Page numbers referenced within this brochure apply only to the printed brochure

APWU Health Plan

www.apwuhp.com
Customer Service 800-222-2798

2022



IMPORTANT:
  • Rates
  • Changes for 2022
  • Summary of Benefits
  • Accreditations
A Fee-for-Service Plan (High Option) and a Consumer Driven Health Plan with Preferred Provider Organizations

This plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 8 for details.  This plan is accredited.  See page 13.

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. To enroll, you must be, or must become, a member or associate member of the American Postal Workers Union, AFL-CIO.

To become a member or associate member: All active Postal Service APWU bargaining unit employees must be, or must become, dues-paying members of the APWU, to be eligible to enroll in the Health Plan.  All Federal and other Postal members and annuitants must become associate member of APWU, see page 125 for details.

Membership dues:  Associate members will be billed by the APWU for the $35 annual membership fee, except where exempt by law.  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.  APWU will bill Retirees Department members $36 annual membership.  Active and retiree non-associate APWU membership dues vary.

 

Enrollment codes for this Plan: 

High Option:  471 Self Only, 473 Self Plus One, 472 Self and Family

Consumer Driven Option:  474 Self Only, 476 Self Plus One, 475 Self and Family
 
Federal Employees Health Benefits Program seal
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Important Notice

Important Notice from APWU Health Plan About

Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that the APWU Health Plan prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all Plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213, (TTY:  800-325-0778). 

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:

  • Visit www.medicare.gov for personalized help.
  • Call 800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048).



Table of Contents

(Page numbers solely appear in the printed brochure)




Introduction

This brochure describes the benefits of APWU Health Plan under contract (CS 1370) between APWU Health Plan and the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. This Plan is underwritten by the American Postal Workers Union, AFL-CIO. Customer Service may be reached at 800-222-2798 or through our website:  www.apwuhp.com.  The address for the APWU Health Plan administrative office is:

APWU Health Plan
799 Cromwell Park Drive, Suites K-Z
Glen Burnie, MD 21061

This brochure is the official statement of benefits. No verbal 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 Plus One or 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, 2022, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2022, and changes are summarized on page 15.  Rates are shown at the end of this brochure.




Plain Language

All FEHB brochures are written in plain language to make them easy to understand.  Here are some examples:

  • Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each covered 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 United States Office of Personnel Management. If we use others, we tell you what they mean.
  • Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.



Stop Healthcare Fraud!

Fraud increases the cost of healthcare for everyone and increases your Federal Employees Health Benefits 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:

  • Do not give your plan identification (ID) number over the phone or to people you do not know, except for your healthcare provider, authorized health benefits plan, or OPM representative.
  • Let only the appropriate medical professionals review your medical record or recommend services.
  • Avoid using healthcare 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) statements that you receive from us.
  • Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.
  • 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 the APWU Health Plan Fraud Hotline at 410-424-1515.
    • If we do not resolve the issue:

      CALL - THE HEALTHCARE FRAUD HOTLINE
      877-499-7295

      OR go to  www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form

      The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker response time.

      You can also write to:
      United States Office of Personnel Management
      Office of the Inspector General Fraud Hotline
      1900 E Street NW Room 6400
      Washington, DC  20415-1100

  • 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 26 or over (unless they were disabled and incapable of self-support prior to age 26).
    • A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.
  • If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).
  • Fraud or intentional misrepresentation of material fact is prohibited under the Plan.  You can be prosecuted for fraud and your agency may take action against you.  Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.
  • If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and premiums are paid, you will be responsible for all benefits paid during the period in which premiums were not paid.  You may be billed by your provider for services received.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you or a family member is no longer eligible to use your health insurance coverage.



Discrimination is Against the Law

The APWU Health Plan complies with all applicable Federal civil rights laws, including Title VII of the Civil Rights Act of 1964.

You can also file a civil rights complaint with the Office of Personnel Management by mail at:  Office of Personnel Management Healthcare and Insurance Federal Employee Insurance Operations, Attention:  Assistant Director FEIO, 1900 E Street NW, Suite 3400 S, Washington, DC  20415-3610.




Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments.  Medical mistakes and their consequences also add significantly to the overall cost of healthcare.  Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies.  You can also improve the quality and safety of your own healthcare and that of your family members by learning more about and understanding your risks.  Take these simple steps:

1.  Ask questions if you have doubts or concerns.

  • Ask questions and make sure you understand the answers.
  • Choose a doctor with whom you feel comfortable talking.
  • Take a relative or friend with you to help you take notes, ask questions and understand answers.

2.  Keep and bring a list of all the medications you take.

  • Bring the actual medication or give your doctor and pharmacist a list of all the medication and dosage that you take, including non-prescription (over-the-counter) medications and nutritional supplements.
  • Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as latex.
  • Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
  • Make sure your medication is what the doctor ordered. Ask the pharmacist about your medication if it looks different than you expected.
  • Read the label and patient package insert when you get your medication, including all warnings and instructions.
  • Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
  • Contact your doctor or pharmacist if you have any questions.
  • Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3.  Get the results of any test or procedure.

  • Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or Provider’s portal?
  • Don’t assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your results.
  • Ask what the results mean for your care.

4.  Talk to your doctor about which hospital or clinic is best for your health needs.

  • Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the healthcare you need.
  • Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5.  Make sure you understand what will happen if you need surgery.

  • Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
  • Ask your doctor, “Who will manage my care when I am in the hospital?”
  • Ask your surgeon:
    • “Exactly what will you be doing?”
    • “About how long will it take?”
    • “What will happen after surgery?”
    • “How can I expect to feel during recovery?”
  • Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

  • www.jointcommision.org/speakup.aspx.  The Joint Commission's Speak Up™ patient safety program.

  • www.jointcommission.org/topics/patient_safety.aspx.  The Joint Commission helps healthcare organizations to improve the quality and safety of the care they deliver.

  • www.ahrq.gov/patients-consumers/.  The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve the quality of care you receive.

  • www.npsf.org.  The National Patient Safety Foundation has information on how to ensure safer healthcare for you and your family.

  • www.bemedwise.org.  The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medications.

  • www.leapfroggroup.org.  The Leapfrog Group is active in promoting safe practices in hospital care.

  • www.ahqa.org.  The American Health Quality Association represents organizations and healthcare professionals working to improve patient safety.

Preventable Healthcare Acquired Conditions ("Never Events")

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, can indicate a significant problem in the safety and credibility of a healthcare facility. These conditions and errors are sometimes called "Never Events" or "Serious Reportable Events."

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores and fractures; and to reduce medical errors that should never happen. When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error.

APWU Health Plan defines a Never Event as any unanticipated event resulting in death or serious physical or psychological injury to a member of the APWU Health Plan, not related to the natural course of the patient’s illness. These incidents/events include loss of a limb or gross motor function, and any event or process variation for which a recurrence would carry a risk of a serious adverse outcome. They also include events such as actual breaches in medical care, administrative procedures or others resulting in an outcome that is not associated with the standard of care or acceptable risks associated with the provision of care and service for a member, including reactions to drugs and materials.

When APWU Health Plan receives notification of a potential Never Event from a member telephone call, by mail, or email or through a claim, or vendor notification, we begin a review process with our management team. An investigation is conducted. If the investigation reveals a Never Event, the member is notified. We conduct a root cause analysis, and provide a final report to the management team and the delegated vendor.




FEHB Facts

Coverage information




TermDefinition
  • No pre-existing condition limitation

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

  • Minimum essential coverage (MEC)

Coverage under this plan qualifies as minimum essential coverage (MEC) and satisfies the Patient Protection and Affordable Care Act's (ACA) individual shared responsibility requirement.  Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

  • Minimum value standard

Our health coverage meets the minimum value standard of 60% established by the ACA.  This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits.  The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

  • Where you can get information about enrolling in the FEHB Program

See www.opm.gov/healthcare-insurance/healthcare for enrollment information as well as:

  • Information on the FEHB Program and plans available to you
  • A health plan comparison tool
  • A list of agencies that participate in Employee Express
  • A link to Employee Express
  • Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give you 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
  • What happens when your enrollment ends
  • When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for updates and questions about your benefit coverage.

  • Types of coverage available for you and your family

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member.  Self and Family coverage is for the enrollee and one or more eligible family members. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or 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 Plus One or 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 Plus One or 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 are married.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

Contact your carrier to obtain a Certificate of Creditable Coverage (COCC) or to add a dependent when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a newborn if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at http://www.opm.gov/healthcare-insurance/life-event. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

  • Family Member Coverage

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described in the chart below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

 

  • 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 Plus One or Self and Family coverage in the 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 in Self Plus One or 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 Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM;
  • 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 Plus One or Self and Family, as appropriate, 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 Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

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 does not 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 cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child.  Contact your employing office for further information.

  • When benefits and premiums start

The benefits in this brochure are effective 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. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2022 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.   When you are enrolled under this Plan's Consumer Driven Option.  Under this Plan's Consumer Driven Option, between January 1 and the effective date of your new plan (or change to High Option of this Plan) you will not receive a new Personal Care Account (PCA) for 2022 but any unused PCA benefits from 2021 will be available to you.  However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2021 benefits until the effective date of your coverage with your new plan. 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.

If your enrollment continues after you are no longer eligible for coverage, (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance 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 Deductible 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




TermDefinition
  • 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 or a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy).

  • Upon divorce

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 provide health coverage for you. However, you may be eligible for your own FEHB coverage under either 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 additional information about your coverage choices, www.opm.gov/healthcare-insurance/healthcare/plan-information/guides.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

  • Temporary Continuation of Coverage (TCC)

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules.  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 age 26, regardless of marital status, etc.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance/healthcare/plan-information/guides. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums.  Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan (such as your spouse's plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

  • Converting to individual coverage

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing 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 contact us in writing 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, a waiting period will not be imposed and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-222-2798 or visit our website at www.apwuhp.com.

  • Health Insurance Marketplace

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov.  This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

  • APWU Health Plan Notice of Privacy Practices

The APWU Health Plan's Notice of Privacy Practices describes how medical information about you may be used by the Health Plan, your rights concerning your health information and how to exercise them, and APWU Health Plan's responsibilities in protecting your health information.  The Notice is posted on the Health Plan's website.  If you need to obtain a copy of the Health Plan's Notice of Privacy Practices, you may either contact the Health Plan via email through the website, www.apwuhp.com, or by calling 800-222-2798.




Section 1. How This Plan Works

This Plan is a fee-for-service (FFS) plan.  OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet or exceed nationally recognized standards.  APWU Health Plan holds the following accreditations: Accreditation Association for Ambulatory Health Care (www.aaahc.org); National Committee for Quality Assurance (www.ncqa.org); URAC (www.urac.org).  To learn more about this plan's accreditation(s), please visit the following website: www.apwuhp.com.

You can choose your own physicians, hospitals, and other healthcare providers. We give you a choice of enrollment in a High Option or a Consumer Driven Health Plan (CDHP).  

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.

General features of our High Option

We have Preferred Provider Organizations (PPOs):

Our fee-for-service plans offer services through PPO networks. This means that certain hospitals and other healthcare providers are “preferred providers."  When you use our network providers, you will receive covered services at a 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.

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. 

High Option PPO Network: You can go to our website, www.apwuhp.com to download a High Option PPO directory.  If you need assistance in identifying a participating provider or to verify their continued participation, call the Plan's PPO administrator for your state:  The Plan uses Cigna as its PPO network in all states and the U.S. Virgin Islands, Cigna 800-582-1314.  For mental health/substance use disorder treatment providers (all states), call Cigna Behavioral Health, 800-582-1314.

When you leave your state of residence, Cigna is your travel network, available in all 50 states and the District of Columbia. When out of your state of residence, if you do not use a Cigna PPO provider or a Cigna PPO provider is not available, standard non-PPO benefits apply. For assistance in identifying a provider in the travel network, call Cigna 800-582-1314.

General features of our Consumer Driven Health Plan (CDHP)

Consumer Driven Option PPO Network:  If you need assistance identifying a participating provider or to verify their continued participation, call the Plan's Consumer Driven Option administrator, UnitedHealthcare, at 800-718-1299 or you can go to their website, www.welcometouhc.com/apwu, for a full nationwide online provider directory. UnitedHealthcare is the PPO network for all states and Puerto Rico, and the U.S. Virgin Islands.  Printed provider directories are not available.

  • Preventive benefits:  Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles or annual limits when received from a network provider.
  • For mental health/substance use disorder treatment providers (all states), call UHC Behavioral Health Solutions toll-free 800-718-1299.  
  • Personal Care Account (PCA) benefits:  This component is used first to provide first dollar coverage for covered medical, dental and vision care services until the account balance is exhausted.
  • Traditional benefits:  After you have used up your Personal Care Account and satisfied a Deductible, the Plan starts paying benefits under the Traditional Health Coverage as described in Section 5 CDHP.

 

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.

For non-PPO providers, we base the Plan allowance on the lesser of the provider's actual charges or the allowed amount for the service you received.  We determine the allowed amount by using healthcare charge guides which compare charges of other providers for similar services in the same geographical area.  We update these charge guides at least once a year.  For surgery, doctor's services, X-ray, lab and therapies (physical, speech and occupational), we use the following:

  • For the High Option Plan we use guides specifically prepared by Context4Healthcare at the 70th percentile.
  • For the Consumer Driven Option we use guides specifically prepared by Fair Health at the 80th percentile.
  • If this information is not available, we will use other credible sources including our own data.

Your rights and responsibilities

OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. 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.

  • 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.

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan.  You can view the complete list of these rights and responsibilities by visiting our website APWU Health Plan, www.apwuhp.com.  You can also contact us to request that we mail a copy to you by calling 800-222-2798, or write to APWU Health Plan, P.O. Box 1358, Glen Burnie, MD  21060-1358.  You may also contact us by fax at 410-424-1564.

By law, you have the right to access your protected health information (PHI).  For more information regarding access to PHI, visit our website APWU Health Plan at www.apwuhp.com to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.




Section 2. Changes for 2022

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Changes to this Plan

Changes to our High Option only

  • Your share of the premium will increase for Self Only, Self Plus One and Self and Family (see page 158).
  • The Plan added a $2,500 maximum per calendar year for infertility drugs (see page 40).
  • The Plan added certain non-Insulin drugs to our Patient Assurance Program (PAP) to treat diabetes with fixed copays - $25 copay for 30 days and $75 copay for 90 days (see page 69).
  • Prior authorization is no longer required for psychological and neuropsychological testing, electroconvulsive therapy, and professional services for intensive outpatient treatment (see page 63).
  • Hypercholesterolemia drugs will no longer be treated as specialty drugs (see Section (f)).
  • The Plan has increased the number of conditions that require authorization and step therapy for prescription drugs (see page 71 for details on these conditions).
  • Preventive migraine medications no longer need to be obtained through Network Mail Order (see Section 5(f)).
  • The plan has added compliancy with the No Surprises Act (NSA), a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances (see page 31).

Changes to our Consumer Driven Health Plan only

  • Your share of the premium will stay the same for Self Only, Self Plus One and Self and Family (see page 158).
  • Your share of the APWU Career premium will decrease for Self Plus One and Self and Family (see page 158).
  • The Plan added a $2,500 maximum per calendar year for infertility drugs (see page 92).
  • The Plan will require prior authorization for hysterectomy, sinuplasty, and functional endoscopic sinus surgery (see page 19).
  • The Plan added a 52-week weight management program called Real Appeal, delivered by a virtual coach (see page 123).
  • The Plan added AbleTo, a customized behavioral health 6-8 week digital treatment program (see page 123).
  • The Plan removed the Source4Women Program (see page 123).
  • The plan has added compliancy with the No Surprises Act (NSA), a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances (see page 31).



Section 3. How You Get Care

TermDefinition

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 electronic enrollment system (such as 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 800-222-2798 (TTY 800-622-2511) or write to us at P.O. Box 1358, Glen Burnie, MD 21060-1358 or through our website at www.apwuhp.comYou may print or request an Identification Card via the Member Portal at www.myAPWUHP.com.
  • Consumer Driven Option:  Call UnitedHealthcare at 800-718-1299 or write to us at P.O. Box 740800, Atlanta, GA 30374-0800 or request replacement cards through the website at www.myuhc.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.

Balance Billing Protection

FEHB Carriers must have clauses in their in-network (participating) providers' agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in-network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, coinsurance) contact your Carrier to enforce the terms of its provider contract.

  • Covered providers

We provide benefits for the services of covered professional providers, as required by Section 2706(a) of the Public Health Service Act.  Coverage of practitioners is not determined by your state's designation as a medically underserved area.

Covered professional providers are medical practitioners who perform covered services when acting within the scope of their license or certification under applicable state law and who furnish, bill, or are paid for their healthcare services in the normal course of business.  Covered services must be provided in the state in which the practitioner is licensed or certified.

This plan recognizes that transsexual, transgender, and gender-nonconforming members require healthcare delivered by healthcare providers experienced in transgender health.  While gender reassignment surgeons (benefit details found in Section 5(b)) and hormone therapy providers (benefit details found in Section 5(f)) play important roles in preventive care, you should see a primary care provider familiar with your overall healthcare needs.  Benefits described in this brochure are available to all members meeting medical necessity guidelines.

  • 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 use disorder treatment. 
  • Hospital
    • An institution which is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Healthcare Organizations, or 
    • 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.
 

  • 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 reasons 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 your PPO benefits will continue until the end of your postpartum care, even if it is beyond the 90 days.

 

  • If you are hospitalized when your enrollment begins

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 800-222-2798.  For the Consumer Driven Option, please call UnitedHealthcare at 800-718-1299.  If you are new to the FEHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage.

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;
  • 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.  If your plan terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply.  In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

You need prior Plan approval for certain services

The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for other services, are detailed in this Section.  A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care or services.  In other words, a pre-service claim for benefits 1) requires precertification or prior approval and 2) will result in a reduction of benefits if you do not obtain precertification or prior approval.

You must get prior approval for certain services.  Failure to do so will result in a minimum $500 penalty for inpatient hospital (High Option and Consumer Driven Option) or $100 for certain outpatient radiology/imaging procedures (for High Option only).

  • Inpatient hospital admission, inpatient residential treatment center admission or skilled nursing facility admission

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 requesting precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician or hospital whether or not they have contacted us.

WarningWe 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 only pay for any covered medical services and supplies that are otherwise payable on an outpatient basis.
Exceptions

You do not need precertification in these cases:

  • You are admitted to a hospital outside the United States and Puerto Rico.
  • You have another group health insurance policy that is the primary payor for the hospital stay.
  • Medicare Part A is the primary payor 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 payor and you do need precertification.
  • Other services

Some services require prior approval.

Under the High Option, call Cigna/CareAllies at 800-582-1314 if you need any of the services listed below:

  • Applied Behavioral Analysis (ABA)
  • Durable medical equipment such as wheelchairs, oxygen equipment and supplies, artificial limbs (prosthetic devices) and braces
  • Gender reassignment surgery
  • Gene Therapy
  • Genetic testing, including BRCA testing (see Definitions, Section 10, page 146)
  • Home healthcare such as nursing visits, infusion therapy, growth hormone therapy (GHT), rehabilitative and habilitative therapy (speech therapy) and pulmonary rehabilitation programs
  • Minimally invasive treatment of back and neck pain.  This requirement applies to both the physician services and the facility.  The following services require prior approval:  epidural steroid injections, facet joint injections, sacroiliac joint injections.
  • Organ transplantation - call before your first evaluation as a potential candidate
  • Procedures which may be cosmetic in nature such as eyelid surgery (blepharoplasty), varicose vein surgery (sclerotherapy), or Botox injections for medical diagnosis
  • Recognized surgery for morbid obesity (bariatric surgery) for organic impotence
  • Residential Treatment Center (RTC)
  • Services and supplies which may be experimental/investigational
  • Skilled Nursing Facilities (SNF)
  • Prior approval for outpatient services at Veterans Administration facilities is not needed 

Under the Consumer Driven Option, call UnitedHealthcare at 800-718-1299 if you need any of the services listed below:

  • Air Ambulance - Non emergent
  • Applied Behavioral Analysis (ABA)
  • Bariatric surgery
  • Clinical Trials
  • Chemotherapy - outpatient
  • Congenital Heart Disease
  • Durable Medical Equipment (including Insulin pumps)
  • Functional endoscopic sinus surgery
  • Gender reassignment surgery
  • Genetic testing
  • Home healthcare - nursing visits, home infusion therapy
  • Hospice - inpatient
  • Hysterectomy
  • Organ transplantation
  • Orthognathic surgery
  • Potential cosmetic procedures
  • Residential Treatment Center (RTC)
  • Services and supplies which may be experimental/investigational
  • Sinuplasty
  • Skilled Nursing Facilities (SNF)
  • Sleep apnea procedures and surgery
  • Therapeutics (outpatient) dialysis, IV infusion, radiation oncology, intensity modulated radiation therapy, MR-guided focused ultrasound
  • Prior approval is required for certain classes of drugs and coverage authorization is required for some medications. This authorization uses Plan rules based on FDA-approved prescribing and safety information, clinical guidelines, and uses that are considered reasonable, safe, and effective. For example, prescription drugs used for cosmetic purposes such as Retin A or Botox may not be covered. Other medications might be limited to a certain amount (such as quantity or dosage) within a specific time period, or require authorization to confirm clinical use based on FDA labeling.  To inquire if your medication requires prior approval or authorization, call Express Scripts Customer Service at 800-841-2734 for the High Option (see Section 5(f), page 71), and Optum Rx at 800-718-1299 for the Consumer Driven Option (see Section 5(f), page 119).
  • Prior approval is also required for mental health and substance use disorder benefits, inpatient, in-network or out-of-network. Prior approval is required for psychological and neuropsychological testing (CDHP Option only), Electroconvulsive therapy (CDHP Option only), Transcranial Magnetic Stimulation (TMS), and services such as partial or full day hospitalization or facility-based intensive outpatient treatment (Cigna Behavioral Health for the High Option and UHC Behavioral Health Solutions for the Consumer Driven Option).  Under the High Option, call Cigna Behavioral Health at 800-582-1314.  Under the Consumer Driven Option, call UHC Behavioral Health Solutions at 800-718-1299.

