ...................................... 80 Vision
services ................... 25, 43, 56 Well
child care............................... 23
Wellness benefit............................. 43
Wheelchairs ....................... 13, 27, 58
Workers' compensation .................. 81 X-
ray ........... 22, 35, 36, 44, 53, 65, 66 93.
93 Page 94 95

2003 APWU Health Plan 91 Summary
Summary of benefits for the APWU Health Plan
High Option -2003

Do not rely on this chart alone. All benefits are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
Below, an asterisk (*) means the item is subject to the calendar year deductible, $275 (PPO) or $350 (Non-PPO). And, after we pay, you generally pay any difference between our allowance and the billed amount if you use a Non-PPO
physician or other health care professional.

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office*............... PPO: $15 copay per visit (No deductible); 10% of Plan allowance

Non-PPO: 30% of our allowance plus amount over
our allowance

Services provided by a hospital:
Inpatient ........................................................................................ PPO: 10% of Plan allowance Non-PPO: $200 copay and 30% of our allowance

plus amount over our allowance
34

Outpatient*.................................................................................... PPO: 10% of Plan allowance Non-PPO: 30% of our allowance plus amount over
our allowance
36

Emergency benefits:
Accidental injury ........................................................................... PPO: Nothing Non-PPO: Any amount over our allowance 37

Medical emergency*...................................................................... Regular benefits 38
Mental health and substance abuse treatment....................................... In-network: Regular cost sharing. Out-of-network:
Benefits are limited.
39

Prescription drugs:
Network pharmacy......................................................................... $7 generic/ 25% brand name 41
Network pharmacy Medicare......................................................... $7 generic/ 25% brand name
Non-network pharmacy.................................................................. 45% of cost
Non-network pharmacy Medicare .................................................. 45% of cost
Mail order...................................................................................... $10 generic/ 20% brand name
Mail order Medicare ...................................................................... $10 generic/ 20% brand name

Dental Care........................................................................................ .. Any difference between our allowance and the
billed amount for covered services
44

Special features: Flexible benefits option, 24-hour nurse line, Services for deaf and hearing-impaired, Wellness benefit,
Review and reward program.. 43

Protection against catastrophic costs (your out-of-pocket maximum) .... PPO: Nothing after $4,000/ Self Only or Family enrollment per year

Non-PPO: Nothing after $8,000/ Self Only or
Family enrollment per year
Some costs do not count toward this protection

16 94.
94 Page 95 96

2003 APWU Health Plan 92 Summary
Summary of benefits for the APWU Health Plan
Consumer-driven Option -2003

Do not rely on this chart alone. All benefits are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
Below, an asterisk (*) means the item is subject to the Member Responsibility, generally $600 per Self Only and $1,200 per Self and Family, once your Personal Care Account has been spent. And, after we pay, you generally pay any
difference between our allowance and the billed amount if you use an out-of-network physician or other health care
professional.

Benefits You Pay Page
In-network preventive care Nothing 47
Personal Care Account
Up to $1,000 for Self Only or $2,000 for Self and Family for
medical, surgical, hospital, mental health and substance abuse
services and prescription drugs plus certain dental and vision care

Nothing up to $1,000 for Self Only or $2,000 for
Self and Family
49

Traditional Health Coverage after Personal Care Account is exhausted
Medical/ Surgical services provided by physicians:
Diagnostic and treatment services provided in the office* ............. In-network: 15% of Plan allowance 53 Services provided by a hospital: Out-of-network: 40% of our allowance plus amount

Inpatient*..................................................................................... over our allowance 64
Outpatient*.................................................................................. 66

Accidental injury* ...........................................................................

Medical emergency* .......................................................................
In-network: 15% of Plan Allowance Out-of-network: 15% of Plan Allowance put

amount over our allowance
67
67

Mental health and substance abuse treatment*.................................. In-network: Regular cost sharing.
Out-of-network: Benefits are limited.
68

Prescription drugs:
Network pharmacy* ..................................................................... 25%/ minimum $8 70
Network pharmacy Medicare*...................................................... 25%/ minimum $8
Mail order*.................................................................................. 25%/ minimum $8
Mail order Medicare*................................................................... 25%/ minimum $8

Dental Care/ Vision Care (covered only under Personal Care
Account) ........................................................................................... ..
Any amount over $400 per Self Only or $800 per
Family
50

Special features: Online tools and resources, Consumer choice information, Services for deaf and hearing-impaired,
24-hour nurse advisory service and Care support.. 71

Protection against catastrophic costs (your out-of-pocket maximum) .... In-network: Nothing after $4,500/ Self Only or Family enrollment per year

Out-of-network: Nothing after $9,000/ Self Only or
Family enrollment per year
Some costs do not count toward this protection

17 95.
95 Page 96
2003 APWU Health Plan 93
2003 Rate Information for
APWU Health Plan

Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB
Guide for that category or contact the agency that maintains your health benefits enrollment.

Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United
States Postal Service Employees, RI 70-2. Different postal rates apply and a special FEHB guide is published for
Postal Service Inspectors and Office of Inspector General (OIG) employees (see RI 70-21N).

Postal rates do not apply to non-career postal employees, postal retirees, or associate members of any postal
employee organization who are not career postal employees. Refer to the applicable FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of
Enrollment Code
Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share
Your
Share

High Option Self Only 471 $109.30 $52.08 $236.82 $112.84 $129.03 $32.35
High Option Self & Family 472 $249.62 $104.53 $540.84 $226.49 $294.70 $59.45
Consumer-driven Option Self Only 474 $109.20 $36.40 $236.60 $78.87 $129.03 $16.57
Consumer-driven Option Self & Family 475 $249.62 $86.30 $540.84 $186.99 $294.70 $41.22 96.

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