How to request precertification for an admission or get prior authorization for Other services

  • High Option:  First you, your representative, your physician, or your hospital must call Cigna/CareAllies at 800-582-1314 at least 2 business days before admission or services requiring prior authorization are rendered.  For mental health and substance use disorder inpatient treatment, your physician or your hospital must call Cigna/CareAllies at 800-582-1314 at least 2 business days before admission or services requiring prior authorization.  These numbers are available 24 hours every day.
  • Consumer Driven Option:  First you, your representative, your physician, or your hospital must call UnitedHealthcare at 800-718-1299 at least 2 business days before admission or services requiring prior authorization are rendered. For mental health and substance use disorder inpatient treatment, your doctor or your hospital must call UnitedHealthcare Behavioral Health Solutions at 800-718-1299 at least 2 business days before admission or services requiring prior authorization.  These numbers are available 24 hours every day.
  • If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must telephone the above number at least 2 business days for the High Option and the Consumer Driven Option following the day of the emergency admission, even if you have been discharged from the hospital.
  • Next, 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 physician
    • name of hospital or facility; and
    • number of days requested for hospital stay
  • We will then tell the physician and/or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your physician, and the hospital.

What happens when you do not follow the precertification rules

  • If no one contacts us, we will decide whether the hospital stay was medically necessary.
  • If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty.

If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis for High Option and Consumer Driven Option out-of-network stays.

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 for High Option and Consumer Driven Option out-of-network stays.

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 for High Option and Consumer Driven Option out-of-network services.
  • Radiology/imaging procedures precertification

High Option: Radiology precertification is required prior to scheduling specific imaging procedures. We evaluate the medical necessity of your proposed procedure to ensure that the appropriate procedure is being requested for your condition. In most cases your physician will take care of the precertification. Because you are responsible for ensuring that precertification is done, you should ask your doctor to contact us.

The following outpatient radiology services require precertification:

  • CT/CAT Scan – Computerized Axial Tomography
  • MRI – Magnetic Resonance Imaging
  • MRA – Magnetic Resonance Angiography
  • PET – Positron Emission Tomography
  • How to precertify a radiology/imaging procedure

For these outpatient studies, you, your representative or doctor must call Cigna/CareAllies before scheduling the procedure. The toll free number is 800-582-1314.

  • Provide the following information:
    • patient’s name, Plan identification number, and birth date
    • requested procedure and clinical support for request
    • name and phone number of ordering provider
    • name of requested imaging facility
Warning We will reduce our benefits for these procedures by $100 if no one contacts us for precertification. If the procedure is not medically necessary, we will not pay any benefits.

Exceptions

You do not need precertification in these cases:

  • You have another health insurance policy that is primary including Medicare Parts A&B or Part B Only
  • The procedure is performed outside the United States or Puerto Rico
  • You are an inpatient at a hospital
  • The procedure is performed while in the Emergency Room
  • Non-urgent care claims

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim.

If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

  • Urgent care claims

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours.  If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim.  You will then have up to 48 hours to provide the required information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-222-2798.  You may also call FEHB at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-222-2798.  If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

Concurrent care claims

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.  

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

  • The Federal Flexible Spending Account Program - FSAFEDS
  • Health Care FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26).
  • FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.
  • Emergency inpatient admission

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 physician, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. If you do not telephone the Plan within two business days, penalties may apply - see Warning under Inpatient hospital admissions earlier in this Section and If your hospital stay needs to be extended below.

  • Maternity care

You do not need precertification of 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, your physician or the hospital must contact us for precertification of additional days for your baby.

Note:  When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in their own right.  If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

  • 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 physician or the hospital must ask us to approve the additional days by calling the precertification vendor Cigna/CareAllies at 800-582-1314. If you remain 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.

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 UnitedHealthcare at 800-718-1299. If you remain 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 for out-of-network services only.
  • If your treatment needs to be extended

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you disagree with our pre-service decision

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

  • To reconsider a non-urgent care claim

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

In the case of a pre-service claim and that is subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to:

1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or

2. Ask you or your provider for more information.

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.

3. Write to you and maintain our denial.

  • To reconsider an urgent care claim

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by telephone, electronic mail, facsimile, or other expeditious methods.
  • To file an appeal with OPM
After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.



Section 4. Your Costs for Covered Services

This is what you will pay out-of-pocket for covered care:



TermDefinition

Cost-sharing

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.

Copayment

High Option:  A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: Under the High Option, when you see your PPO physician you pay a copayment of $25 per office visit.

Consumer Driven Option:  There are no copayments under the Consumer Driven Option.

Note: If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full), is less than your copayment, you pay the lower amount.

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 and coinsurance amounts do not count toward any deductible.  When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply counts toward the deductible.

High Option

  • If you use PPO providers, the calendar year deductible is $450 person.  Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $450. Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $800.  Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $800.  If you use non-PPO providers, your calendar year deductible increases to a maximum of $1,000 per person ($2,000 per Self Plus One and Self and Family).  Whether or not you use PPO providers, your calendar year deductible will not exceed $1,000 per person ($2,000 per Self Plus One and Self and Family).

If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full) is less than the remaining portion of your deductible, you pay the lower amount.

Example: If the billed amount is $100, the provider has an agreement with us to accept $80, and you have not paid any amount toward meeting your calendar year deductible, you must pay $80. We will apply $80 to your deductible. We will begin paying benefits once the remaining portion of your calendar year deductible ($450) has been satisfied.

Note: If you change plans during Open Season, and the effective date of your new plan is after January 1 of the next year, you do not have to start a new deductible under your prior 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.

If you change from Self Plus One or Self and Family to Self Only, or from Self Only to Self Plus One or 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:  Your Deductible is the amount of eligible expenses you are required to meet before Traditional Health Coverage begins.  Your plan's deductible is reduced by applying the funds in your Personal Care Account (PCA) which is funded in January by the APWU Health Plan.  Your Net Deductible is the remaining deductible amount you have to pay once the funds in your PCA have been exhausted.  By using the funds in your PCA to pay for eligible medical expenses you decrease your total deductible and out-of-pocket expenses.  Your Net Deductible for in-network providers is generally $1,000 for a Self Only enrollment or $2,000 for a Self Plus One or a Self and Family enrollment.  For Self Plus One or Self and Family coverage, once one individual meets the Self Only Net Deductible of $1,000, Traditional Health Coverage begins for that individual.  Once the other covered members meet the additional $1,000 Net Deductible, Traditional Health Coverage begins for them. If you use out-of-network providers, your calendar year Net Deductible increases to $1,500 Self Only and $3,000 for Self Plus One and Self and Family.  Your Deductible 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).  

In-Network Plan Deductible:
Self Only: $2,200
Self Plus One: $4,400
Self and Family: 4,400

In-Network PCA (APWU HP Funded)
Self Only: $1,200
Self Plus One: $2,400
Self and Family: $2,400

In-Network Net Deductible (You Pay)
Self Only: $1,000
Self Plus One: $2,000
Self and Family: $2,000

Coinsurance

High Option:  Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance does not begin until you have met your calendar year deductible.

Example: You pay 40% of our allowance for office visits to a non-PPO physician.

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 Deductible.

If your provider routinely waives your cost

If your provider routinely waives (does not require you to pay) your copayments, deductibles, or coinsurance, the provider is misstating the fee and may be violating the law. In this case, when we calculate our share, we will reduce the provider’s fee by the amount waived.

For example, if your physician ordinarily charges $100 for a service but routinely waives your 40% coinsurance, the actual charge is $60. We will pay $36 (60% of the actual charge of $60).

Waivers

In some instances, an APWU Health Plan provider may ask you to sign a “waiver” prior to receiving care. This waiver may state that you accept responsibility for the total charge for any care that is not covered by your health plan. If you sign such a waiver, whether or not you are responsible for the total charge depends on the contracts that the Plan has with its providers. If you are asked to sign this type of waiver, please be aware that, if benefits are denied for the services, you could be legally liable for the related expenses. If you would like more information about waivers, please contact us at 800-222-2798.

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 10.

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 -- 15% of our $100 allowance ($15). Because of the agreement, your PPO physician will not bill you for the $50 difference between our allowance and the 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 40% of our $100 allowance ($40). Plus, because there is no agreement between the non-PPO physician and us, the physician can bill you for the $50 difference between our allowance and the bill.

The information below 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 information uses our example of a service for which the physician charges $150 and our allowance is $100. It shows the amount you pay if you have met your calendar year deductible.

EXAMPLE

PPO physician
Physician's charge: $150 
Our allowance: We set it at:  $100 
We pay: 85% of our allowance:  $85
You owe: Coinsurance: 15% of our allowance: $15 
+ Difference up to charge?: No:  0 
TOTAL YOU PAY: $15

Non-PPO physician
Physician's charge: $150 
Our allowance: We set it at:  $100 
We pay: 60% of our allowance:  $60
You owe: Coinsurance: 40% of our allowance: $40 
+ Difference up to charge?: Yes:  $50 
TOTAL YOU PAY: $90

 

 

Consumer Driven Option:

In-network providers agree to accept our Plan allowance so if you use an in-network 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 Deductible and also coinsurance under the Traditional Health Coverage.

Out-of-network providers - If you use an out-of-network 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 in-network 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.

You should also see section Important Notice About Surprise Billing - Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

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

There is a limit to the amount you must pay out-of-pocket for combined medical and prescription drug 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 $6,500 for combined medical and prescription drugs for Self Only enrollment or $13,000 for a Self Plus One or a Self and Family enrollment if you are using PPO providers and in-network pharmacies. Only eligible expenses for PPO providers and in-network pharmacies count toward this limit.

Non-PPO benefit:  Your out-of-pocket maximum is $12,000 for combined medical and prescription drugs for Self Only enrollment, or $24,000 for a Self Plus One or a Self and Family enrollment if you are using non-PPO providers or out-of-network pharmacies. Eligible expenses for network providers or in-network pharmacies also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers.

Note:  For Self Plus One or Self and Family coverage, the maximum out-of-pocket for any individual in the family will not exceed the maximum out-of-pocket for Self Only coverage. When an individual meets the Self Only out-of-pocket maximum, they pay no coinsurance for covered services for the remainder of the calendar year.  Once the other covered members in the family meet the remaining out-of-pocket family maximum, then they pay no coinsurance for covered services for the remainder of the calendar year.

Out-of-pocket expenses for the purposes of this benefit are:

  • The 15% you pay (or the 5% you pay for Cancer Centers of Excellence) for PPO; inpatient medical services and supplies, surgical and anesthesia services, services provided by a hospital or other facility and ambulance services, emergency services/accidents, mental health and substance use disorder treatment; and the medical deductible
  • The 40% you pay for non-PPO; medical services and supplies, surgical and anesthesia services, services provided by a hospital or other facility and ambulance services, mental health and substance use disorder treatment (dental 30%); and the medical deductible
  • The copayment of $25 for outpatient visits to PPO physicians and $15 for virtual visits
  • The copayment of $30 for outpatient facility charges in a PPO Urgent Care Center
  • The 25% you pay for in-network preferred brand name prescription drugs (Tier 2), 45% for in-network non-preferred brand name prescription drugs (Tier 3) and the $10 and $20 you pay for in-network generic prescription drugs (Tier 1), and 25% for generic specialty drugs (Tier 4), 25% for preferred brand name drugs (Tier 5) and 45% non-preferred brand name drugs (Tier 6)

 The following cannot be included in the accumulation of out-of-pocket expenses:

  • Expenses in excess of our allowance or maximum benefit limitations
  • Any amounts you pay because benefits have been reduced for non-compliance with this Plan's cost containment requirements, (see Section 3, pages 18-20)
  • The $300 per admission for non-PPO inpatient hospital charges or skilled nursing facility
  • Expenses in excess of visit maximums for physical, occupational and speech therapy, see pages 41-42, and acupuncture, see page 46
  • Expenses in excess of Hospice care and preventive care maximums
  • The difference in cost when brand name drugs are purchased and a generic is available
  • Drugs reimbursed at the non-network pharmacy level
  • 50% coinsurance for retail drugs after the first two fills if mail order is not used
  • 100% of the cost for targeted drugs if the Plan's step therapy is not followed
  • Any associated costs when you purchase medications in excess of the Plan's dispensing limitations
  • Cost associated with non-covered drugs and supplies

Consumer Driven Option:

If you have exceeded your Personal Care Account and met your Deductible the following would apply:

In-network benefit:  Your out-of-pocket maximum is $6,500 for combined medical and prescription drugs for a Self Only enrollment or $13,000 for a Self Plus One or Self and Family enrollment if you are using in-network providers and pharmacies. Only eligible expenses for network providers and pharmacies count toward this limit.

Out-of-network benefit:  Your out-of-pocket maximum is $12,000 for combined medical and prescription drugs for a Self Only enrollment or $24,000 for a Self Plus One or Self and Family enrollment if you are using out-of-network providers. Eligible expenses for network providers and pharmacies also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers.

Note:  For Self Plus One or Self and Family coverage, the maximum out-of-pocket for any individual in the family will not exceed the maximum out-of-pocket for Self Only coverage. When an individual meets the Self Only out-of-pocket maximum, they pay no coinsurance for covered services for the remainder of the calendar year.  Once the other covered members in the family meet the remaining out-of-pocket family maximum, then they pay no coinsurance for covered services for the remainder of the calendar year.

Out-of-pocket expenses for the purposes of this benefit are:

  • The 15% you pay (or the 10% you pay for Cancer Centers of Excellence) for in-network inpatient and outpatient hospital charges, surgical, medical, virtual visits and emergency services under the Traditional Health Coverage; and the Deductible
  • The 50% you pay for out-of-network inpatient and outpatient hospital charges, surgical, medical, and maternity services under the Traditional Health Coverage; and the Deductible
  • The 25% you pay for in-network Tier 1 and Tier 2 prescription drugs; and 40% for in-network Tier 3 drugs
  • The Personal Care Account (PCA) of $1,200 for Self Only or $2,400 for Self Plus One or Self and Family

The following cannot be included in the accumulation of out-of-pocket expenses:

  • Any expenses paid by the Plan under your in-network Preventive Care benefit
  • Expenses in excess of our allowance or maximum benefit limitations or expenses not covered under the 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 Section 3, pages 18-20)
  • Expenses in excess of Hospice care maximums
  • Drugs purchased at a non-network pharmacy
  • The difference in cost when brand name drugs are purchased and a generic is available
  • Any associated costs when you purchase medications in excess of the Plan's dispensing limitations
  • Cost associated with non-covered drugs and supplies

Carryover

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note:  If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.

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.
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.  You may be responsible to pay for certain services and charges.  Contact the government facility directly for more information.

Important Notice About Surprise Billing - Know Your Rights

The No Surprises Act (NSA) is a federal law that provides you with protections against "surprise billing" and "balance billing" under certain circumstances.  A surprise bill is an unexpected bill you receive from a nonparticipating healthcare provider, facility, or air ambulance service for healthcare.  Surprise bills can happen when you receive emergency care - when you have little or no say in the facility or provider from whom you receive care.  They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from unexpected bills.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.apwuhp.com or contact your health plan at 800-222-2798.




Section 5.  High Option Health Plan Benefits

See page 15 for how our benefits changed this year. Page 150 is a benefits summary of the High Option. Make sure that you review the benefits that are available under the option in which you are enrolled.




(Page numbers solely appear in the printed brochure)




High Option Overview (High Option)

The Plan offers a High Option, described in this section. Make sure that you review the benefits that are available under the benefit program in which you are enrolled.

The High Option Section 5 is divided into subsections. Please read Important things you should keep in mind at the beginning of each subsection. Also read the  general exclusions in Section 6; they apply to the benefits in the following subsections.  To obtain claim forms, claims filing advice, or more information about the High Option benefits, contact us at 800-222-2798 or on our website at www.apwuhp.com.

The APWU Health Plan’s High Option provides a wide range of comprehensive benefits for preventive services, doctors’ visits and services, care in a hospital, laboratory tests and procedures, accidental and emergency services, mental health and substance use disorder treatment and prescription drugs. We have extensive networks of preferred providers for both medical and mental health services to help lower your costs, but you may use any provider you wish, in or out of our networks.

The High Option includes:

Preventive care

The Plan emphasizes prevention by providing an extensive range of preventive benefits to help members stay well. We include 100% coverage for an array of in-network preventive tests and screenings, routine physical exams, and a Tobacco Cessation program to stop smoking. To keep children well, we have 100% coverage for recommended immunizations, physical exams and laboratory tests for children.  We emphasize women's wellness with our Well Woman benefit that provides 100% coverage for a full range of in-network preventive services, preventive tests and screenings, counseling services and generic and single source brand FDA approved prescription contraceptives.

Medical and Surgical services

The Plan provides coverage for doctors’ visits and surgical services and supplies. You pay only a flat copayment for office visits to a network physician, including visits for chiropractic and acupuncture treatment. In-network maternity care is covered 100%, including breastfeeding support.  Mental health and substance use disorder treatment has the same comprehensive coverage as is provided for medical care.

Hospitalization and Emergency care

We offer extensive benefits for hospital and other inpatient healthcare services. There is no deductible or per admission charge for in-network hospital care. You also receive 100% coverage for unexpected outpatient care when you need it most with the Plan’s Accidental Injury benefit.

Prescription drugs

Our prescription drug program offers prescription savings with no deductible and low copayments for (Tier 1) generic drugs. The prescription drug program is easy to use, with a huge network of pharmacies and a mail order service where medications are delivered right to your door. The Plan’s prescription drug program provides savings and convenience for generic and brand name drugs, and you never have to file a claim.

Special features

Obtaining help from a medical professional is quick, confidential, and free with the Plan’s voluntary Nurse Advisory Line, available 24/7 anywhere in the country. Our voluntary Disease and Weight Management programs offer some $0 copays and coinsurance for members with these conditions.  Online access to claims information and customer service is available through  www.myAPWUHP.com.  We help members navigate the healthcare system with an online Preferred Provider Organization (PPO) directory, Hospital Quality Ratings Guide, Treatment Cost Estimator, and prescription drug information.  We also offer online consumer health information and non-FEHB savings on health and wellness products, and a CignaPlus Savings dental discount card when a Health Risk Assessment is completed.

We also offer the UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan for High Option retiree/annuitants with primary Medicare Part A and B.  Membership is voluntary and members may opt-in or out of this plan at any time. Members have access to a nationwide PPO network and may seek care within the network or out-of-network. Members that join will have access to certain benefit enhancements that are noted on page 139.




Section 5 (a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals (High Option)

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 - $450 per person ($800 per Self Plus One enrollment, or $800 per Self and Family enrollment); non-PPO - $1,000 per person ($2,000 per Self Plus One enrollment, or $2,000 per Self and Family enrollment). 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.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
  • YOU MUST GET PRECERTIFICATION FOR CERTAIN OUTPATIENT IMAGING PROCEDURES. FAILURE TO DO SO WILL RESULT IN A MINIMUM OF A $100 PENALTY. Please refer to precertification information in Section 3 to be sure which procedures require precertification.
  • If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our FEHB members.  This plan enhances your FEHB coverage by reducing/eliminating cost-sharing for services and/or adding benefits at no additional cost.  This would be an enhancement to your APWU Health Plan's High Option benefits.  It includes a $50 monthly Part B reimbursement.  The UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.  (See Section 9 for additional details.)



Benefit Description : Diagnostic and treatment services High Option (You Pay After the calendar year deductible...)

Professional services of physicians

  • In physician’s office

PPO: $25 copayment (No deductible)

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

Professional services of physicians

  • During a hospital stay
  • In a skilled nursing facility
  • Second surgical opinion
  • At home

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

  • At Cancer Centers of Excellence

Note:  To receive the higher level of benefits for cancer related treatment, you are required to visit a designated Cancer Center of Excellence facility.

PPO Cancer Center of Excellence (COE):  5% of the Plan allowance

Benefit Description : TeleHealth ServicesHigh Option (You Pay After the calendar year deductible...)
  • Virtual visits are available through AmWell

You can receive treatment from board-certified doctors for your non-emergency conditions such as the flu, strep throat, eye infections, bronchitis, and much more.  Covered services include visits through the web or your mobile device to obtain a consultation, diagnosis and prescriptions (when appropriate).  The service is available 24 hours a day, 7 days a week.

Note:  Telehealth services are available in most states, but some states do not allow telehealth or prescriptions per state regulations.

Please see www.AmWell.com, or call 855-818-DOCS for information on virtual visits

Note:  There are no out-of-network benefits for Virtual visits.

AmWell:  $15 copayment (No deductible)

PPO:  $25 copayment (No deductible)

Non-PPO:  N/A

Benefit Description : Lab, X-ray and other diagnostic testsHigh Option (You Pay After the calendar year deductible...)

Tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine Pap test
  • Pathology
  • X-ray
  • Non-routine mammogram, including 3D mammogram
  • CT/CAT Scan/MRI/MRA/NC/PET (Outpatient requires precertification – see Section 3, except for NC)
  • Ultrasound
  • Electrocardiogram and EEG

PPO: 15% of the Plan allowance

Non-PPO: 40% 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 lab and X-ray charges billed by these non-PPO providers.

If LabCorp or Quest Diagnostics performs your covered lab services, you will have no out-of-pocket expense and you will not have to file a claim.  To find a location near you, in all states, call Cigna at 800-582-1314; or visit our website at www.apwuhp.com.

Note:  Not available in the U.S. Virgin Islands.

Nothing (No deductible)

 Not covered:

  • Professional fees for automated lab tests
  • Genetic screening (see Definition, Section 10)
  • Qualitative (definitive) urine drug panel testing that is not medically necessary

All charges

Benefit Description : Preventive care, adultHigh Option (You Pay After the calendar year deductible...)

Routine physical every calendar year.

The following preventive services are covered at the time interval recommended at each of the links below:

  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV).  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at:  https://www.cdc.gov/vaccines/schedules/
  • Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening.  For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at: https://www.uspreventiveservicestaskforce.org
  • Individual counseling on prevention and reducing health risks
  • Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence.  For a complete list of Well Women preventive care services go to the Health and Human Services (HHS) website at: https://www.healthcare.gov/preventive-care-women/
  • Routine Prostate Specific Antigen (PSA) test, one annually for men age 40 and older
  • Urinalysis
  • Routine Electrocardiogram (EKG)
  • Chest X-ray
  • Hemoglobin A1C, age 18 and above
  • At home Colorectal Cancer Screening Cologuard Kit provided through Exact Sciences Laboratories, every three years starting at age 50, prescription needed from physician

PPO: Nothing (No deductible)

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

  • Routine mammogram - covered for women, including 3D mammograms covered for women age 35 and older; as follows:
    • From age 35 through 39, one during this five year period
    • From age 40, one every calendar year
  • To build your personalized list of preventive services go to https://health.gov/myhealthfinder 

PPO: Nothing (No deductible)

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

  • Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC):  based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Note:  For immunizations at a network pharmacy, (see Section 5(f), Prescription drug benefits).

Note:  Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

PPO:  Nothing (No deductible)

Non-PPO:  40% of the Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Preventive care, childrenHigh Option (You Pay After the calendar year deductible...)
  • Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics.  For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to: https://brightfutures.aap.org
  • Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella.  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at: https://www.cdc.gov/vaccines/schedules/index.html
  • You may also find a complete list of preventive care services recommended under the U.S. Preventive Services Task force (USPSTF) online at: https://www.uspreventiveservicestaskforce.org

PPO: Nothing (No deductible)

Non-PPO: Any difference between the Plan allowance and the billed charge (No deductible)
  • Examinations, limited to:
    • Examinations for amblyopia and strabismus - limited to one screening examination (ages 3 through 5)
    • Examinations done on the day of immunizations (ages 3 through 21)
    • One Screening Examination of Premature Infants for Retinopathy of Prematurity or infants with low birth weight or gestational age of 32 weeks or less 
  • To build your personalized list of preventive services go to https://health.gov/myhealthfinder 

Note: In-network facility and lab services directly related to covered, in-network preventive care will also be covered at 100%.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and 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 18) each year (No deductible)

Not covered:

  • Adult immunizations not endorsed by the CDC
  • Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel
  • Immunizations, boosters, and medications for travel or work-related exposure

All charges

Benefit Description : Maternity careHigh Option (You Pay After the calendar year deductible...)

Complete maternity (obstetrical) care, such as:

  • Screening for gestational diabetes for pregnant women
  • Prenatal care
  • Delivery
  • Postnatal care
  • Initial examination of a newborn child covered under a Self Plus One or Self and Family enrollment
  • Breastfeeding support, supplies and counseling for each birth

Note: Maternity care expenses incurred by a Plan member serving as a surrogate mother are covered by the Plan subject to reimbursement from the other party to the surrogacy contract or agreement.  The involved Plan member must execute our Reimbursement Agreement completed by APWU Health Plan against any payment they may receive under the surrogacy contract or agreement.  Expenses of the newborn child are not covered under this or any other benefit in a surrogate mother situation.

Note:  Here are some things to keep in mind:

  • You do not need to precertify your vaginal or cesarean delivery; see page 23 for other circumstances, such as extended stays for you or your baby.
  • You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery.
  • We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay.
  • We pay hospitalization and surgeon services for non-maternity care, as well as covering an extended stay, if medically necessary, the same as for illness and injury.
  • Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note:  When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in their own right.  If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

Note:  To obtain the in-network, breastfeeding equipment and supplies, please call 877-466-0164 after 28 weeks of pregnancy.  A physician's order is required.

PPO:  Nothing (No deductible)

Non-PPO:  40% of the Plan allowance and any difference between our allowance and the billed amount

 

Note:  For inpatient hospital care related to maternity, we pay for covered services in full when you use preferred providers.

Note:  In-network facility and lab services directly related to covered, in-network maternity care will also be covered at 100%.

Note:  For Non-PPO inpatient hospital, a $300 per admission fee applies.

  • We will cover other care of an infant who requires non-routine treatment if we cover the infant under a Self Plus One or Self and Family enrollment.  Surgical benefits, not maternity benefits, apply to circumcision of a covered newborn.

PPO:  15% of the Plan allowance

Non-PPO:  40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Amniocentesis if for diagnosing multiple births
  • Genetic screening (see Definitions, Section 10, page 146)

All charges

Benefit Description : Family PlanningHigh Option (You Pay After the calendar year deductible...)

A range of voluntary family planning services, limited to:

  • Contraceptive counseling for women
  • Voluntary sterilization for women, (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 and devices under Section 5(f), Prescription drug benefits, page 69.  

PPO: Nothing (No deductible)

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

  • Voluntary sterilization for men, (see Surgical procedures, Section 5(b))

PPO:  15% of the Plan allowance

Non-PPO:  40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Reversal of voluntary surgical sterilization
  • Genetic testing and counseling

All charges

Benefit Description : Infertility servicesHigh Option (You Pay After the calendar year deductible...)
  • Diagnosis and treatment of infertility, except as shown in Not covered

Limited benefits:  We pay a maximum of $2,500 for medical and $2,500 for prescription drugs each calendar year per person to diagnose and treat infertility.  See Section 5(f) for prescription drugs.

PPO: 15% of the Plan allowance and all charges after we pay $2,500 in a calendar year

Non-PPO: 40% of the Plan allowance and all charges after we pay $2,500 in a calendar year

Not covered:

  • Infertility services after voluntary sterilization
  • Assisted reproductive technology (ART) procedures, such as:
    • Artificial insemination (all procedures) (AI)
    • In vitro fertilization (IVF)
    • Embryo transfer and gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
    • 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
Benefit Description : Allergy careHigh Option (You Pay After the calendar year deductible...)
  • Testing and treatment, including materials (such as allergy serum)
  • Allergy injections

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Provocative food testing
  • Sublingual allergy desensitization
All charges
Benefit Description : Treatment therapiesHigh Option (You Pay After the calendar year deductible...)
  • Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on pages 51-53.

  • Dialysis – hemodialysis and peritoneal dialysis
  • Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy - preauthorization is required, (see Other services, Section 3, page 18)
  • Specialty drugs administered on an outpatient basis

Note:  For Specialty drugs, you or your prescriber must contact Accredo at 844-581-4862 to ask if a specialty medication you are receiving from the physician's office or outpatient setting must be obtained through Accredo Specialty Pharmacy.  If the drugs are obtained through Accredo Specialty Pharmacy, they will be paid at the in-network prescription drug benefit, (see Section 5(f), Prescription drug benefits, page 69).  If your specialty medication is available through Accredo Specialty Pharmacy and you do not obtain your medication through Accredo Specialty Pharmacy, you will be responsible for the full cost of your medication.

  • Respiratory and inhalation therapies
  • Cardiac rehabilitation following qualifying event/condition

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

  • Gene Therapy:  Curative gene therapy for rare genetic conditions

Note: Preauthorization of gene therapy is required, (see Other services, Section 3, page 18)

PPO: 15% of the Plan allowance

NON PPO: All charges

Benefit Description : Physical and occupational therapies High Option (You Pay After the calendar year deductible...)

Physical therapy and occupational therapy provided by a licensed registered therapist or physician up to a combined 60 visits per calendar year

Note:  We also have the right to deny any type of therapy, service or supply for the treatment of a condition which ceases to be therapeutic treatment and is instead administered to maintain a level of functioning or to prevent a medical problem from occurring or recurring.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Maintenance therapies
  • Exercise programs
All charges
Benefit Description : Applied behavioral analysis (ABA)High Option (You Pay After the calendar year deductible...)

Outpatient Applied Behavioral Analysis (ABA) services, for the treatment of Autism Spectrum Disorder. Services must be provided under the supervision of a Board Certified Behavior Analyst who is contracted with Cigna Behavioral Health, or agrees to participate with Cigna Behavioral Health's care management activities. (Preauthorization required by Cigna Behavioral Health)

Note: Cigna Behavioral Health Options' review of ABA services is based on an intensive care management model that monitors treatment plans, objectives, and progress milestones.

We have the right to deny services for treatment when outcomes do not meet the defined treatment plan objectives and milestones.

PPO:  15% of the Plan allowance

Non-PPO:  All charges

Benefit Description : Speech therapy High Option (You Pay After the calendar year deductible...)

Speech therapy where medically necessary and provided by a licensed therapist

Note: Preauthorization of speech therapy is required, (see Other services, Section 3, page 18). 

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

Note: We also have the right to deny any type of therapy, service or supply for the treatment of a condition which ceases to be therapeutic treatment and is instead administered to maintain a level of functioning or to prevent a medical problem from occurring or recurring.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Hearing services (testing, treatment, and supplies)High Option (You Pay After the calendar year deductible...)
  • For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist
  • One examination and testing for hearing aids every 2 years

Note:  For routine hearing screening performed during a child's preventive care visit, (see Section 5(a), Preventive care, children, page 38).

 

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

  • External hearing aids
  • Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Note:  For benefits for the devices see Section 5(a), Orthopedic and prosthetic devices, see page 43.

Not covered:

  • Hearing services that are not shown as covered
All charges
Benefit Description : Vision services (testing, treatment, and supplies)High Option (You Pay After the calendar year deductible...)
  • 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 Section 5(a), Preventive care, children, page 38 for eye exams for children.

PPO: 15% of the Plan allowance

Non-PPO: 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
  • Eye exercises and visual training
  • Radial keratotomy and other refractive surgery
  • Refraction
All charges
Benefit Description : Foot care High Option (You Pay After the calendar year deductible...)

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

PPO: $25 copayment for the office visit (No deductible) plus 15% of the Plan allowance for other services performed during the visit

Non-PPO: 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
Benefit Description : Orthopedic and prosthetic devices High Option (You Pay After the calendar year deductible...)
  • Artificial limbs and eyes
  • Prosthetic sleeve or sock
  • Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
  • Leg, arm, neck, joint and back braces
  • Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
  • Internal prosthetic devices, and surgically implanted breast implant following mastectomy 

Note:  We recommend preauthorization of orthopedic and prosthetic devices, (see Other services, Section 3, page 18).

Note:  We require preauthorization of artificial limbs, (see Other services, Section 3, page 18).

Note:  For information on the professional charges for the surgery to insert an implant, see Section 5(b), Surgical procedures.  For information on the hospital and/or ambulatory surgery center benefits see Section 5(c), Services provided by a hospital or other facility, and ambulance services.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

External hearing aids

  • Covered every 3 years limited to $1,500

Note:  Excluding batteries, benefits for hearing aid dispensing fees, accessories, supplies, and repair service are included in the benefit limit described above.

PPO: All charges in excess of $1,500, up to the PPO allowance  (No deductible)

Non-PPO: All charges in excess of $1,500 (No deductible)

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
Benefit Description : Durable medical equipment (DME)High Option (You Pay After the calendar year deductible...)

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, of durable medical equipment, at our option, including repair and adjustment. Covered items include but are not limited to:

  • Oxygen
  • Dialysis equipment
  • Hospital beds
  • Wheelchairs (standard and electric)
  • Ostomy supplies (including supplies purchased at a pharmacy)
  • Crutches
  • Walkers

Note: Preauthorization of durable medical equipment is required, (see Other services, Section 3, page 18).

Note: We will pay only for the cost of the standard item. Coverage for specialty equipment, such as all-terrain wheelchairs, is limited to the cost of the standard equipment.

Note:  We limit the Plan allowance for DME rental benefit to an amount no greater than what we would have considered if the equipment had been purchased.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

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
Benefit Description : Home health servicesHigh Option (You Pay After the calendar year deductible...)

Services for skilled nursing care up to 25 visits per calendar year, not to exceed two hours 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 (see Other services, Section 3, page 18).

PPO: 15%; all charges in excess of two hours

Non-PPO: 40%; all charges in excess of two hours

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, rehabilitative, or habilitative
  • Nursing services without preauthorization
  • Services of nurses' aides or home health aides
  • All charges in excess of two hours
All charges
Benefit Description : Chiropractic High Option (You Pay After the calendar year deductible...)

Chiropractic treatment limited to 24 visits and/or manipulations per year

Note:  X-ray covered under Lab, X-ray and other diagnostic tests, page 36.

PPO: $25 copayment (No deductible)

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount.

Not covered:

  • Massage therapy
  • Maintenance therapy

All charges

Benefit Description : Alternative treatmentsHigh Option (You Pay After the calendar year deductible...)

Acupuncture – by a doctor of medicine or osteopathy or licensed acupuncturist, benefits are limited to 26 visits per person per calendar year

PPO: $25 copayment (No deductible)

Non-PPO: 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, Section 3, page 16)
All charges
Benefit Description : Educational classes and programsHigh Option (You Pay After the calendar year deductible...)

If you are an APWU Health Plan member, you may enroll in a Tobacco Cessation program as follows:

  • Telephonic counseling sessions with Cigna/CareAllies or;
  • Group therapy sessions or;
  • Educational sessions with a physician

Note:  Enrollment in the Cigna/CareAllies program must be initiated by member after effective date of Health Plan enrollment.  For more information contact Cigna/CareAllies at 800-582-1314.

PPO:  Nothing (No deductible)

Non-PPO:  40% of the Plan allowance and any difference between our allowance and the billed amount

Select over-the-counter and prescription Tobacco Cessation medications approved by the FDA to treat tobacco dependence.

To qualify for these drugs, you need to be age 18 or older; get a prescription for these products from your doctor, even if the products are sold over-the-counter; fill the prescription at a network pharmacy.

PPO:  Nothing (No deductible)

Non-PPO:  All charges

 

Childhood obesity education

PPO:  Nothing (No deductible)

Non-PPO:  40% of the Plan allowance and any difference between our allowance and the billed amount

Diabetes self-management training services, up to 10 hours initial training the first year and 2 hours subsequent training annually.

PPO:  15% of the Plan allowance

Non-PPO:  40% of the Plan allowance and any difference between our allowance and the billed amount




Section 5 (b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals (High Option)

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 - $450 per person ($800 per Self Plus One enrollment, or $800 per Self and Family enrollment); Non-PPO - $1,000 per person ($2,000 per Self Plus One enrollment, or $2,000 per Self and Family enrollment). 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.

  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.

  • YOU MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification.

  • If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our FEHB members.  This plan enhances your FEHB coverage by reducing/eliminating cost-sharing for services and/or adding benefits at no additional cost.  This would be an enhancement to your APWU Health Plan's High Option benefits.  It includes a $50 monthly Part B reimbursement.  The UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.  (See Section 9 for additional details.)



Benefit Description : Surgical proceduresHigh Option (You Pay After the calendar year deductible…)

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
  • Removal of tumors and cysts
  • Correction of congenital anomalies (see Reconstructive  surgery)
  • Surgical treatment of morbid obesity (bariatric surgery) requires preauthorization (see Other services, Section 3, page 18)
  • Insertion of internal prosthetic devices (see Section 5(a), Orthopedic and prosthetic devices, page 43, for device coverage information)
  • Voluntary sterilization for men (e.g., Vasectomy)
  • Treatment of burns
  • Assistant surgeons - We cover up to 20% of our allowance for the surgeon’s charge
  • Surgical treatment of gender dysphoria such as surgical change of sex characteristics.  For female to male surgery: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, and placement of testicular and erectile prosthesis.  For male to female surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, labiaplasty
    • Benefits are limited to once per covered procedure, per lifetime
    • Benefits are not available for repeat or revision procedure when benefits were provided for initial procedure

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

  • Voluntary sterilization for women (e.g. Tubal ligation)
  • Surgical implanted contraceptives
  • Intrauterine devices (IUDs)

PPO:  Nothing (No deductible)

Non-PPO:  40% of the Plan allowance and any difference between our allowance and the billed amount

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: 85% of the Plan allowance; or
    • Non-PPO: 60% of the Plan allowance
  • For the secondary procedure(s):
    • PPO: 85% of one-half of the Plan allowance or
    • Non-PPO: 60% of one-half of the Plan allowance

Note: When multiple or bilateral surgical procedures add complexity to an operative session, the Plan allowance for the second or less expensive procedure is one-half of what the Plan allowance would have been if that procedure had been performed independently.

  • When a surgery requires two primary surgeons (co-surgeons), the Plan allowance for each surgeon will not exceed 62.5% of our allowance.  This allowance will be further reduced by half for secondary procedures.
  • 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: 15% of the Plan allowance for the primary procedure and 15% of one-half of the Plan allowance for the secondary procedure(s)

Non-PPO: 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 allowance 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
  • Routine treatment of conditions of the foot (see Foot care, Section 5(a), page 43)
All charges
Benefit Description : Reconstructive surgery High Option (You Pay After the calendar year deductible…)
  • 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 of breasts
    • Treatment of any physical complications, such as lymphedema
    • Breast prostheses; and surgical bras and replacements, (see Section 5(a), Prosthetic devices, page 43, for coverage)

Note: We pay for internal breast prostheses as hospital benefits.

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

  • Gender reassignment surgery benefits are only available for the diagnosis of gender dysphoria         

Requirements:

  1. Prior approval is required
  2. Must be at least 18 years of age at time prior approval is requested and treatment plan is submitted
  3. Must have diagnosis of gender dysphoria by a qualified healthcare professional
  4. New gender identity has been present for at least 24 continuous months
  5. Member has a strong desire to be rid of primary and/or secondary sex characteristics because of a marked incongruence with the member’s identified gender
  6. Member’s gender dysphoria is not a symptom of another mental disorder or chromosomal abnormality
  7. Gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning
  8. 12 months of continuous hormone therapy appropriate to the member's gender identity
  9. Two referral letters from qualified mental health professionals, one of them being a psychiatrist or clinical psychologist (PhD). One must be from the psychotherapist who has treated the member for at least 12 continuous months. Letters must document: diagnosis of persistent and chronic gender dysphoria; any existing co-morbid conditions are stable; member is prepared to undergo surgery and understands all practical aspects of the planned surgery
  10. If medical or mental health concerns are present, they are being optimally managed and are reasonably well-controlled

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury if repair is initiated within two years of the accident
All charges
Benefit Description : Oral and maxillofacial surgeryHigh Option (You Pay After the calendar year deductible…)

Oral surgical procedures, limited to:

  • Reduction of fractures of the jaw or facial bones
  • Surgical correction of cleft lip, cleft palate 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 800-222-2798 to determine whether a procedure is covered.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Oral implants and transplants
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva and alveolar bone)
  • Dental bridges, replacement of natural teeth, dental/orthodontic/temporomandibular joint dysfunction appliances and any related expenses
  • Treatment of periodontal disease and gingival tissues, and abscesses
  • Charges related to orthodontic treatment
All charges
Benefit Description : Organ/tissue transplantsHigh Option (You Pay After the calendar year deductible…)

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan.  Refer to Other services in Section 3, page 18, for prior authorization procedures. 

Solid organ transplants are limited to:

  • Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
  • Cornea
  • Heart
  • Heart/lung
  • Intestinal transplants
    • Isolated small intestine
    • Small intestine with the liver
    • Small intestine with multiple organs, such as the liver, stomach, and pancreas
  • Kidney
  • Kidney-pancreas
  • Liver
  • Lung single/bilateral/lobar
  • Pancreas

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $50,000 for kidney transplants or $100,000 for other listed transplants

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan.  Refer to Other services in Section 3, page 18, for prior authorization procedures.

  • Autologous tandem transplants for
    • AL Amyloidosis
    • Multiple myeloma (de novo and treated)
    • Recurrent germ cell tumors (including testicular cancer)

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $50,000 for kidney transplants or $100,000 for other listed transplants

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below:

  • Allogeneic transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Acute myeloid leukemia
    • Advanced Hodgkin's lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced Myeloproliferative Disorders (MPDs)
    • Advanced neuroblastoma
    • Amyloidosis
    • Beta Thalassemia Major
    • Chronic inflammatory demyelination polyneuropathy (CIDP)
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Hemoglobinopathy
    • Infantile malignant osteopetrosis
    • Kostmann's syndrome
    • Leukocyte adhesion deficiencies
    • Marrow failure and related disorders (i.e., Fanconi's Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia) 
    • Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
    • Mucopolysaccharidosis (e.g., Hunter's syndrome, Hurler's syndrome, Sanfillippo's syndrome, Maroteaux-Lamy syndrome variants)
    • Multiple Myeloma
    • Myelodysplasia/Myelodysplastic Syndromes 
    • Myeloproliferative disorders
    • Paroxysmal Nocturnal Hemoglobinuria
    • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
    • Sickle cell anemia (pediatric only)
    • X-linked lymphoproliferative syndrome
  • Autologous transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced childhood kidney cancers
    • Advanced Hodgkin's lymphoma with recurrence (relapsed) 
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Aggressive non-Hodgkin's lymphomas
    • Breast cancer
    • Childhood rhabdomyosarcoma
    • Ependymoblastoma
    • Epithelial ovarian cancer
    • Ewing's sarcoma
    • Mantle cell (non-Hodgkin's lymphoma)
    • Medulloblastoma
    • Multiple myeloma
    • Neuroblastoma
    • Pineoblastoma
    • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors
    • Waldenstrom's macroglobulinemia

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $50,000 for kidney transplants or $100,000 for other listed transplants

Mini-transplants (non-myeloablative, reduced intensity conditioning or RIC) are subject to medical necessity review by the Plan.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $50,000 for kidney transplants or $100,000 for other listed transplants

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient's condition) if it is not provided by the clinical trial.  Section 9 has additional information on costs related to clinical trials.  We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $50,000 for kidney transplants or $100,000 for other listed transplants

Transplant Network  

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 the precertification vendor (see Other services, Section 3); Cigna at 1-800-668-9682; and ask to speak to a Transplant Case Manager. You will be provided with information about transplant preferred providers. If you choose a Plan-designated transplant facility, you may receive prior approval for travel and lodging costs.

Limited Benefits – If you don’t use a Plan-designated transplant facility, benefits for pretransplant evaluation, organ procurement, inpatient hospital, surgical and medical expenses for covered transplants, whether incurred by the recipient or donor, are limited to a maximum of $50,000 for kidney transplants or $100,000 for each other listed transplant, including multiple organ transplants.

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

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $50,000 for kidney transplants or $100,000 for other listed transplants

Not covered:

  • Donor screening tests and donor search expenses, except as shown above
  • Transplants not listed as covered
All charges
Benefit Description : AnesthesiaHigh Option (You Pay After the calendar year deductible…)

Professional services for administration of anesthesia

Note: If surgical services are rendered at a PPO hospital or a PPO freestanding ambulatory facility, we will pay the services of non-PPO anesthesiologists at the PPO rate, based on Plan allowance.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount




Section 5 (c). Services Provided by a Hospital or Other Facility, and Ambulance Services (High Option)

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 this Section, unlike Sections 5(a) and 5(b), the calendar year deductible applies to only a few benefits. We added “(calendar year deductible applies).” The calendar year deductible is: PPO - $450 per person ($800 per Self Plus One enrollment, or $800 per Self and Family enrollment); Non-PPO - $1,000 per person ($2,000 per Self Plus One enrollment, or $2,000 per Self and Family enrollment).
  • 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. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over. 
  • The services 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 FOR 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.
  • You must get prior approval for gender reassignment surgery.  See page 18 for prior approval and pages 49-50 for the surgical benefit.
  • When you receive hospital observation services, we apply outpatient benefits to covered services up to 48 hours.  Inpatient benefits will apply only when your physician formally admits you to the hospital as inpatient.
  • If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our FEHB members.  This plan enhances your FEHB coverage by reducing/eliminating cost-sharing for services and/or adding benefits at no additional cost.  This would be an enhancement to your APWU Health Plan's High Option benefits.  It includes a $50 monthly Part B reimbursement.  The UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.  (See Section 9 for additional details.)



Benefit Description : Inpatient hospitalHigh Option (You Pay)

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 will cover the private room rate.

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: 15% of the covered charges

Non-PPO: $300 per admission and 40% of the covered charges and any difference between our allowance and the billed amount

Note:  For inpatient hospital care related to maternity, we pay for covered services in full when you use preferred providers, (see Section 5(a), Maternity care, page 39.)

Other hospital services and supplies, such as:

  • Operating, recovery, maternity, and other treatment rooms
  • Prescribed drugs and medications
  • 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 healthcare 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.

PPO: 15% of the covered charges

Non-PPO: $300 per admission and 40% of the covered charges and any difference between our allowance and the billed amount.

Note:  For inpatient hospital care related to maternity, we pay for covered services in full when you use preferred providers, (see Section 5(a), Maternity care, page 39.)

Not covered:

  • Any part of a hospital admission that is not medically necessary (see Section 10, Definitions, page 145), 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 Section 10, Definitions, page 145)
  • Non-covered facilities, such as, 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
Benefit Description : Cancer Centers of ExcellenceHigh Option (You Pay)

The Plan provides access to designated Cancer Centers of Excellence.  For information, you must contact Cigna/CareAllies at 800-582-1314 prior to obtaining covered services.  To receive the higher level of benefits for a cancer related treatment, you are required to visit a designated facility.

When you contact Cigna/CareAllies, you will be provided with information about the Cancer Centers of Excellence.

PPO Cancer Centers of Excellence (COE): 5% of the Plan allowance

Benefit Description : Outpatient hospital or ambulatory surgical centerHigh Option (You Pay)
  • Operating, recovery, and other treatment rooms
  • Prescribed drugs and medications
  • 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 an underlying medical condition.  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: 15% of the Plan allowance (calendar year deductible applies)

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

Benefit Description : Extended care benefits/Skilled nursing care facility benefitsHigh Option (You Pay)

When APWU Health Plan is Primary

Semiprivate room, board, services and supplies provided in a skilled nursing care facility (SNF) for up to 30 days per person per calendar year when you are admitted directly from a covered inpatient hospital stay.

Note: Prior approval for these services is required.  Call CareAllies at 800-582-1314, (see Other services, Section 3, page 18).

When Medicare A or Other Insurance is Primary

Semiprivate room, board, services and supplies provided in a skilled nursing care facility (SNF) for up to 30 days per person per calendar year when you are admitted directly from a covered inpatient hospital stay.

Note: If Medicare pays the first 20 days in full, Plan benefits will begin on the 21st day (when Medicare Part A coinsurance begins) and will end on the 30th day.

PPO:  15% of the covered charges

Non-PPO:  $300 per admission and 40% of the covered charges and any difference between our allowance and the billed amount

Note:  If enrolled in Medicare A, we waive the deductible and coinsurance.

Not covered:

  • Custodial care (see Section 10, Definitions, page 145)
  • All charges after 30 days per person per calendar year

All charges

Benefit Description : Hospice careHigh Option (You Pay)

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 up to $15,000 lifetime maximum for combined outpatient and inpatient services, which includes advance care planning

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

Any amount over the maximums shown

Benefit Description : End of life careHigh Option (You Pay)

End of life care

  • See Hospice care benefit, which includes advance care planning, (see above).

Any amount over the maximums shown

Benefit Description : AmbulanceHigh Option (You Pay)
  • Local professional ambulance service when medically appropriate immediately before, during or after an inpatient admission

PPO: 15% of the Plan allowance

Non-PPO: 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



Section 5 (d).  Emergency Services/Accidents (High Option)

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 calendar year deductible is: PPO - $450 per person ($800 per Self Plus One enrollment, or $800 per Self and Family enrollment); Non-PPO - $1,000 per person ($2,000 per Self Plus One enrollment, or $2,000 per Self and Family enrollment). 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 for emergency services, the emergency room physician who provides the services to you in the emergency room may not be a preferred provider.  If they are not, they will be paid by this Plan as a PPO provider at the PPO rate, based on the Plan allowance.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
  • If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our FEHB members.  This plan enhances your FEHB coverage by reducing/eliminating cost-sharing for services and/or adding benefits at no additional cost.  This would be an enhancement to your APWU Health Plan's High Option benefits.  It includes a $50 monthly Part B reimbursement.  The UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.  (See Section 9 for additional details.)



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 800-582-1314, option 7, or your physician. 

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




Benefit Description : Accidental injuryHigh Option (You Pay After the calendar year deductible…)

If you receive care for your accidental injury within 72 hours, we cover:

  • Physician services and supplies
  • Related outpatient hospital services
  • Air ambulance to nearest facility where necessary treatment is available is covered if no emergency ground transportation is available or suitable and the patient's condition warrants immediate evacuation.  Air ambulance will not be covered if transport is beyond the nearest available suitable facility, but is requested by patient or physician for continuity of care or other reasons

Note: See Section 5(c), pages 55-56, for hospital benefits if you are admitted.  Services received after 72 hours are considered the same as any other illness and regular Plan benefits will apply.

PPO: Nothing (No deductible)

Non-PPO: Nothing (No deductible)

If you receive care for your accidental injury within 72 hours, we cover:

  • Professional Ambulance Services

PPO: Nothing

Non-PPO: Only the difference between our allowance and the billed amount (No deductible)

Benefit Description : Medical emergencyHigh Option (You Pay After the calendar year deductible…)

Outpatient facility charges including medical or surgical services and supplies in an Urgent Care Center

Note:  High technology radiology/imaging services including CT/CAT Scan, MRI, MRA, Nuclear Cardiology and PET are subject to coinsurance and deductible (outpatient requires precertification except for Nuclear Cardiology), (see Section 5(a), page 36).

PPO: $30 copayment (No deductible)

Non-PPO: 40% of the Plan allowance

Note:  For Non-PPO benefits, members may be billed the difference between the Plan allowance and the billed amount.

Outpatient medical or surgical services and supplies, other than an Urgent Care Center

PPO: 15% of the Plan allowance

Non-PPO: 15% of the Plan allowance

Benefit Description : AmbulanceHigh Option (You Pay After the calendar year deductible…)

Professional ambulance services within 24 hours of a medical emergency

Note: See Section 5(c), page 58, for non-emergency service.

PPO: 15% of the Plan allowance
(No deductible)

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Benefit Description : Air ambulanceHigh Option (You Pay After the calendar year deductible…)

Air ambulance to nearest facility where necessary treatment is available is covered if no emergency ground transportation is available or suitable and the patient's condition warrants immediate evacuation. Air ambulance will not be covered if transport is beyond the nearest available suitable facility, but is requested by patient or physician for continuity of care or other reasons

PPO: 15% of the Plan allowance (No deductible)

Non-PPO: 15% of the Plan allowance (No deductible)

Not covered:

  • Air ambulance if transport is beyond the nearest available suitable facility, but is requested by patient or physician for continuity of care or other reasons

All charges




Section 5 (e). Mental Health and Substance Use Disorder Benefits (High Option)

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 - $450 per person ($800 per Self Plus One enrollment, or $800 per Self and Family enrollment); Non-PPO - $1,000 per person ($2,000 per Self Plus One enrollment, or $2,000 per Self and Family enrollment). 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 calendar year deductible or, for facility care, the inpatient deductible applies to almost all benefits in this Section.  We added "(No deductible)" to show when a deductible does not apply.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
  • YOU MUST GET PREAUTHORIZATION FOR 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.
  • To obtain preauthorization of an admission for mental conditions or substance use disorder treatment, call Cigna/CareAllies at 800-582-1314. 
  • We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or otherwise required.
  • 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.
  • We do not make available provider directories for mental health or substance use disorder treatment providers.  Cigna Behavioral Health will provide you with a choice of network providers at 800-582-1314 or visit our website at www.apwuhp.com.
  • Schools or other educational institutions are not covered.
  • If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our FEHB members.  This plan enhances your FEHB coverage by reducing/eliminating cost-sharing for services and/or adding benefits at no additional cost.  This would be an enhancement to your APWU Health Plan's High Option benefits.  It includes a $50 monthly Part B reimbursement.  The UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.  (See Section 9 for additional details.)



Benefit Description : Professional servicesHigh Option (You Pay After the calendar year deductible…)

We cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

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

In a physician's office

  • Treatment and counseling (including individual or group therapy visits)
  • Diagnosis and treatment to address gender dysphoria and gender transition (in-network only), (see Section 5(b) and 5(c) for exclusions)
  • Diagnosis and treatment of substance use disorders (outpatient)
  • Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:
    • Diagnostic evaluation
    • Crisis intervention and stabilization for acute episodes
    • Medication evaluation and management (pharmacotherapy)
  • Repetitive Transcranial Magnetic Stimulation, TMS, for the treatment of depressive disorders which have not been responsive to other interventions such as psychotherapy and antidepressant medications (preauthorization required by Cigna/CareAllies)
  • Professional charges for intensive outpatient treatment in a provider's office or other professional setting 

PPO:  $25 copayment (No deductible)

Non-PPO:  40% of the Plan allowance and any difference between our allowance and the billed charges

Professional and other services for the diagnosis and treatment of psychiatric conditions, mental illness or mental disorders:

  • Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
  • Diagnosis and treatment of substance use disorders, including detoxification, treatment and counseling (inpatient)
  • Repetitive Transcranial Magnetic Stimulation, TMS, for the treatment of depressive disorders which have not been responsive to other interventions such as psychotherapy and antidepressant medications (preauthorization required by Cigna/CareAllies)
  • Electroconvulsive therapy

Note: Applied Behavioral Analysis (ABA) therapy benefit is listed in Section 5(a), Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals, page 42.

PPO:  15% of the Plan allowance

Non-PPO:  40% of the Plan allowance and any difference between our allowance and the billed charges

Benefit Description : TeleHealth servicesHigh Option (You Pay After the calendar year deductible…)

Virtual visits through AmWell for non-emergency visits

Covered services include consultation, diagnosis and prescriptions (when appropriate) through the web or your mobile device.

Note:  Telehealth services are available in most states, but some states do not allow telehealth or prescriptions per state regulations.

Please see www.AmWell.com, or call 855-818-DOCS to start your virtual visit.

Note:  There are no out-of-network benefits for Virtual visits.

AmWell:  $15 copayment (No deductible)

PPO:  $25 copayment (No deductible)

Non-PPO:  N/A

Benefit Description : DiagnosticsHigh Option (You Pay After the calendar year deductible…)
  • Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
  • Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility

PPO:  15% of the Plan allowance

Non-PPO:  40% of the Plan allowance and any difference between our allowance and the billed charges

Benefit Description : Inpatient hospital or other covered facilityHigh Option (You Pay After the calendar year deductible…)

Inpatient services provided and billed by a hospital, Residential Treatment Center (RTC), or other covered facility (preauthorization required by Cigna/CareAllies)

  • Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
  • Inpatient diagnostic tests provided and billed by a hospital, Residential Treatment Center (RTC), or other covered facility

PPO:  15% of the Plan allowance (No deductible)

Non-PPO:  After $300 per admission, 40% of our allowance and any difference between our allowance and the billed charges (No deductible)

Not covered:

  • For Residential Treatment Centers, benefits are not available for non-covered services, including: respite care; outdoor residential programs; services provided outside of the provider’s scope of practice; recreational therapy; educational therapy; educational classes; bio-feedback; Outward Bound programs; equine therapy provided during the approved stay; personal comfort items, such as guest meals and beds, telephone, television, beauty and barber services, which may be part of the treatment program’s milieu and/or physical environment, are not covered as separately billed items; custodial or long term care; and domiciliary care provided because care in the home is not available or is unsuitable.

All charges

Benefit Description : Outpatient hospital or other covered facilityHigh Option (You Pay After the calendar year deductible…)

Outpatient services provided and billed by a hospital or other covered facility

  • Services such as partial hospitalization, full-day hospitalization, or facility-based intensive outpatient treatment (preauthorization required by Cigna/CareAllies)

PPO:  15% of the Plan allowance

Non-PPO:  40% of the Plan allowance and any difference between our allowance and the billed charges

Not covered:

  • Services that require preauthorization that are not part of a preauthorized approved treatment plan
  • Services that are not medically necessary
  • Services performed at schools or other education institutions

All charges




Section 5 (f). Prescription Drug Benefits (High Option)

Important things to keep in mind about these benefits:

  • We cover prescribed drugs and medications, as described in the chart below.
  • 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.
  • Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies.  Prior approval/authorizations must be renewed periodically.
  • Federal law prevents the pharmacy from accepting unused medications.
  • The calendar year deductible does not apply to prescription drug benefits.
  • The non-network benefits are the standard benefits of this Plan. Network benefits apply only when you use a network provider. When no network provider is available, non-network benefits apply.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works.  Also read Section 9, for information about how we pay if you have other coverage, or if you are age 65 or over.  
  • Prior authorization is required for certain drugs and must be renewed periodically.  This review uses Plan rules based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective.  See the coverage authorization information shown in Section 3, Other services and page 71, for more information about this program.
  • If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our FEHB members.  This plan enhances your FEHB coverage by reducing/eliminating cost-sharing for services and/or adding benefits at no additional cost.  This would be an enhancement to your APWU Health Plan's High Option benefits.  It includes a $50 monthly Part B reimbursement.  The UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.  See Section 9 for additional details.



There are important features you should be aware of.  These include:

  • Who can write your prescription.  A licensed prescriber or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice.
  • Where can you obtain them.  You can fill the prescription at an Express Scripts 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.
  • You may only obtain a 30-day supply and one refill of maintenance prescriptions at a network pharmacy participating with Express Scripts.  After two courtesy 30-day fills at regular network retail, you will pay the non-network pharmacy benefit level.
  • You may purchase maintenance prescription medications (non-specialty drugs that you take regularly for ongoing conditions, for a 90-day supply) from a participating Smart90® Retail Network pharmacy or Express Scripts mail order.
  • To find a Smart90® Retail Network pharmacy that participates in filling 90-day supplies, log in or register at express-scripts.com/90day, select "Manage Prescriptions," and look for a link directing you to the Participating Smart90® Retail Network pharmacies, or call 866-890-1419.  The pharmacy can tell you how to transfer your non-specialty maintenance medication prescription or start a new one.  If you continue to use a non-participating Smart90® pharmacy, you will pay the non-network pharmacy benefit level.
  • Your copayment for your 90-day supply will be the same whether you fill your prescription through Express Scripts Mail order or at a participating Smart90® Retail Network pharmacy.
  • We use a formulary.  Our formulary is the National Preferred Formulary through Express Scripts.  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.  There are safe, proven medication alternatives in each therapy class that are covered on the formulary.  Some drugs will be excluded from the formulary and coverage, see www.apwuhp.com/high_option_pharmacy_program.php for a list of excluded medications.  This list is not all inclusive and there may be changes to the list during the year.  A formulary exception process is available to prescribers if they feel the formulary alternatives are not appropriate.  Prescribers may request a clinical exception by calling 800-753-2851.  During the year, the Plan's formulary may change. 
  • Member cost-share for prescription drugs is determined by the tier to which a drug has been assigned. To determine the tier assignments for formulary drugs, our Pharmacy Benefit Managers (PBM) work with their Pharmacy and Therapeutic Committee, a group of physicians and pharmacists who are not employees or agents of, nor have financial interest in the Plan. The Committee’s recommendations, together with our PBM's evaluation of the relative cost of the drugs, determine the placement of formulary drugs on a specific tier. Using lower cost preferred drugs will provide you with a high quality, cost-effective prescription drug benefit.  You can view a list on our website at www.apwuhp.com/high_option_pharmacy_program.php.
  • Our payment levels are generally categorized as:
    • Tier 1 Includes generic drugs
    • Tier 2 Includes preferred brand name drugs
    • Tier 3 Includes non-preferred brand name drugs
    • Tier 4 Includes generic specialty drugs
    • Tier 5 Includes preferred brand name specialty drugs
    • Tier 6 Includes non-preferred brand name specialty

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 generally 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 prescriber specifically requires a brand name drug. If you receive a brand name drug when a Federally-approved generic drug is available, and your prescriber 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 800-753-2851.
  • The Plan may have certain coverage limitations to ensure clinical appropriateness. For example, prescription drugs used for cosmetic purposes may not be covered, a medication might be limited to a certain amount (such as the number of pills or total dosage) within a specific time period, or require authorization to confirm clinical use based on FDA labeling. In these cases, you or your prescriber can begin the coverage review process by calling Express Scripts Customer Service at 800-841-2734.

These are the dispensing limitations:

  • The Express Scripts Retail Network – you may obtain up to a 30-day supply plus one 30-day refill for each prescription purchased from an Express Scripts network pharmacy. After one 30-day refill, you must obtain a new prescription and either purchase your non-specialty maintenance prescription medications (drugs you take regularly for ongoing conditions) at either a participating Smart90 Retail Network pharmacy or the Express Scripts mail order. 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.
  • Exceptions for special circumstances – the Plan will authorize up to a 90-day supply at a network pharmacy for covered persons called to active military service. Also, the Plan will authorize an extra 30-day supply, either at network retail or Home Delivery, for civilian Government employees who are relocated for assignment in the event of a national emergency. Authorization may be obtained from Express Scripts at 800-841-2734 or from the Plan at 800-222-2798.
  • Non-network pharmacy – if you do not use your identification card, if you elect to use a non-network pharmacy, or if an Express Scripts 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 Express Scripts by Mail even though the prescription is for 90 days.
  • Refills for maintenance medications are not considered new prescriptions except when the doctor changes the strength or 180 days has elapsed since the previous purchase. Refill orders submitted too early after the last one was filled are held until the right amount of time has passed. As part of the administration of the prescription drug program, we reserve the right to maximize your quality of care as it relates to the utilization of pharmacies.
  • You may fill your prescription at any pharmacy participating in the Express Scripts system. For the names of participating pharmacies, call 800-841-2734, or go to www.express-scripts.com.

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.




Benefit Description : Covered medications and suppliesHigh Option (You Pay)

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 pre-addressed reply envelope.

You may purchase the following medications and supplies prescribed from either a pharmacy or by mail:

  • Drugs and medications, for use at home that are obtainable only upon a doctor’s prescription and listed in official formularies
  • Drugs and medications (including those administered during a non-covered admission or in a non-covered facility) that by Federal law of the United States require a prescription for their purchase, except those listed as not covered
  • Insulin, Insulin Pump supplies and test strips for known diabetics
  • Disposable needles and syringes for the administration of covered medications
  • Approved drugs for organic impotence such as Viagra and Levitra are subject to prior authorization, (see Section 3, Other services, page 18, and Section 5(f), page 71)
  • Drugs that could be used for cosmetic purposes such as: Retin A or Botox (requires prior authorization), (see Section 3, Other services, page 18, and Section 5(f), page 71)
  • FDA approved drugs for weight management (prior authorization is required), page 71
  • Drugs to treat gender dysphoria
  • Network Retail: $10 Tier 1. 25% Tier 2 up to a maximum of $200 coinsurance per prescription for a 30-day supply. 45% Tier 3 up to a maximum of $300 coinsurance per prescription for a 30-day supply
  • Non-network Retail: 50% of cost for a 30-day supply
  • Network Mail Order: $20 Tier 1. 25% Tier 2 up to a maximum of $300 coinsurance per prescription for a 90-day supply. 45% Tier 3 up to a maximum of $500 coinsurance per prescription for a 90-day supply

Diabetes medications and supplies

  • Certain Insulins and non-Insulin Diabetes drugs to treat diabetes

For a list of Insulins and non-Insulin Diabetes drugs with fixed copays, go to https://apwuhp.com/members/high-option/pharmacy/

Note: Standard Plan coinsurance applies to all other covered diabetic medications and supplies.

  • Network Retail: $25 copay for a 30-day supply
  • Network Mail Order: $75 copay for a 90-day supply

Diabetic medications and supplies

  • Oral Generic (Tier 1) medications for the specific purpose of lowering blood sugar
  • Formulary (Tier 2) blood glucose test strips and lancets
  • Network Mail Order:  $0

Specialty Prescription Drugs

  • Specialty drugs must be obtained through Accredo Specialty Pharmacy.  This benefit pertains to specialty drugs administered either at home or in an outpatient setting.

Note:  See pages 71-72 for definition.

Note:  If your specialty medication is available through Accredo Specialty Pharmacy and you do not obtain your medication through Accredo Specialty Pharmacy, you will be responsible for the full cost of your medication.

  • Network Retail: 25% Tier 4 with up to a maximum of $300 per prescription for a 30-day supply. 25% Tier 5 up to a maximum of $600 coinsurance per prescription for a 30-day supply.  45% Tier 6 up to a maximum of $1,000 coinsurance per prescription for a 30-day supply
  • Non-network Retail:  50% of cost for a 30-day supply
  • Network Mail order:   25% Tier 4 with up to a maximum of $150 per prescription for a 90-day supply. 25% Tier 5 up to a maximum of $300 coinsurance per prescription for a 90-day supply.  45% Tier 6 up to a maximum of $500 coinsurance per prescription for a 90-day supply

Contraceptives

  • In-network prescription drugs from Express Script's Patient Protection and Affordable Care Act (PPACA) Preventive Contraceptive Drug List for contraception for women.  Find list at www.apwuhp.com.

Note:  Standard Plan coinsurance applies to brand name contraceptives (when a generic is available) unless the brand is required by your prescriber.

  • Network Retail: $0
  • Network Mail order:  $0

In-network devices approved by the FDA for contraception for women

Nothing

Naloxone 0.4 mg/ml vial and Naloxone 2 mg/ml syringe; and Narcan nasal spray for the prevention of opioid overdose related deaths

Note: Copay maximum does not apply to out-of-network retail drugs or to brand name drugs when there is a generic available.

Note: If you choose a brand name drug when a generic is available and the physician has not received prior authorization, you are responsible for the difference in cost between the brand name drug and the generic, in addition to your coinsurance.

Note: The Plan requires a coverage review (prior authorization) of certain prescription drugs based on FDA-approved prescribing and safety information, clinical guidelines, and uses that are considered reasonable, safe and effective. See page 71 for more information. To find out if your prescription requires prior authorization or more about your prescription drug plan, visit Express Scripts online at www.express-scripts.com or call Express Scripts member services at 800-841-2734.

Note:  Over-the-counter or prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation programs benefit, see Educational classes and programs, page 46.

Network Retail:  Nothing

Non-network Retail:  50% of cost for a 30-day supply

Network Mail Order:  Nothing

Not covered:

  • Drugs and supplies for cosmetic purposes
  • Drugs to enhance athletic performance
  • Vitamins, nutrients and food supplements not listed as a covered benefit even if a doctor prescribes or administers them
  • Medical supplies such as dressings and antiseptics
  • Nonprescription medications/over-the-counter drugs, except as stated below:
    • Over-the counter emergency contraceptive drugs, the "morning after pill", are covered at no cost if prescribed by a doctor and purchased at a network pharmacy
    • Over-the-counter FDA-approved female birth control methods are covered at no cost if prescribed by a doctor and purchased at a network pharmacy
  • Prescription drugs approved by the U.S. Food and Drug Administration when an over-the-counter equivalent is available.

All charges

Benefit Description : Preventive care medicationsHigh Option (You Pay)
  • Medications to promote better health as recommended by ACA.
  • Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy.  These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients.  For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations. 

Network Retail:  Nothing

Non-network Retail:  50% of cost for a 30-day supply




Prescription Drug Utilization Management

  • The information below describes a feature of your prescription drug plan known as utilization management. Utilization management programs help to ensure you are taking safe and effective medications at a reasonable cost.
  • Some medications require a prior authorization and are not covered unless you receive approval through a coverage review (prior authorization). Examples of drug categories that require a coverage review include but are not limited to, growth hormones, Botox, Interferons, rheumatoid arthritis agents, Retin A, drugs for organic impotence/sexual disorders, FDA approved drugs for weight management, gender dysphoria and gender transition, blood disorders treatment, pain treatment, cardiovascular disease, respiratory disease treatment, skin conditions, ophthalmic conditions, neuromuscular, mental/neurological, renal disease, anti infectives, gastrointestinal and endocrine. This review uses Plan rules based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective. There are other medications that may be covered with limits (for example, only for a certain amount or for certain uses) unless you receive approval through a review. During this review, Express Scripts asks your doctor for more information than what is on the prescription before the medication may be covered under your plan. If coverage is approved, you simply pay your normal copayment for the medication. If coverage is not approved, you will be responsible for the full cost of the medication.
  • In our ongoing effort to provide a robust yet cost-effective prescription drug benefit, APWU Health Plan participates in programs to encourage the prescribing and use of generics and lower-cost alternative brands when appropriate.  In most cases, you save money when the preferred generic or formulary brand is dispensed. Step therapy helps to ensure that your prescriber considers cost-effective alternatives before prescribing more expensive medications. If you have received one or more of the less costly alternatives in the past, you will be able to get your medicine at the pharmacy without any delay.  Currently the Plan offers step therapy programs on specialty cholesterol, hypnotic, osteoporosis, migraine, glaucoma, hypoglycemic, Non Steroidal Anti-Inflammatory (NSAID's), COX-2 Inhibitors, nasal steroids, Proton Pump Inhibitors (PPI's), oral Tetracyclines, topical acne, topical Corticosteroids, topical Immunomodulator medications, allergies, respiratory conditions, stimulants, bone conditions, genitourinary conditions, diabetes, endocrine disorders, blood disorders, cardiovascular disease, inflammatory conditions, depression, metabolic disorders, pain, gastrointestinal disorders, mental/neurological, electrolyte imbalance, BPH, hypertension, birth control, and vitamin deficiency. In situations where your prescribed drug is targeted and there is no history of a first line agent, a new prescription for a first line agent will need to be obtained or a coverage review will be necessary for coverage of your medication.  If the coverage review is approved, the member is responsible for the normal coinsurance found on pages 68-70. If the coverage review is denied, the member is responsible for the full cost of the drug.  If the member does not first obtain the coverage review (prior authorization) approval, they will pay the full cost of the drug. Coverage reviews can be initiated by the member, pharmacist, or doctor by calling Express Scripts at 800-841-2734.
  • The APWU Health Plan prescription benefit plan will no longer cover prescriptions for certain compound medications. The U.S. Food and Drug Administration (FDA) defines a compound medication as one that requires a licensed pharmacist to combine, mix or alter the ingredients of a medication when filling a prescription. The FDA does not verify the quality, safety and/or effectiveness of compound medications, therefore the Plan will no longer cover certain compounded prescriptions unless FDA approved. To avoid paying the full cost of these medications, you should ask your doctor for a new prescription for a manufactured FDA-approved drug before your next fill. 
  • The Plan will participate in other approved managed care programs to ensure patient safety and appropriate therapy in accordance with the Plan rules based on FDA guidelines referenced above.
  • To find out more about your prescription drug plan, please visit Express Scripts online at www.express-scripts.com or call Express Scripts Member Services at 800-841-2734.
  • “Specialty Drugs” are injectable, infused, oral or inhaled drugs defined as having one or more of several key characteristics: (1) requires frequent dosing adjustments and intensive clinical monitoring to decrease potential for drug toxicity and increase probability for beneficial treatment outcomes; (2) need for intensive patient training and compliance assistance to facilitate therapeutic goals; (3) limited or exclusive product availability and distribution; (4) specialized product handling and/or administration requirements.

Some examples of the disease categories currently in Express Scripts specialty pharmacy programs include cancer, cystic fibrosis, Gaucher disease, growth hormone deficiency, hemophilia, immune deficiency, hepatitis C, infertility, multiple sclerosis, rheumatoid arthritis and RSV prophylaxis.

In addition, a follow-on-biologic or generic product will be considered a Specialty Drug if the innovator drug is a Specialty Drug.

Many of the Specialty Drugs covered by the Plan fall under the Prescription Drug Utilization Management program mentioned. Many of the Specialty medications must be obtained through Accredo. You can send your prescription through your normal mail service process or have your physician fax your prescription to Accredo.

You or your prescriber must contact Accredo at 844-581-4862 to determine if a specialty medication that you are receiving from the physician's office or outpatient setting must be obtained through Accredo Specialty Pharmacy.  Contact Accredo to speak to a representative to inquire how your medication can be obtained through Accredo and possibly administered at home using Accredo nursing services.  If your specialty medication is available through Accredo Specialty Pharmacy and you do not obtain your medication through Accredo Specialty Pharmacy, you will be responsible for the full cost of the medication.

  • For Medicare Part B insurance coverage. If Medicare Part B is primary, ask about your options for submitting claims for Medicare-covered medications and supplies, whether you use a Medicare-approved supplier or Express Scripts by Mail.  Prescriptions typically covered by Medicare Part B include diabetes supplies (test strips and meters), specific medications used to aid tissue acceptance (such as with organ transplants), certain oral medications used to treat cancer, and ostomy supplies.
  • When you do 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 800-222-2798 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, prescriber's name, date of purchase and charge for the drug. Mail the claim form and receipt(s) to:

    APWU Health Plan
    P.O. Box 1358
    Glen Burnie, MD  21060-1358



Section 5 (g). Dental Benefits (High Option)

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.
  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan.  See Section 9, Coordinating benefits with other coverage.
  • The calendar year deductible is: PPO - $450 per person ($800 per Self Plus One enrollment, or $800 per Self and Family enrollment); Non-PPO - $1,000 per person ($2,000 per Self Plus One enrollment, or $2,000 per Self and Family enrollment). 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.  Also read Section 9, for information abut how we pay if you have other coverage, or if you are age 65 or over.

Note: We cover hospitalization and anesthesia 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), Inpatient hospital benefits).




Accidental injury benefit : Accidental injury benefitHigh Option (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, page 60).

Within 72 hours of accident:

PPO: Nothing (No deductible)

Non-PPO: Only the difference between our allowance and the billed amount (No deductible)

More than 72 hours after accident:

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any difference between our allowance and the billed amount

Accidental injury benefit : Dental benefits serviceHigh Option (You Pay)
  • Office visits (routine limited to 2 visits per year)
  • Restorative care (fillings)
  • X-rays of all types (limited to 2 per year)
  • Prophylaxis (cleanings), (limited to 2 per year)
  • Simple extractions

Note: Office visits include examinations and fluoride treatment.

Note:  Restorative care does not include crowns or in-lay/on-lay restoration.

Note:  General anesthetics not covered unless due to an underlying medical condition.

30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Note:  No in-network dental providers; choose any provider.




Section 5 (h). Wellness and Other Special Features (High Option)

TermDefinition

Flexible benefits option

Under the flexible benefits option, we determine the most effective way to provide services.

  • We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
  • Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
  • By approving an alternative benefit, we do not guarantee you will get it in the future.
  • The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
  • If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
  • Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.  However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits under the OPM disputed claims process (see Section 8, pages 131-133).

24-hour nurse line

We offer a 24-hour nurse advisory service for your use. This program is strictly voluntary and confidential. You may call toll-free at 800-582-1314 and reach registered nurses to discuss an existing medical concern or to receive information about numerous healthcare issues.

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

Disease Management Program

A voluntary program that provides a variety of services to help you manage a chronic condition with outpatient treatment and avoid unnecessary emergency care or inpatient admissions. As an example, members with cardiac conditions can participate in this program.  We use medical and/or pharmacy claims data as well as interactions with you and your physician(s). If you have a chronic condition and would like additional information, call Cigna/CareAllies at 800-582-1314.

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.

 

Weight Management Program

$0 copay for in-network office visit to a registered Dietician/Nutritionist 

 

Healthy Pregnancies, Healthy Babies Program
Enroll in this program and you take the first step toward giving your baby a healthy start in life.  Enroll by calling CareAllies at 1-800-582-1314, prompt 8.

Special Programs

  • Lifestyle Programs - Wellness Coaches help you develop a personalized plan for tobacco cessation and weight management.  For information, call Cigna/CareAllies at 800-582-1314, select Weight Management/Tobacco Cessation option.
  • Healthy Rewards - MyCigna provides non-FEHB savings on gym memberships, tobacco cessation, weight reduction programs, and more. Visit www.apwuhp.com or call 800-558-9443.
    • Tobacco cessation - find discounts on smoking cessation products
    • Weight and nutrition - get help to lose weight with discounts on weight reduction programs from Jenny Craig
    • Fitness - get fit and save on gym memberships
    • Vision and hearing care - receive vision and hearing exams and discounts on hearing aids, discounts on glasses and frames, and discounts on Lasik vision corrections
    • Wellness products - enjoy 40% savings on herbal supplements and vitamins, and 5% at checkout from www.drugstore.com
    • Alternative medicine - find discounts for acupuncture, chiropractor, and massage
    • Dental care - save on dental care with discounts on anti-cavity products and toothbrushes

Online tools and resources

Online tools are available at www.myAPWUHP.com:

  • www.myAPWUHP.com - online information for member services and claims to view claims and find year-to-date information with claim details
  • HealthVault - an online tool to organize important medical information in one secure and central location to share with family and doctors
  • Health Risk Assessment - answer questions about your health and receive a personalized health program through MyCigna

Health Risk Assessment (HRA)

A Health Risk Assessment (HRA) is available at www.apwuhp.com, click Take a Health Risk Assessment, click High Option, click Register Now.  Access to the Health Risk Assessment is also available via the Member Portal at www.myAPWUHP.com.  The HRA is an online program that analyzes your health related responses and gives you a personalized plan to achieve specific health goals.  Your HRA profile provides information to put you on a path to good physical and mental health.

When you complete the HRA, we will enroll you in the CignaPlus Savings discount dental program.  For Self Only coverage, we will pay the Self Only CignaPlus Savings discount dental premium; and for Self Plus One and Self and Family, when at least two family members complete the HRA, we will pay the family CignaPlus Savings discount dental premium.  We will pay these discount dental premiums for the remainder of the calendar year in which the HRAs were completed provided you remain enrolled in our Plan.

CignaPlus Savings is a discount dental program that provides members access to discounted fees with participating dental providers.  For more information on this program, call 877-521-0244 or visit www.cignaplussavings.com.

Consumer choice information

Access by Internet (www.apwuhp.com) is provided to support your important health and wellness decisions, including:

  • Online Preferrred Organization (PPO) Directory - nationwide PPO network to find doctors, hospitals and other outpatient providers anywhere in the country
  • Hospital Quality Ratings Guide - Compare hospitals for quality in your area or anywhere in the country
  • Treatment Cost Estimator - receive cost estimates for the most common medical conditions, tests and procedures
  • Prescription drug information, pricing, and network retail pharmacies



Consumer Driven Health Plan Benefits (CDHP)

See page 15 for how our benefits changed this year and page 152 for a benefits summary.




(Page numbers solely appear in the printed brochure)




Consumer Driven Health Plan Overview (CDHP)

The Plan offers a Consumer Driven Health Plan (CDHP). The CDHP benefit package is described in this section. Make sure that you review the benefits that are available under the benefit product in which you are enrolled.

CDHP Section 5, which describes the CDHP benefits, is divided into subsections. Please read Important things you should keep in mind about these benefits at the beginning of each subsection. Also read the general exclusions in Section 6, they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about CDHP benefits, contact us at 800-718-1299 or on our website at www.welcometouhc.com/apwu.

This CDHP focuses on you, the healthcare consumer, and gives you greater control in how you use your healthcare benefits. With this Plan, eligible in-network preventive care is covered in full, and you can use the Personal Care Account for any covered care. If you use up your Personal Care Account, the Traditional Health Coverage begins after you satisfy your Deductible. If you don’t use up your Personal Care Account for the year, you can roll it over to the next year, up to the maximum account balance amount, as long as you continue to be enrolled in this CDHP.

The CDHP includes:

In-network Preventive Care

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 5, In-network preventive care. They are based on recommendations by the American Medical Association.  We emphasize women's wellness through a Well woman benefit that includes a broad range of preventive services, preventive tests and screenings, counseling services, and contraceptives, including prescription drug contraceptives.

Personal Care Account (PCA)

The Plan also provides a Personal Care Account (PCA) for each enrollment. Each year, the Plan provides $1,200 for a Self Only enrollment or $2,400 for a Self Plus One or 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 it in the future. The Personal Care Account is described in Section 5, Personal Care Account (PCA).

Note that the in-network Preventive Care benefits paid under Section 5 do NOT count against your Personal Care Account (PCA).

Traditional Health Coverage

After you have used up your Personal Care Account (PCA) and paid your Net Deductible, the Plan starts paying benefits under the Traditional Health Coverage described in Section 5, Traditional Health Coverage. The Plan generally pays 85% of the cost for in-network care and 50% of the Plan allowance for out-of-network care.

Covered services include:

  • Medical services and supplies, Section 5(a) 
  • Surgical and anesthesia services, Section 5(b) 
  • Hospital services, other facilities and ambulance, Section 5(c)
  • Emergency services/Accidents, Section 5(d)
  • Mental health and substance use disorder treatment benefits, Section 5(e)
  • Prescription drug benefits, Section 5(f)

Health Education Resources and Account Management Tools

Section 5(i) describes the health tools and resources available to you under the Consumer Driven Option to help you improve the quality of your healthcare and manage your expenses. You can receive a $25 wellness incentive when you complete an annual physical with a clinical professional each year.




Section 5. In-Network Preventive Care (CDHP)

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 CDHP Section 5, Personal Care Account (PCA).
  • For all other covered expenses, please see CDHP Section 5, Personal Care Account (PCA), page 83, and 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).
  • 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.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works.  Also read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
  • Receive $25 when you complete an annual physical with a clinical professional each year, see Section 5(i) for details.



Benefit Description : Preventive care, adultConsumer Driven Option (You Pay)

Routine physical every calendar year.

The following preventive services are covered at the time interval recommended at each of the links below:

  • Receive $25 when you complete an annual physical with a clinical professional each year (see Section 5(i) for details)
  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV).  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at:  https://www.cdc.gov/vaccines/schedules/
  • Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening.  For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at: https://www.uspreventiveservicestaskforce.org
  • Individual counseling on prevention and reducing health risks
  • Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence.  For a complete list of Well Women preventive care services go to the Health and Human Services (HHS) website at: https://www.healthcare.gov/preventive-care-women/
  • Routine Prostate Specific Antigen (PSA) test, one annually for men age 40 and older
  • Urinalysis
  • Routine Electrocardiogram (EKG)
  • Chest X-ray
  • Hemoglobin A1C, age 18 and above
  • At home Colorectal Cancer Screening Cologuard Kit provided through Exact Sciences Laboratories, every three years starting at age 50, prescription needed from physician

In-network:  Nothing

Out-of-network:  Uses PCA while funds available

Routine mammogram - covered for women, including 3D mammograms 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
  • To build your personalized list of preventive services go to https://health.gov/myhealthfinder 

In-network:  Nothing

Out-of-network:  Uses PCA while funds available

Immunizations, such as:

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Note:  Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

In-network:  Nothing

Out-of-network:  Uses PCA while funds available

Benefit Description : Preventive care, childrenConsumer Driven Option (You Pay)
  • Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics.  For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to: https://brightfutures.aap.org
  • Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella.  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at: https://www.cdc.gov/vaccines/schedules/index.html
  • You may also find a complete list of preventive care services recommended under the U.S. Preventive Services Task force (USPSTF) online at:  https://www.uspreventiveservicestaskforce.org
  • To build your personalized list of preventive services go to https://health.gov/myhealthfinder 

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member coinsurance, and deductible.

Note:  For directly related associated facilities services and lab work for preventive care, we pay for covered services in full when you use preferred providers.

In-network:  Nothing

Out-of-network:  Uses PCA while funds available

  • Examinations limited to:
    • Examinations for amblyopia and strabismus - limited to one screening examination (ages 3 through 5)
    • Examinations done on the day of immunizations (ages 3 through 21)
    • One Screening Examination of Premature Infants for Retinopathy of Prematurity or infants with low birth weight or gestational age of 32 weeks or less 

In-network:  Nothing

Out-of-network:  Uses PCA while funds available

Not covered:

  • Adult immunizations not endorsed by the CDC
  • Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel
  • Immunizations, boosters, and medications for travel or work-related exposure

All charges




Section 5. Personal Care Account (PCA) (CDHP)

Important things you should keep in mind about your Personal Care Account:

  • All eligible healthcare expenses (except in-network preventive care) are paid first from your Personal Care Account (PCA). Traditional Health Coverage (under CDHP Section 5) will only start once your Personal Care Account is exhausted.
  • Note that in-network preventive care covered under CDHP Section 5, 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 1-800-718-1299 (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 ($1,200 per Self Only, $2,400 per Self Plus One or $2,400 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 $100 per month for Self Only or $200 per month for Self Plus One or Self and Family for each full month of coverage remaining in that calendar year.
  • Unused PCA benefits are forfeited when leaving this Plan.
  • If PCA benefits are available in your account at the time a claim is processed, out-of-pocket expenses will be paid from your PCA regardless of the date the expense was incurred.
  • If the member has funds available in the PCA account, claims will always be paid out of the PCA first.  If the member would like to use their FSA to pay a bill prior to using the PCA, please instruct the provider not to submit the claim to UnitedHealthcare.  The member should get a copy of the bill from the provider and submit to the FSA carrier for reimbursement.  This means that in some cases, the member may have to pay the cost of the services up front.
  • 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.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works.  Also read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over. 
  • YOU MUST GET PRECERTIFICATION FOR 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.
  • Members can turn off the PCA for medical claims only via www.myuhc.com.  Medical claims must then be submitted manually to UnitedHealthcare.  Pharmacy claims will continue to pay from the PCA.



Benefit Description : Personal Care Account (PCA)Consumer Driven Option (You pay)

A Personal Care Account (PCA) is provided by the Plan for each enrollment. Each year the Plan adds to your account:

  • $1,200 per year for a Self Only enrollment or
  • $2,400 per year for a Self Plus One or 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, the doctor will submit your claim and the provider's contracted rate for the visit will be deducted automatically from your PCA; you pay nothing.

     Balance in PCA for Self Only                        $1,200
     Less provider contracted rate for visit               -$60
     Remaining Balance in PCA                           $1,140

There are two types of eligible expenses covered by your PCA.

  • Basic PCA Expenses are the same medical, surgical, hospital, emergency, mental health and substance use disorder treatment, and prescription drug services and supplies covered under the Traditional Health Coverage (see CDHP Section 5 for details)
  • Extra PCA Expenses include:
    • Dental and/or vision services are reimbursable out of your PCA.  Only the PCA amount paid for the dental/vision services is applied to the plan year deductible/out-of-pocket.  We will reimburse up to a combined maximum of $400 per Self Only enrollment or $800 per Self Plus One or 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)
    • In-network preventive care services not included under CDHP Section 5, In-network Preventive Care benefits
    • Out-of-network preventive care limited to services shown as covered under CDHP Section 5
    • 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.

To make the most of your Personal Care Account, you should:

  • Use the network providers wherever possible;
  • Use Tier 1 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
In-network and Out-of-network: Nothing up to $1,200 for a Self Only enrollment or $2,400 for a Self Plus One or Self and Family enrollment

Not covered:

  • Orthodontia
  • Dental treatment for cosmetic purposes including teeth whitening
  • Out-of-network preventive care services not included under CDHP Section 5
  • Services or supplies shown as not covered under Traditional Health Coverage (see CDHP Section 5) and not included under Extra PCA Expenses above
All charges



PCA Rollover

As long as you remain in this Plan, any unused remaining balance in your PCA at the end of the calendar year may be rolled over to subsequent years.  The maximum amount allowed in your PCA may not exceed $5,000 per Self Only enrollment, $10,000 per Self Plus One enrollment and $10,000 per Self and Family enrollment.




Section 5. Traditional Health Coverage Overview (CDHP)

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 CDHP Section 5 and does not count against your Personal Care Account.
  • Your Personal Care Account must be used first for eligible healthcare expenses.
  • If your Personal Care Account has been exhausted, you must pay your Net Deductible before your Traditional Health Coverage may begin. Your Deductible 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 Deductible for your first year will be prorated at a rate of:  in-network $83.33 per month for Self Only, $166.67 per month for Self Plus One or Self and Family; or out-of-network $125.00 per month for Self Only or $250.00 per month for Self Plus One or Self and Family for each full month of coverage remaining in that calendar year.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
  • YOU MUST GET PRECERTIFICATION FOR 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.



Benefit Description : Deductible before Traditional Health Coverage beginsConsumer Driven Option (You Pay)

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

Traditional Health Coverage benefits begin for in-network after covered eligible expenses (deductible) total $2,200 for Self Only, $4,400 for Self Plus One or $4,400 for Self and Family (the combination of eligible expenses paid out of your PCA and your Net Deductible) each calendar year.  For out-of-network, covered benefits begin after covered eligible expenses total $2,700 for Self Only, $5,400 for Self Plus One and $5,400 for Self and Family.

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

In year one, therefore, the Net Deductible is $1,000 for Self Only, $2,000 for Self Plus One and $2,000 for Self and Family enrollment.

 

 

 

 

Type of Plan

In-Network Deductible
Self Only: $2,200 Deductible ($1,200 PCA + $1,000 Net Deductible)
Self Plus One:  $4,400 Deductible ($2,400 PCA + $2,000 Net Deductible)
Self and Family: $4,400 Deductible ($2,400 PCA + $2,000 Net Deductible 

Out-of-Network Deductible
Self Only: $2,700 Deductible ($1,200 PCA + $1,500 Net Deductible)
Self Plus One:  $5,400 Deductible ($2,400 PCA + $3,000 Net Deductible)
Self and Family: $5,400 Deductible ($2,400 PCA + $3,000 Net Deductible)

Basic PCA Expenses paid by PCA
Self Only: $1,200
Self Plus One: $2,400
Self and Family: $2,400

Deductible paid by you 
Self Only: In-network $1,000; Out-of-network $1,500
Self Plus One: In-network $2,000; Out-of-network $3,000
Self and Family: In-network $2,000; Out-of-network $3,000

Traditional Health Coverage starts after
Self Only: In-network $2,200; Out-of-network $2,700
Self Plus One: In-network $4,400; Out-of-network $5,400
Self and Family: In-network $4,400; Out-of-network $5,400

Any PCA dollars that you rollover at the end of the year will reduce your Deductible next year.  In future years, the amount of your Deductible 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:

PCA for year 2 Rollover from year 1
Self Only:  $1,200 + $300 $1,500
Self Plus One: $2,400+ $300 $2,700
Self Self and Family:  $2,400+ $300 $2,700

Net Deductible paid by you
Self Only: In-network + $700 Out-of-network + $1,200
Self Plus One: In-network + $700 Out-of-network + $2,700
In-network + $700 Out-of-network + $2,700

Traditional Health Coverage starts when eligible expenses total
Self Only:  In-network $2,200 Out-of-network  $2,700
Self Plus One:  In-network $4,400 Out-of-network  $5,400
Self and Family:  In-network $4,400 Out-of-network $5,400

If you decide to use your PCA for Extra PCA Expenses for other than covered dental and/or vision services, you may increase your Deductible.  For example, if you have out-of-network preventive care for $150 and later than an accident that leads to a hospital stay, you will have to pay your Deductible plus "make up" the $150 dollars you spent on Extra PCA Expenses.

In-network:  $1,000 per Self Only enrollment, $2,000 for Self Plus One enrollment or $2,000 per Self and Family enrollment

Out-of-network:  $1,500 per Self Only enrollment, $3,000 for Self Plus One and $3,000 for Self and Family enrollment





Section 5 (a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals (CDHP)

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.
  • In-network Preventive Care is covered at 100% under CDHP Section 5 and does not count against your Personal Care Account.
  • Your Personal Care Account must be used first for eligible healthcare expenses.
  • If your Personal Care Account has been exhausted, you must pay your Net Deductible before your Traditional Health Coverage may begin. Your Deductible 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 Deductible for your first year will be prorated at a rate of:  In-network $83.33 per month for Self Only, $166.67 per month for Self Plus One or Self and Family; or out-of-network $125.00 per month for Self Only or $250.00 per month for Self Plus One or Self and Family, for each full month of coverage remaining in that calendar year.  
  • YOU MUST GET PRECERTIFICATION FOR 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.



Benefit Description : Diagnostic and treatment servicesConsumer Driven Option (You Pay)

Professional services of physicians

  • In physician's office
  • At home
  • In an urgent care center
  • During a hospital stay
  • In a skilled nursing facility
  • Second surgical opinion

In-network:  15% of the Plan allowance

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount

  • At a Cancer Center of Excellence

Note:  To receive the higher level of benefits for cancer related treatment, you are required to visit a designated Cancer Center of Excellence facility.

In-network Cancer Center of Excellence (COE):  10% of the Plan allowance

Benefit Description : TeleHealth servicesConsumer Driven Option (You Pay)
  • Virtual visits are available through AmWell, Doctor on Demand, or Teladoc

Please see www.apwuhp.com for information on virtual visits, or log into www.myuhc.com

Note:  There is no out-of-network benefit for Virtual visits.

In-network:  15% of the Plan allowance

Out-of-network:  N/A

Benefit Description : Lab, X-ray and other diagnostic testsConsumer Driven Option (You Pay)

Tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine mammogram, including 3D mammogram
  • Pathology
  • X-ray
  • Non-routine Pap test
  • CT/CAT Scans/MRI/MRA/NC/PET
  • Ultrasound
  • Electrocardiogram and EEG

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.

In-network:  15% of the Plan allowance

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Professional fees for automated lab tests
  • Genetic screening (see Definitions, Section 10, page 146)
  • Qualitative (definitive) urine drug panel testing that is not medically necessary
All charges
Benefit Description : Maternity careConsumer Driven Option (You Pay)

Complete maternity (obstetrical) care, such as:

  • Screening for gestational diabetes for pregnant women
  • Prenatal care
  • Delivery
  • Postnatal care
  • Initial examination of a newborn child covered under a Self Plus One, or Self and Family enrollment
  • Breastfeeding support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

  • You do not need to precertify your vaginal or cesarean delivery; see page 23 for other circumstances, such as extended stays for you or your baby.
  • You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery.
  • We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. 
  • We pay hospitalization and surgeon services for non-maternity care, as well as covering an extended stay, if medically necessary, the same as for illness and injury.
  • Hospital services are covered under Section 5(c), and Surgical benefits are covered under Section 5(b).

Note:  When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in their own right.  If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

Note: Maternity care expenses incurred by a Plan member serving as a surrogate mother are covered by the Plan subject to reimbursement from the other party to the surrogacy contract or agreement.  The involved Plan member must execute our Reimbursement Agreement completed by APWU Health Plan against any payment they may receive under the surrogacy contract or agreement.  Expenses of the newborn child are not covered under this or any other benefit in a surrogate mother situation.

In-network:  Nothing

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount

 

Note:  For inpatient hospital care related to maternity, we pay for covered services in full when you use preferred providers.

Note:  In-network facility and lab services directly related to covered, in-network maternity care will also be covered at 100%.

Note:  For out-of-network inpatient hospital, a $300 per admission fee applies.

  • We will cover other care of an infant who requires non-routine treatment if we cover the infant under a Self Plus One or Self and Family enrollment.  Surgical benefits, not maternity benefits, apply to circumcision of a covered newborn.

In-network:  15% of the Plan allowance

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Amniocentesis if for diagnosing multiple births
  • Genetic screening (see Definitions, Section 10, page 146)
All charges
Benefit Description : Family PlanningConsumer Driven Option (You Pay)

A range of voluntary family services limited to:

  • Contraceptive counseling for women
  • Voluntary sterilization for women (see Surgical Procedures, Section 5(b), page 100)
  • Surgically implanted contraceptives
  • Injectable contraceptive drugs (such as Depo Provera)
  • Intrauterine devices (IUDs)
  • Diaphragms

Note:  We cover oral contraceptives under Section 5, Preventive Care, adult, page 80

In-network:  Nothing

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount

  • Voluntary sterilization for men (see Surgical Procedures, Section 5(b), page 99).

In-network:  15% of the Plan allowance

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Reversal of voluntary surgical sterilization
  • Genetic testing and counseling
All charges
Benefit Description : Infertility servicesConsumer Driven Option (You Pay)
  • Diagnosis and treatment of infertility, except as shown in Not covered

Limited benefits:  We pay a maximum of $2,500 for medical and $2,500 for prescription drugs each calendar year per person to diagnose and treat infertility.

See Section 5(f) for prescription drugs

In-network:  15% of the Plan allowance and all charges after we pay $2,500 in a calendar year

Out-of-network:  50% of the Plan allowance  and all charges after we pay $2,500 in a calendar year

Not covered:

  • Infertility services afer voluntary sterilization
  • Assisted reproductive technology (ART) procedures, such as:
    • Artificial insemination (all procedures) (AI)
    • In vitro fertilization (IVF)
    • Embryo transfer and gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
    • 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
Benefit Description : Allergy careConsumer Driven Option (You Pay)
  • Testing and treatment, including materials (such as allergy serum)
  • Allergy injections

In-network:  15% of the Plan allowance

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Provocative food testing
  • Sublingual allergy desensitization
All charges
Benefit Description : Treatment therapiesConsumer Driven Option (You Pay)
  • Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on pages 103-104.

  • 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. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary, (see Other services, Section 3, page 19).

  • Respiratory and inhalation therapies
  • Cardiac rehabilitation following qualifying event/condition

In-network:  15% of the Plan allowance

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Physical and occupational therapiesConsumer Driven Option (You Pay)

Physical therapy and occupational therapy provided by a licensed registered therapist or physician up to a combined 60 visits per calendar year

We cover rehabilitative and habilitative therapies; a physician should:

  • Order the care;
  • Identify the specific professional skills the patient requires and the medical necessity for skilled services; and
  • Indicate the length of time services are needed.

Note:  We also have the right to deny any type of therapy, service or supply for the treatment of a condition which ceases to be therapeutic treatment and is instead administered to maintain a level of functioning or to prevent a medical problem from occurring or recurring.

In-network:  15% of the Plan allowance

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Maintenance therapies
  • Exercise programs
All charges
Benefit Description : Applied behavioral analysis (ABA)Consumer Driven Option (You Pay)

Outpatient Applied Behavioral Analysis (ABA) services, for the treatment of Autism Spectrum Disorder. Services must be provided under the supervision of a Board Certified Behavior Analyst who is contracted with UHC Behavioral Health Solutions, or agrees to participate with UHC Behavioral Health Solutions' care management activities. (Preauthorization required by UHC Behavioral Health Solutions)

Note:  UHC Behavioral Health Solutions' review of ABA services is based on an intensive care management model that monitors treatment plans, objectives, and progress milestones.

Note:  We have the right to deny services for treatment when outcomes do not meet the defined treatment plan objectives and milestones.

In-network:  15% of the Plan allowance

Out-of-network:  All charges

Benefit Description : Speech therapyConsumer Driven Option (You Pay)

Speech therapy where medically necessary and provided by a licensed therapist

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

Note:   We also have the right to deny any type of therapy, service or supply for the treatment of a condition which ceases to be therapeutic treatment and is instead administered to maintain a level of functioning or to prevent a medical problem from occurring or recurring.

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Hearing services (testing, treatment, and supplies)Consumer Driven Option (You Pay)
  • For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist
  • One examination and testing for hearing aids every 2 years

Note: For routine hearing screening performed during a child's preventive care visit see Section 5, Preventive care, children, pages 81-82.

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

  • External hearing aids
  • Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Note: For benefits for the devices, see Section 5(a), Orthopedic and prosthetic devices, page 95.

Not covered:

  • Hearing services that are not shown as covered
All charges
Benefit Description : Vision services (testing, treatment, and supplies)Consumer Driven Option (You Pay)
  • 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.

In-network: 15% of the Plan allowance

Out-of-network: 50% 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
  • Refraction
All charges
Benefit Description : Foot careConsumer Driven Option (You Pay)

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

Note:  See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

In-network: 15% of the Plan allowance

Out-of-network: 50% 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
Benefit Description : Orthopedic and prosthetic devicesConsumer Driven Option (You Pay)
  • Artificial limbs and eyes
  • Prosthetic sleeve or sock
  • Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
  • Leg, arm, neck, joint and back braces
  • Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
  • Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b), Surgical procedures. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c).

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

External hearing aids

  • Covered every 3 years limited to $1,500

Note:  Excluding batteries, benefits for hearing aid dispensing fees, accessories, supplies, and repair service are included in the benefit limit described above.

In-network:  All charges in excess of $1,500

Out-of-network:  All charges in excess of $1,500

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
Benefit Description : Durable medical equipment (DME)Consumer Driven Option (You Pay)

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, of durable medical equipment, at our option, including repair and adjustment. Covered items include but are not limited to:

  • Oxygen
  • Dialysis equipment
  • Hospital beds
  • Wheelchairs (standard and electric)
  • Ostomy supplies (including supplies purchased at a pharmacy)
  • Crutches; and
  • Walkers

Note: We will pay only for the cost of the standard item. Coverage for specialty equipment, such as all-terrain wheelchairs, is limited to the cost of the standard equipment.

Note:  We limit the Plan allowance for DME rental benefit to an amount no greater than what we would have considered if the equipment had been purchased.

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

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
Benefit Description : Home health servicesConsumer Driven Option (You Pay)

Services for skilled nursing care up to 25 visits per calendar year, not to exceed two hours 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 UnitedHealthcare at 800-718-1299.

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance; all charges in excess of two hours, and any difference between our allowance and the billed amount

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, rehabilitative or Habilitative
  • Nursing services without preauthorization
  • Services of nurses' aides or home health aides
All charges
Benefit Description : ChiropracticConsumer Driven Option (You Pay)

Chiropractic treatment limited to 24 visits and/or manipulations per year

Note:  X-ray covered under Lab, X-ray and other diagnostic tests, page 90.

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Massage therapy
  • Maintenance therapy

All charges

Benefit Description : Alternative treatmentsConsumer Driven Option (You Pay)

Acupuncture - by a doctor of medicine or osteopathy or licensed acupuncturist

In-network: 15% of the Plan allowance

Out-of-network: 50% 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, Section 3, page 16)
All charges
Benefit Description : Educational classes and programsConsumer Driven Option (You Pay)

If you are an APWU Health Plan member, you may enroll in a Tobacco Cessation program as follows:

  • Telephonic counseling sessions with UnitedHealthcare or;
  • Group therapy sessions or;
  • Educational sessions with a physician

Note: Enrollment in the UnitedHealthcare program must be initiated by the member after effective date of Health Plan enrollment.  For more information contact UnitedHealthcare at 800-718-1299.

In-network:  Nothing

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount

Select over-the-counter and prescription Tobacco Cessation medications approved by the FDA to treat tobacco dependence.

To qualify for these drugs, you need to be age 18 or older; get a prescription for these products from your doctor, even if the products are sold over-the-counter; fill the prescription at a network pharmacy.

In-network:  Nothing

Out-of-network:  All charges

Childhood obesity education

In-network:  Nothing

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount

Diabetes self-management training services, up to 10 hours initial training the first year and 2 hours subsequent training annually.

In-network:  15% of the Plan allowance

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount




Section 5 (b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals (CDHP)

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.
  • In-network Preventive Care is covered at 100% under CDHP Section 5 and does not count against your Personal Care Account.
  • Your Personal Care Account must be used first for eligible healthcare expenses.
  • If your Personal Care Account has been exhausted, you must pay your Net Deductible before your Traditional Health Coverage may begin. Your Deductible 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 Deductible for your first year will be prorated at a rate of:  In-network $83.33 per month for Self Only, $166.67 per month for Self Plus One or Self and Family; or out-of-network $125.00 per month for Self Only or $250.00 per month for Self Plus One or Self and Family, for each full month of coverage remaining in that calendar year.  
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
  • YOU MUST GET PRECERTIFICATION FOR 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.



Benefit Description : Surgical proceduresConsumer Driven Option (You Pay)

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
  • Removal of tumors and cysts
  • Correction of congenital anomalies (see Reconstructive surgery, page 100)
  • Surgical treatment of morbid obesity (bariatric surgery) (requires preauthorization), (see Other services, Section 3, page 19).
  • Insertion of internal prosthetic devices (see Section 5(a), Orthopedic and prosthetic devices, page 95, for device coverage information) 
  • Voluntary sterilization for men (e.g., Vasectomy)
  • Treatment of burns
  • Assistant surgeons - We cover up to 20% of our allowance for the surgeon’s charge
  • Surgical treatment of gender dysphoria such as surgical change of sex characteristics.  For female to male surgery: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, and placement of testicular and erectile prosthesis.  For male to female surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, labiaplasty
    • Benefits are limited to once per covered procedure, per lifetime
    • Benefits are not available for repeat or revision procedure when benefits were provided for initial procedure

In-network:  15% of the Plan allowance

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount

  • Voluntary sterilization for women (e.g., Tubal ligation)
  • Surgical implanted contraceptives
  • Intrauterine devices (IUDs)

In-network:  Nothing

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount

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: 50% of the Plan allowance
  • For the secondary procedure(s):
    • In-network: 85% of one-half of the Plan allowance or
    • Out-of-network: 50% of one-half of the Plan allowance

Note: When multiple or bilateral surgical procedures add complexity to an operative session, the Plan allowance for the second or less expensive procedure is one-half of what the Plan allowance would have been if that procedure had been performed independently.

  • When a surgery requires two primary surgeons (co-surgeons), the Plan allowance for each surgeon will not exceed 63% of our allowance.  This allowance will be further reduced by half for secondary procedures.
  • 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.

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: 50% of the Plan allowance for the primary procedure and 50% 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
  • Routine treatment of conditions of the foot (see Foot care, Section 5(a))
All charges
Benefit Description : Reconstructive surgeryConsumer Driven Option (You Pay)
  • Surgery to correct a functional defect
  • Surgery to correct a condition caused by injury or illness if:
    • The condition produced a major effect on the member’s appearance and
    • The condition can reasonably be expected to be corrected by such surgery
  • Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks (including port wine stains); and webbed fingers and toes.
  • All stages of breast reconstruction surgery following a mastectomy, such as:
    • Surgery to produce a symmetrical appearance of breast
    • Treatment of any physical complications, such as lymphedema
    • Breast prostheses; and surgical bras and replacements (see Section 5(a), Prosthetic devices, page 95, 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.

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

  • Gender reassignment surgery benefits are only available for the diagnosis of gender dysphoria

 Requirements:

  1. Prior approval is required
  2. Must be at least 18 years of age at time prior approval is requested and treatment plan is submitted
  3. Must have diagnosis of gender dysphoria by a qualified healthcare professional
  4. New gender identity has been present for at least 24 continuous months
  5. Member has a strong desire to be rid of primary and/or secondary sex characteristics because of a marked in-congruence with the member’s identified gender
  6. Member’s gender dysphoria is not a symptom of another mental disorder or chromosomal abnormality
  7. Gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning
  8. 12 months of continuous hormone therapy appropriate to the member's gender identity
  9. Two referral letters from qualified mental health professionals, one of them being a psychiatrist or clinical psychologist (PhD). One must be from the psychotherapist who has treated the member for at least 12 continuous months. Letters must document: diagnosis of persistent and chronic gender dysphoria; any existing co-morbid conditions are stable; member is prepared to undergo surgery and understands all practical aspects of the planned surgery
  10. If medical or mental health concerns are present, they are being optimally managed and are reasonably well-controlled

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Cosmetic surgery– any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury if repair is initiated within two years of the accident
All charges
Benefit Description : Oral and maxillofacial surgeryConsumer Driven Option (You Pay)

Oral surgical procedures, limited to:

  • Reduction of fractures of the jaw or facial bones
  • Surgical correction of cleft lip, cleft palate 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 UnitedHealthcare at 800-718-1299 to determine whether a procedure is covered.

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Oral implants and transplants
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva and alveolar bone)
  • Dental bridges, replacement of natural teeth, dental/orthodontic/temporomandibular joint dysfunction appliances and any related expenses
  • Treatment of periodontal disease and gingival tissues, and abscesses
  • Charges related to orthodontic treatment
All charges
Benefit Description : Organ/tissue transplantsConsumer Driven Option (You Pay)

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. Refer to Other services, Section 3, for prior authorization procedures.

Solid organ transplants are limited to:

  • Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
  • Cornea
  • Heart
  • Heart/lung
  • Intestinal transplants
    • Isolated small intestine
    • Small intestine with the liver
    • Small intestine with multiple organs, such as the liver, stomach, and pancreas
  • Kidney
  • Kidney-pancreas
  • Liver
  • Lung single/bilateral/lobar
  • Pancreas

In-network Transplant Center of Excellence (COE):  10% of the Plan allowance

In-network:  15% of the Plan allowance

Out-of-network:  50% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $100,000

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Section 3, Other services, page 19, for prior authorization procedures.

  • Autologous tandem transplants for
    • AL Amyloidosis
    • Multiple myeloma (de novo and treated)
    • Recurrent germ cell tumors (including testicular cancer)

In-network Transplant Center of Excellence (COE): 10% of the Plan allowance

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $100,000

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below: 

  • Allogeneic transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Acute myeloid leukemia
    • Advanced Hodgkin's lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced Myeloproliferative Disorders (MPDs)
    • Advanced neuroblastoma
    • Amyloidosis
    • Beta Thalassemia Major
    • Chronic inflammatory demyelination polyneuropathy (CIDP)
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Hemoglobinopathy
    • Infantile malignant osteopetrosis
    • Kostmann's syndrome
    • Leukocyte adhesion deficiencies
    • Marrow failure and related disorders (i.e., Fanconi's Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia) 
    • Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
    • Mucopolysaccharidosis (e.g., Hunter's syndrome, Hurler's syndrome, Sanfillippo's syndrome, Maroteaux-Lamy syndrome variants)
    • Multiple Myeloma
    • Myelodysplasia/Myelodysplastic Syndromes 
    • Myeloproliferative disorders
    • Paroxysmal Nocturnal Hemoglobinuria
    • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
    • Sickle cell anemia (pediatric only)
    • X-linked lymphoproliferative syndrome
  • Autologous transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced childhood kidney cancers
    • Advanced Hodgkin's lymphoma with recurrence (relapsed) 
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Aggressive non-Hodgkin's lymphomas
    • Breast cancer
    • Childhood rhabdomyosarcoma
    • Ependymoblastoma
    • Epithelial ovarian cancer
    • Ewing's sarcoma
    • Mantle cell (non-Hodgkin's lymphoma)
    • Medulloblastoma
    • Multiple myeloma
    • Neuroblastoma
    • Pineoblastoma
    • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors
    • Waldenstrom's macroglobulinemia

In-network Transplant Center of Excellence (COE): 10% of the Plan allowance

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $100,000

Mini-transplants (non-myeloablative, reduced intensity conditioning or RIC) are subject to medical necessity review by the Plan.

In-network Transplant Center of Excellence (COE): 10% of the Plan allowance

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount and any amount over $100,000

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient's condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

Transplant Network

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 UnitedHealthcare at 800-718-1299 and ask to speak to a Transplant Case Manager. You will be provided with information about transplant preferred providers. If you choose a Plan-designated transplant facility, you may receive prior approval for travel and lodging costs.

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

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

In-network Transplant Center of Excellence (COE): 10% of the Plan allowance

In-network: 15% of the Plan allowance

Out-of-network: 50% 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 as shown above
  • Transplants not listed as covered
  • Implants of artificial organs
All charges
Benefit Description : AnesthesiaConsumer Driven Option (You Pay)

Professional services for administration of anesthesia

Note: If surgical services are rendered at an in-network hospital or an in-network freestanding ambulatory facility, we will pay the services of out-of-network anesthesiologists at the in-network rate, based on Plan allowance.

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount




Section 5 (c). Services Provided by a Hospital or Other Facility, and Ambulance Services (CDHP)

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.
  • In-network Preventive Care is covered at 100% under CDHP Section 5 and does not count against your Personal Care Account.
  • Your Personal Care Account must be used first for eligible healthcare expenses.
  • If your Personal Care Account has been exhausted, you must pay your Net Deductible before your Traditional Health Coverage may begin. Your Deductible 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 Deductible for your first year will be prorated at a rate of:  In-network $83.33 per month for Self Only, $166.67 per month for Self Plus One or Self and Family; or out-of-network $125.00 per month for Self Only or $250.00 per month for Self Plus One or Self and Family, for each full month of coverage remaining in that calendar year.  
  • YOU MUST GET PRECERTIFICATION FOR 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.
  • You must get prior approval for gender reassignment surgery.  See page 19 for prior approval and page 99 for the surgical benefit.
  • When you receive hospital observation services, we apply outpatient benefits to covered services up to 48 hours.  Inpatient benefits will apply only when your physician admits you to the hospital as inpatient.



Benefit Description : Inpatient hospitalConsumer Driven Option (You Pay)

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 will consider a semiprivate equivalent allowance of up to 90% of the private room charge.

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: 50% of the Plan allowance and any difference between our allowance and the billed amount

Note: For inpatient hospital care related to maternity, we pay for covered services in full when you use preferred providers, (see Section 5(a), Maternity care, page 90).

Other hospital services and supplies, such as:

  • Operating, recovery, maternity and other treatment rooms
  • Prescribed drugs and medications
  • 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 healthcare 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: 50% of the Plan allowance and any difference between our allowance and the billed amount

Note: For inpatient hospital care related to maternity, we pay for covered services in full when you use preferred providers, (see Section 5(a), Maternity care, page 90). 

Not covered:

  • Any part of a hospital admission that is not medically necessary (see Definitions, Section 10), 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 for out-of-network services only
  • Custodial care (see Definitions, Section 10, page 145)
  • Non-covered 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
Benefit Description : Cancer Centers of ExcellenceConsumer Driven Option (You Pay)

The Plan provides access to designated Cancer Centers of Excellence. To locate a Cancer Center of Excellence, contact UnitedHealthcare at 800-718-1299 and enroll in the program prior to obtaining covered services. The Plan will only pay the higher level of benefits if UnitedHealthcare provides the proper notification to the designated facility/provider performing the services.

To receive the higher level of benefits for a cancer-related treatment, you are required to visit a designated facility. Cancer treatment includes the following:

  • Physician's office services;
  • Professional fees for surgical and medical services;
  • Hospital - inpatient stay; and
  • Outpatient surgery, diagnostic and therapeutic services.

If you decide to use a designated Center of Excellence, you may receive prior approval for travel and lodging costs.

In-network Cancer Centers of Excellence (COE): 10% of the Plan allowance

Benefit Description : Outpatient hospital or ambulatory surgical centerConsumer Driven Option (You Pay)
  • Operating, recovery, and other treatment rooms
  • Prescribed drugs and medications
  • 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 an underlying medical condition. 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.

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Note: For inpatient hospital care related to maternity, we pay for covered services in full when you use preferred providers (see Section 5(a), Maternity care).

Benefit Description : Extended care benefits/Skilled nursing care facility benefitsConsumer Driven Option (You Pay)

When APWU Health Plan is Primary

Semiprivate room, board, services and supplies provided in a skilled nursing care facility (SNF) for up to 30 days per person per calendar year when you are admitted directly from a covered inpatient hospital stay.

Note: Prior approval for these services is required.  Call UnitedHealthcare at 800-718-1299,  (see Other services, Section 3, page 19).

When Medicare A or Other Insurance is Primary

Semiprivate room, board, services and supplies provided in a skilled nursing care facility (SNF) for up to 30 days per person per calendar year when you are admitted directly from a covered inpatient hospital stay.

Note:  If Medicare pays the first 20 days in full, Plan benefits will begin on the 21st day (when Medicare Part A copayments begin) and will end on the 30th day. 

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Custodial care (see Section 10, Definitions)
  • All charges after 30 days per person per calendar year

All charges

Benefit Description : Hospice careConsumer Driven Option (You Pay)

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 up to $15,000 lifetime maximum for combined outpatient and inpatient services, which includes advance care planning
  • We pay a $200 bereavement benefit per family unit
Any amount over the annual maximums shown
Benefit Description : End of life careConsumer Driven Option (You Pay)

End of life care

  • See Hospice care benefit which includes advance care planning, above
Any amount over the annual maximums shown
Benefit Description : AmbulanceConsumer Driven Option (You Pay)

Local professional ambulance service when medically appropriate immediately before, during or after an inpatient admission

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Ambulance service used for routine transport
All charges



Section 5 (d). Emergency Services/Accidents (CDHP)

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.
  • In-network Preventive Care is covered at 100% under CDHP Section 5 and does not count against your Personal Care Account.
  • Your Personal Care Account must be used first for eligible healthcare expenses.
  • If your Personal Care Account has been exhausted, you must pay your Net Deductible before your Traditional Health Coverage may begin. Your Deductible 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 Deductible for your first year will be prorated at a rate of:  In-network $83.33 per month for Self Only, $166.67 per month for Self Plus One or Self and Family; or out-of-network $125.00 per month for Self Only or $250.00 per month for Self Plus One or Self and Family, for each full month of coverage remaining in that calendar year.  
  • When you use a PPO hospital for emergency services, the emergency room physician who provides the services to you in the emergency room may not be a preferred provider.  If they are not, they will be paid by this Plan as a PPO provider at the PPO rate.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.



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.

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




Benefit Description : Accidental injuryConsumer Driven Option (You Pay)

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.

In-network: 15% of the Plan allowance

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

Benefit Description : Medical emergencyConsumer Driven Option (You Pay)
  • Outpatient facility charges in an Urgent Care Center

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance

Note:  For out-of-network benefits, members may be billed the difference between the Plan allowance and the billed amount.

  • 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 

Benefit Description : AmbulanceConsumer Driven Option (You Pay)

Professional ambulance service within 24 hours of an accidental injury or medical emergency

Note: See Hospital benefits, Section 5(c), page 109, for non-emergency service.

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Air ambulanceConsumer Driven Option (You Pay)

Air ambulance to nearest facility where necessary treatment is available is covered if no emergency ground transportation is available or suitable and the patient's condition warrants immediate evacuation. Air ambulance will not be covered if transport is beyond the nearest available suitable facility, but is requested by patient or physician for continuity of care or other reasons

In-network: 15% of the Plan allowance

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

Not covered:

  • Air ambulance if transport is beyond the nearest available suitable facility, but is requested by patient or physician for continuity of care or other reasons

All charges




Section 5 (e). Mental Health and Substance Use Disorder Benefits (CDHP)

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.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.
  • If you join at any time during the year other than Open Season, your Net Deductible for your first year will be prorated at a rate of:  In-network $83.33 per month for Self Only, $166.67 per month for Self Plus One or Self and Family; or out-of-network $125.00 per month for Self Only or $250.00 per month for Self Plus One or Self and Family, for each full month of coverage remaining in that calendar year.  
  • YOU MUST GET PREAUTHORIZATION FOR 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. 
  • To obtain preauthorization of an admission for mental conditions or substance use disorder treatment, call UHC Behavioral Health Solutions at 800-718-1299.
  • We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.
  • 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.
  • We do not make available provider directories for mental health or substance use disorder treatment providers. UHC Behavioral Health Solutions will provide you with a choice of network providers at 800-718-1299 or visit our website at www.myuhc.com.
  • Schools or other educational institutions are not covered.



Benefits Description : Professional servicesConsumer Driven Option (You Pay)

We cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

  • In a physician's office
  • Professional charges for intensive outpatient treatment in a provider's office or other professional setting
Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include:

  • Diagnostic evaluation
  • Crisis intervention and stabilization for acute episodes
  • Medication evaluation and management (pharmacotherapy)
  • Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment (preauthorization required by UHC Behavioral Health Solutions)
  • Treatment and counseling (including individual or group therapy visits)
  • Diagnosis and treatment of substance use disorders, including detoxification, treatment and counseling
  • Repetitive Transcranial Magnetic Stimulation, TMS, for the treatment of depressive disorders which have not been responsive to other interventions such as psychotherapy and antidepressant medications (preauthorization required by UHC Behavioral Health Solutions)
  • Electroconvulsive therapy (preauthorization required by UHC Behavioral Health Solutions)
  • Professional charges for intensive outpatient treatment in a provider's office or other professional setting (preauthorization required by UHC Behavioral Health Solutions)
  • Diagnosis and treatment to address gender dysphoria and gender transition (in-network only). See Sections 5(b) and 5(c) for exclusions.

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Benefits Description : TeleHealth ServicesConsumer Driven Option (You Pay)

Virtual visits through UHC Behavioral Health Solutions for non-emergency visits

Covered services include consultation, diagnosis and prescriptions (when appropriate) through the web or your mobile device.

Please see www.myuhc.com, or call 800-718-1299 to start your virtual visit.

Note:  There is no out-of-network benefit for Virtual visits.

In-network:  15% of the Plan allowance

Out-of-network:  N/A

Benefits Description : DiagnosticsConsumer Driven Option (You Pay)
  • Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
  • Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Benefits Description : Inpatient hospital or other covered facilityConsumer Driven Option (You Pay)

Inpatient services provided and billed by a hospital, Residential Treatment Center (RTC), or other covered facility (preauthorization required by UHC Behavioral Health Solutions)

  • Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
  • Inpatient diagnostic tests provided and billed by a hospital, Residential Treatment Center (RTC), or other covered facility

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • For Residential Treatment Centers, benefits are not available for non-covered services, including: respite care; outdoor residential programs; services provided outside of the provider’s scope of practice; recreational therapy; educational therapy; educational classes; bio-feedback; Outward Bound programs; equine therapy provided during the approved stay; personal comfort items, such as guest meals and beds, telephone, television, beauty and barber services, which may be part of the treatment program’s milieu and/or physical environment, are not covered as separately billed items; custodial or long term care; and domiciliary care provided because care in the home is not available or is unsuitable.

All charges

Benefits Description : Outpatient hospital or other covered facilityConsumer Driven Option (You Pay)

Outpatient services provided and billed by a hospital or other covered facility

  • Services such as partial hospitalization, or facility-based intensive outpatient treatment (preauthorization required by UHC Behavioral Health Solutions)

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Services that require preauthorization that are not part of a preauthorized approved treatment plan
  • Services that are not medically necessary
  • Services performed at schools or other educational institutions
All charges



Section 5 (f). Prescription Drug Benefits (CDHP)

Important things to keep in mind about these benefits:

  • We cover prescribed drugs and medications, as described in the chart below.
  • 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.
  • Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies.  Prior approval/authorizations must be renewed periodically.
  • Federal law prevents the pharmacy from accepting unused medications.
  • In-network Preventive Care is covered at 100% under CDHP Section 5 and does not count against your Personal Care Account.
  • Your Personal Care Account must be used first for eligible healthcare expenses.
  • If your Personal Care Account has been exhausted, you must pay your Net Deductible before your Traditional Health Coverage may begin.  Your Deductible applies to all benefits in this section.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works.  Also read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over. 
  • Prior authorization/medical necessity review is required for certain drugs and must be renewed periodically. Prior authorization uses Plan rules based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective. See the coverage authorization information shown in Section 3, Other services and page 119 for more information about this program.
  • Specialty drugs must be obtained through Optum Rx specialty pharmacy.  Any discount associated with a manufacturer coupon for specialty medications does not apply toward your Deductible or out-of-pocket expenses. 



There are important features you should be aware of.  These include:

Who can write your prescription.  A licensed prescriber or dentist, and in states allowing it, licensed providers with prescriptive authority prescribing within their scope of practice.  

Where can you obtain them.  You can fill the prescription at an Optum Rx 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 the Traditional Prescription Drug Formulary through OptumRx. 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. There are safe, proven medication alternatives in each therapy class that are covered on the formulary. Some drugs will be excluded from the formulary and coverage, visit www.myuhc.com to view a list of excluded medications. This list is not all inclusive and there may be changes to the list during the year. A formulary exception process is available to physicians if they feel the formulary alternatives are not appropriate. Physicians may request a clinical exception by calling 800-718-1299.
  • Member cost-share for prescription drugs is determined by the tier to which a drug has been assigned. To determine the tier assignments for formulary drugs, our Pharmacy Benefit Managers (PBM) work with their Pharmacy and Therapeutic Committee, a group of physicians and pharmacists who are not employees or agents of, nor have financial interest in the Plan. The Committee’s recommendations, together with our PBM's evaluation of the relative cost of the drugs, determine the placement of formulary drugs on a specific tier. Using lower cost preferred drugs will provide you with a high quality, cost-effective prescription drug benefit.
    • Tier 1 - Mostly generic drugs, but some brand-name drugs may be included
    • Tier 2 - A mix of brand-name and generic drugs
    • Tier 3 - Mostly brand-name drugs and some generics

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 generally 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 brand name drug.



Benefit Description : Covered medications and suppliesConsumer Driven Option (You Pay)

Each new enrollee will receive a combined prescription drug/Plan identification card.

You may purchase the following medications and supplies prescribed by a doctor from either a network pharmacy or by mail:

  • Drugs and medications, including those for Tobacco Cessation programs, for use at home that are obtainable only upon a doctor’s prescription
  • Drugs and medications (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 test strips for known diabetics
  • FDA approved drugs for weight management.  Prior approval is required, see page 119
  • Disposable needles and syringes for the administration of covered medications
  • Prior authorization/medical necessity review is required for certain drugs and must be renewed periodically.  Prior authorization/medical necessity review uses Plan rules based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective.  For example, approved drugs for organic impotence are subject to prior Plan approval and limitations on dosage and quantity.  See Section 3, Other services, page 19 and page 119 for more information about this program. 
  • Drugs to treat gender dysphoria
  • Network Retail:
    • Tier 1 and Tier 2 - 25% of charge with a minimum of $15 and a maximum per prescription of $200 for a 30-day supply, $400 for a 60-day supply, $600 for a 90-day supply;
    • Tier 3 - 40% of charge with a minimum $15 and a maximum per prescription of $300 for a 30-day supply, $600 for a 60-day supply, $900 for a 90-day supply
  • Network Home Delivery:
    • Tier 1 and Tier 2 - 25% of charge with a minimum of $10 and a maximum per prescription of $200 for a 30-day supply, $400 for a 60-day supply, $600 for a 90-day supply;
    • Tier 3 - 40% of charge with a minimum $10 and a maximum per prescription of $300 for a 30-day supply, $600 for a 60-day supply, $900 for a 90-day supply

Contraceptives

  • In-network prescription drugs from UnitedHealthcare's Patient Protection and Affordable Care Act (PPACA) Preventive Medications Drug List for contraception for women.  Find the list at www.apwuhp.com.

Note:  If your physician receives prior authorization because it is medically necessary that a contraceptive drug not on the PPACA list be dispensed, you will pay $0.  Your prescriber may seek prior authorization by calling 800-718-1299.

Network Retail:  $0

Network Home Delivery: $0

  • In-network devices approved by the FDA for contraception for women
Nothing
  • Naloxone 0.4 mg/ml vial and Naloxone 2 mg/ml syringe; and Narcan nasal spray for the prevention of opioid overdose related deaths

Network Retail:  Nothing

Network Home Delivery:  Nothing

Not covered:

  • Drugs and supplies for cosmetic purposes
  • Drugs to enhance athletic performance
  • Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them
  • Medical supplies such as dressings and antiseptics
  • Nonprescription medicines/over-the-counter drugs, except as stated below:
    • Over-the counter emergency contraceptive drugs, the "morning after pill", are covered at no cost if prescribed by a doctor and purchased at a network pharmacy
    • Over-the counter FDA-approved female birth control methods are covered at no cost if prescribed by a doctor and purchased at a network pharmacy
    • Certain new prescription drug products until they are reviewed and evaluated by Optum Rx
  • Prescription drugs approved by the U.S. Food and Drug Administration when an over-the-counter equivalent is available.

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation programs, see Educational classes and programs.

Note: Prescription drugs approved by the FDA for contraception for women, see In-network preventive care, Section 5, and for devices for birth control see Family planning, Section 5(a).

All charges



Benefit Description : Preventive care medicationsConsumer Driven Option (You Pay)
  • Medications to promote better health as recommended by ACA.

Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy.  These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients.  For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

  • Network Retail:  Nothing
  • Network Home Delivery:  Nothing



Coverage Authorization

  • The information below describes a feature of your prescription drug plan known as coverage authorization. Coverage authorization determines how your prescription drug plan will cover certain medications.
  • Some medications are not covered unless you receive approval through a coverage review (prior authorization/medical necessity review). Examples of drug categories that require a coverage review include but are not limited to, specialty cholesterol, growth hormones, Botox, Interferons, rheumatoid arthritis agents, Retin A, drugs for organic impotence, and FDA approved drugs for weight management, gender dysphoria and gender transition (in-network only). This review uses plan rules based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective. There are other medications that may be covered with limits (for example, only for a certain amount or for certain uses) unless you receive approval through a review. During this review, Optum Rx asks your prescriber for more information than what is on the prescription before the medication may be covered under your plan. If coverage is approved, you simply pay your normal copayment/coinsurance for the medication. If coverage is not approved, you will be responsible for the full cost of the medication.
  • To determine if a prescription drug product requires prior authorization/medical necessity review visit www.myuhc.com or call 800-718-1299.
  • In our ongoing effort to provide a robust yet cost-effective prescription drug benefit, APWU Health Plan participates in programs to encourage the prescribing and use of generics and lower-cost alternative brands when appropriate.  In most cases, you save money when the preferred generic or formulary brand is dispensed.  One method that has proved effective in saving members money is “Step Therapy.” Step therapy ensures that a first-line generic or brand alternative within a therapeutic category is used first, before the use of a similar but more expensive drug.  Specific therapeutic categories are identified as appropriate for step therapy. Currently, the Plan offers step therapy programs on adrenal agents, specialty cholesterol drugs, Amino Acid Disorder, Asthma, Anticonvulsants, Benign Prostatic Hyperplasia/Erectile Dysfunction, depression, Diabetes, fungal infections, heartburn/reflux/ulcer, hemophilia, Hepatitis C, high cholesterol, infertility, Methotrexate, skin conditions, sleep aids, Opioids and Lyrica. In situations where a targeted drug is prescribed, the pharmacist will be notified to discuss Step 1 alternatives with the prescribing physician.  If a first line therapy is not appropriate, your physician may contact OptumRx’s coverage review unit.  If the coverage is approved, the normal coinsurance and a letter of explanation will be sent to both you and your physician.  If the coverage is not approved, you will be responsible for the full cost of the prescription.  If you do not first obtain the Plan’s approval, you will pay the full cost of the prescription.  The prescriber can request a notification/prior authorization with OptumRx by logging into www.optumrx.com, Healthcare Professionals, Prior Authorization to submit an online notification/prior authorization request or by calling 800-711-4555. You may determine whether a particular prescription is subject to Step Therapy by visiting www.myuhc.com or by calling the number on the back of your ID card.
  • Some Prescription Drugs are subject to supply limits that may restrict the amount dispensed per prescription order or refill and/or the amount dispensed per month’s supply. To determine if a Prescription Drug has been assigned a maximum quantity level for dispensing, either visit www.myuhc.com or call the toll-free number on your ID card. Supply limits are subject to periodic review and modification. Supply limits are based upon the dosing recommendations included in the United States Food and Drug Administration (FDA) labeling, manufacturer’s package size, and information in the medical literature or guidelines. If your current prescription is more than the supply limit, you have the following options: Accept the supply limit; either pay the full cost or an extra copayment for the additional supply; talk to your doctor about medication alternatives.  To determine if your prescription drug product has been assigned a supply limit for dispensing, visit www.myuhc.com or call 800-718-1299.
  • The U.S. Food and Drug Administration (FDA) defines a compound medication as one that requires a licensed pharmacist to combine, mix or alter the ingredients of a medication when filling a prescription.  The FDA does not verify the quality, safety and/or effectiveness of compound medications, therefore the Plan will no longer cover certain compound prescriptions unless FDA approved.  To avoid paying the full cost of these medications, you should ask your prescriber for a new prescription for an FDA-approved drug before your next fill.  Your compound medication may require notification/prior authorization.  The prescriber can request a notification/prior authorization with OptumRx by logging into www.optumrx.com, Healthcare Professionals, Prior Authorization to submit an online notification/prior authorization request or by calling 800-711-4555. If coverage of the medication is approved, you may continue to fill your prescription at the Plan’s normal coinsurance.  If the coverage of the medication is not approved, you will be responsible for the full cost of the prescription.
  • The Plan will participate in other approved managed care programs to ensure patient safety and appropriate therapy in accordance with the Plan rules based on FDA-guidelines referenced above.
  • To find out more about your prescription drug plan, please visit www.myuhc.com or call Member Services at 800-718-1299.
  • “Specialty Drugs” are injectable, infused, oral or inhaled drugs defined as having one or more of several key characteristics:  (1) requires frequent dosing adjustments and intensive clinical monitoring to decrease potential for drug toxicity or increased probability for beneficial treatment outcomes; (2) need for patient training and compliance assistance to facilitate therapeutic goals; (3) limited or exclusive product availability and distribution; (4) specialized product handling and/or administration requirements.  

Some examples of the disease categories currently in the Optum Rx specialty pharmacy programs include cancer, cystic fibrosis, growth hormone deficiency, hemophilia, hypercholesterolemia, immune deficiency, hepatitis C, infertility, multiple sclerosis and rheumatoid arthritis.  In addition, a follow-on-biologic or generic product will be considered a Specialty Drug if the innovator drug is a Specialty Drug.

Many of the Specialty Drugs covered by the Plan fall under the Coverage Authorization.

To determine if your prescription drug product is a Specialty Drug, visit www.myuhc.com or call 800-718-1299.

Specialty medications must be obtained through the Optum Rx specialty pharmacy.  You can send your prescription through your normal mail service process or have your physician fax your prescription to Optum Rx.

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).




Section 5 (g). Dental Benefits (CDHP)

Important things to keep in mind about these benefits:

  • Refer to Personal Care Account (PCA).



Benefits Description : DentalConsumer Driven Option (You Pay)
No benefit

See Personal Care Account, page 83




Section 5 (h). Wellness and Other Special Features (CDHP)

TermDefinition

Flexible benefits option

Under the flexible benefits option, we determine the most effective way to provide services.

  • We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
  • Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
  • By approving an alternative benefit, we do not guarantee you will get it in the future.
  • The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
  • If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
  • Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.  However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process, see Section 8.



Section 5 (i). Health Education Resources and Account Management Tools (CDHP)

TermDefinition

Online tools and resources

  • 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
  • Personal Health Record
  • You can also download UHC Mobile app for the same great features 
Consumer choice information

Each member is provided access by Internet (www.myuhc.com) or telephone 800-718-1299 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

Special Programs

Online programs and services provide extra support and savings, at www.myuhc.com or call 800-718-1299.

  • Maternity Support Program - Mothers-to-be receive support through every stage of pregnancy and delivery.
  • Kidney Resources Program - For those diagnosed with end-stage renal disease or those who are currently receiving dialysis treatment, this program will help you manage your care for the best outcome.
  • Orthopedic Health Support - Orthopedic health support provides support for back, hip, knee, shoulder and neck conditions.
  • Cancer Support Program - Enroll in the program, and receive enhanced benefits at Cancer Centers of Excellence.
  • Real Appeal - This intensive, multi-component behavioral intervention provides a 52-week virtual approach that includes one-on-one coaching and online group participation with supporting video content, delivered by a live virtual coach. ACCESS BY: Calling UHC Member Services or visit the website at https://member.realappeal.com/
  • AbleTo - Customized Behavioral Health 6-8 week digital treatment program.  Includes evidence-based treatment, care plan, digital reinforcement, and clinician/coaching.  24/7 access. ACCESS BY: Calling UHC Member Services or visit the website at https://www.ableto.com/

Wellness Incentive

Receive $25 when you complete an annual physical with a clinical professional each year.

When you complete an annual physical, if you have Self Only coverage, we will add $25 to your Personal Care Account (PCA).  If you have Self Plus One or Self and Family coverage we will add $25 to the Personal Care Account (PCA) for the member, spouse, and each covered dependent who completes the Wellness Exam.  We will add these amounts in the calendar year in which the physical was completed.

Health Risk Assessment

A Health Risk Assessment (HRA) is available at www.myuhc.com or call 800-718-1299. The HRA is an online program that analyzes your health related responses and gives you a personalized plan to achieve specific health goals. Your HRA profile provides information to put you on a path to good physical and mental health.




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 a FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums.  These programs and materials are the responsibility of the Plan, and all appeals must follow the Plan’s guidelines. For additional information contact the Plan at 800-222-2798 or visit their website at www.apwuhp.com.

Conversion Plan Health Insurance

When coverage as an employee or family member ends with any Plan in the Federal Employees Health Benefits Program (FEHB), or when Temporary Continuation of Coverage (TCC) ends (except by cancellation or non-payment of premium), you may be eligible to convert to the APWU Health Plan Conversion Plan.  There is no waiting period, no limitation of coverage for preexisting conditions, and no evidence of good health is necessary.  For additional information, please contact us by calling 800-222-2798 or by going to www.apwuhp.com/Members/for-all-members/Conversion-Option.

Start Hearing                                                                                                                               

The Start Hearing program is an optional program with no additional premium that supplements the 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 Start Hearing Plan through this offer will receive a discount on hearing aid devices and free hearing consultations annually offered through Starkey Hearing Technologies.  To enroll in the plan you must call Start Hearing toll free at 888-863-7222 or visit www.starthearing.com/partners/APWU.  Please specify that you are an APWU Health Plan participant.

Enroll in our Dental Plans

Anyone who is eligible to sign up for an APWU Health Plan can enroll in the following Dental Plans. These are optional programs with an additional premium that supplements the dental benefits in your medical coverage. FEHB members have two options, APWU Health Plan Dental Insurance Plan or Voluntary Benefits Plan Dental Plan. Insured members may use any dentist they choose. The cost of these benefits are not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles, out-of-pocket maximum, copay, charges, etc. These benefits are not subject to the FEHB disputed claims review procedure. For the APWU Health Plan Dental Insurance Plan visit www.apwuhp.com for a brochure and enrollment forms.  All participants of the APWU Health Plan, either High Option or Consumer Driven Option, who enroll in the Voluntary Benefits Plan Dental Plan automatically receive a 7.5% premium reduction off this dental plan's rates.  The Plan is available to all APWU Active, Retired, Associate, PSE and Private Sector due-paying members.  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 800-422-4492; or visit www.voluntarybenefitsplan.com; or email voluntarybenefitsplan@gmail.com.  Please specify that you are an APWU Health Plan participant. This optional dental plan is an indemnity insurance plan underwritten by the United States Life Insurance Company. 

The Supplemental Discount Drug Program

The Supplemental Discount Drug Program will provide discounts to High Option members on all FDA-approved prescription drugs that are dispensed through Express Scripts Mail Order and Retail pharmacies, yet are not covered on the prescription drug plan administered by Express Scripts; www.express-scripts.com, 800-818-6717.

APWU Membership Information

Any annuitant who was in the bargaining unit represented by the APWU prior to retirement must be, or must become, members of the APWU Retirees Department.  All Federal employees, other Postal Service employees in non-APWU bargaining Units, and annuitants will automatically become associate members of the APWU upon enrollment in the APWU Health Plan.  Associate members will be billed by the APWU for annual membership dues, except where exempt by law (survivor annuitant or someone who is eligible for coverage under Spouse Equity Law or TCC).




Section 6. General Exclusions - Services, Drugs and Supplies We Do Not Cover

The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure.  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.  For information on obtaining prior approval for specific services, such as transplants, (see Section 3, You need prior Plan approval for certain services).

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 (see specifics regarding transplants).
  • Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus was carried to term, or when the pregnancy is the result of an act of rape or incest.
  • Services, drugs, or supplies related to sexual dysfunction or sexual inadequacy except for organic impotence, see pages 18-19, 68, 71, 116 and 118.
  • Unless otherwise specified in Section 5, services and supplies for weight reduction/control or treatment of obesity.
  • 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.
  • Services or supplies we are prohibited from covering under Federal Law.
  • 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 yourself, 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 non-covered facility, except 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.
  • General anesthetics for dental services unless due to an underlying medical condition.
  • Services, drugs and supplies billed by schools or other education institutions.
  • Prolotherapy
  • Naturopathic and homeopathic services such as naturopathic medications.
  • 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 16.
  • Any portion of a provider’s fee or charge ordinarily due from the enrollee 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 137-139, doctor charges exceeding the amount specified by the Department of Health and Human Services when benefits are payable under Medicare limiting charge, see page 143, or State premium taxes however applied.
  • Biofeedback; non-medical self care or self help training, such as recreational, educational, or milieu therapy unless specifically listed.
  • Charges that we determine to be in excess of the Plan allowance.
  • "Never Events" are errors in patient care that can and should be prevented.  The APWU Health Plan will follow the policy of the Centers for Medicare and Medicaid Services (CMS).  The Plan will deny payments for care that fall under these policies.  For additional information, please visit www.cms.gov, and enter "Never Events" into SEARCH box.



Section 7.  Filing a Claim For Covered Services

This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received).

See Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval), including urgent care claims procedures.




TermDefinition

How to claim benefits

High Option: To obtain claim forms, claims filing advice or answers about our benefits, contact us at 800-222-2798, or at our website at www.apwuhp.com.

Mail to:

  • Cigna Healthcare, P.O. Box 188004, Chattanooga, TN  37422, or Payor ID 62308
     

Express Scripts claims mail to:

  • APWU Health Plan, P.O. Box 1358, Glen Burnie, MD  21060-1358

Consumer Driven Option: Contact UnitedHealthcare at 800-718-1299 or visit their website at www.myuhc.com.

Mail to:

  • UnitedHealthcare,  P.O. Box 740800, Atlanta, GA 30374-0800

Mental Health/Substance Use Disorder Treatment:  Mail to:

High Option

  • Cigna Healthcare, P.O. Box 188004, Chattanooga, TN  37422 or Payor ID 62308

Consumer Driven Option

  • UnitedHealthcare, P.O. Box 740800, Atlanta, GA  30374-0800

In most cases, providers and facilities file claims for you. Your provider must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, call us at 800-222-2798.

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

  • Patient’s name, date of birth, address, phone number and relationship to enrollee
  • Patient’s plan identification number
  • Name and address of person or company providing the service or supply
  • Dates that services or supplies were furnished
  • Diagnosis
  • Type of each service or supply
  • 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:

  • If another health plan is your primary payor, you must send a copy of the explanation of benefits (EOB) statement you received from your primary payor (such as the Medicare Summary Notice (MSN)) with your claim.
  • Bills for home nursing care must show that the nurse is a registered or licensed practical nurse.
  • If your claim is for the rental or purchase of durable medical equipment; private duty nursing; physical therapy, occupational therapy, or speech therapy, you must provide a written statement from the provider specifying the medical necessity for the service or supply and the length of time needed.
  • Claims for prescription drugs and supplies must include receipts that show the prescription number, name of drug or supply, prescribing provider name, date, and charge.
  • We will provide translation and currency conversion services for claims for overseas (foreign) services.
Post-service claims procedures

We will notify you of our decision within 30 days after we receive your post-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

RecordsKeep 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 claimSend us all 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.  If you could not file on time because of Government administrative operations or legal incapacity, you must submit your claim as soon as reasonably possible.  Once we pay benefits, there is a three-year limitation on the re-issuance of uncashed checks.

Overseas claims

For covered services you receive by providers and hospitals outside the United States and Puerto Rico, 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 1358, Glen Burnie, MD 21060-1358.
  • Consumer Driven Option: UnitedHealthcare at the claims address shown on the back of your UnitedHealthcare ID card.
When we need more informationPlease reply promptly when we ask for additional information. We may delay processing or deny benefits for your claim if you do not respond.  Our deadline for responding to your claim is stayed while we await all of the additional information needed to process your claim.

Authorized Representative

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us.  For urgent care claims, a healthcare professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent.  For the purposes of this section, we are also referring to your authorized representative when we refer to you.

Notice Requirements

The Secretary of Health and Human Services has identified counties where at least 10 percent of the population is literate only in certain non-English languages.  The non-English languages meeting this threshold in certain counties are Spanish, Chinese, Navajo and Tagalog.  If you live in one of these counties, we will provide language assistance in the applicable non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as telephone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes and its corresponding meaning, and the treatment code and its corresponding meaning.




Section 8.  The Disputed Claims Process

You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes.  For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plan's customer service representative at the phone number found on your enrollment card, plan brochure, or plan website.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs or supplies have already been provided).  In Section 3, If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim.  To make your request, please contact our Customer Service Department by writing to APWU Health Plan, Public Relations Department, P.O. Box 1358, Glen Burnie, MD  21060-1358 or calling 800-222-2798.

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

Our reconsideration will not take into account the initial decision.  The review will not be conducted by the same person, or their subordinate, who made the initial decision.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjustor or medical expert) based upon the likelihood that the individual will support the denial of benefits.

Disagreements between you and the CDHP fiduciary regarding the administration of a Personal Care Account (PCA) are not subject to the disputed claims process.




StepDescription

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 1358, Glen Burnie, MD  21060-1358 or send your Consumer Driven Option request to: UnitedHealthcare Appeals, P.O. Box 740816, Atlanta, GA  30374-0816; 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) statements.

(e) Include your email address (optional), if you would like to receive our decision via email.  Please note that by giving us your email, we may be able to provide our decision more quickly. 

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision.  We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date.  However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration.  You may respond to that new evidence or rationale at the OPM review stage described in step 4.

2

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or  

b) Write to you and maintain our denial or

c) Ask you or your provider for more information. 

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. 

3

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 intial 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:  United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB2, 1900 E Street, NW, Washington, DC  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; 
  • Your email address, if you would like to receive OPM’s decision via email.  Please note that by providing your email address, you may receive OPM’s decision more quickly.

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.  However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note:  The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

4

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 file a lawsuit, 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 file a lawsuit 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 you did not indicate that your claim was a claim for urgent care, then, call us at 800-222-2798. We will expedite our review (if we have not yet responded to your claim): or we will inform OPM so they can quickly review your claim on appeal. You may call FEHB2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues.  For example, we do not determine whether you or a dependent is covered under this Plan.  You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.



Section 9. Coordinating Benefits with Medicare and Other Coverage

TermDefinition

When you have other health coverage

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare 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 payor and the other plan pays a reduced benefit as the secondary payor.  We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For example:

  • If you are covered under our Plan as a dependent, any group health insurance you have from your employer will pay primary and we will pay secondary,
  • If you are an annuitant under our Plan and also are actively employed, any group health insurance you have from your employer will pay primary and we will pay secondary.

This Plan always pays secondary to:

  • Any medical payment, PIP or No-Fault coverage under any automobile policy available to you,
  • Any plan or program which is required by law.  You should review your automobile insurance policy to ensure that uncoordinated medical benefits have been chosen so that the automobile insurance policy is the primary payer.

For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.apwuhp.com.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, 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 the secondary payor, we will not waive specified visit limits.

Please see Section 4, Your costs for covered services, for more information about how we pay claims.

  • TRICARE and CHAMPVA

TRICARE is the healthcare 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 TRICARE or CHAMPVA.

  • Workers' Compensation

We do not cover services that:

  • You (or a covered family member) 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.

Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these State programs, eliminating your FEHB 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 under the State program.

When other Government agencies are responsible for your careWe 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

The terms “Reimbursement” and “Subrogation” are defined by the U.S. Office of Personnel Management in Part 890 of the Code of Federal Regulations, 89 C.F.R. § 890.101(a), and those definitions are hereby incorporated into this brochure. Our subrogation and reimbursement rights arise when the individual who suffers an injury or illness has a right to be compensated from another source for that injury or illness as described below.

Reimbursement means a carrier’s pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a Workers' Compensation program or insurance policy, and the terms of the carrier’s health insurance plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

Subrogation means a carrier’s pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a Workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier’s health benefits plan.

The terms reimbursement and subrogation have the same meaning in this brochure as they do in the OPM Rules. Our right to pursue and receive subrogation and reimbursement recoveries is a condition of and a limitation on the nature of benefits or benefit payments and on the provision of benefits under our coverage. This section explains your basic obligations and procedures related to this reimbursement requirement. The funds the Plan recovers through reimbursement and subrogation help lower the subscription charges for all enrollees.

If we pay benefits for an injury or illness suffered by a covered individual, and monetary compensation related to that injury or illness is received from someone else (referred to as a “third party”), the Plan must be reimbursed out of the compensation received for the total amount of benefits it paid or reasonably expects to pay. The amount the Plan is entitled to recover is sometimes referred to as the Plan’s "lien", and the Plan may ask a court to issue an order confirming the Plan’s lien. Reimbursement to the Plan is a requirement and condition on a covered individual obtaining benefits from the Plan under this brochure. The Plan’s recoveries through reimbursement and subrogation help lower subscription charges for all enrollees in the Plan. 

By enrolling in the Plan and in accordance with the FEHB Program and this brochure, you agree that the Plan’s right to pursue and receive subrogation and reimbursement recoveries is a condition of and a limitation on the nature of benefits or benefit payments and on the provision of benefits under our coverage, and you agree to the following:

  • The Plan must be reimbursed in any and all situations where a covered individual, or their representatives, heirs, administrators, successors or assignees receive payment from any source related to an injury or illness for which the individual has received benefits or benefit payments from the Plan. This may include money recovered from another party who may be liable, a third party’s insurance policy, your own insurance policy, or a Workers' Compensation program or policy, through a lawsuit, a judgment, settlement, or other recovery. The Plan must be reimbursed to the extent of the benefits we have paid or provided, or reasonably expect to pay or provide, in connection with the injury or illness.
  • Reimbursement of the Plan must be done on a first priority basis (before any of the rights of any other party are honored) out of any recovery obtained no matter the source (litigation, judgment, settlement, insurance claim or otherwise) and no matter how the recovery is characterized, designated, or apportioned (such as your claim against the third party being for “pain and suffering”).
  • The Plan’s right to reimbursement applies even if the Plan paid benefits before we knew of the accident or illness.
  • Restrictive endorsements or other statements on checks accepted by the Plan or its agents to reimburse the Plan in a subrogation matter will not bind the Plan.
  • Neither you nor your representatives, heirs, administrators, successors or assignees will do anything that would prevent us from being fully reimbursed for the benefits we paid, and you and your representatives, heirs, administrators, successors and assignees will cooperate in assisting us in recovering the cost of the benefits we paid.
  • You agree and authorize the Plan to communicate directly with any involved insurance carriers regarding your injury or illness and their reimbursements.
  • This reimbursement responsibility covers benefits for you and any other person on your membership.

The Plan is entitled to be reimbursed fully even if the amount received does not compensate the injured individual fully or if there are other liens or expenses. We are entitled to be reimbursed for our benefit payments even if the injured individual is not legally “made whole” for all damages arising out of the injury or illness. Our right of recovery is also not subject to reductions for attorney’s fees or costs in recovering the money under the “common fund” or other legal doctrines.

If you wish to discuss the amount of reimbursement to pay to the Plan, please contact Customer Service (High Option, 800-222-2798; Consumer Driven Option, 800-718-1299) or our subrogation representatives at the contact information at the end of this section.

If you or your representatives, heirs, administrators, successors or assignees do not pursue a claim or demand against a third party, we may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

What to communicate to the Plan

  • Promptly inform us if a covered individual has an injury or illness for which benefits paid by the Plan might be reimbursed or subrogated as described here. This includes reporting third party cases to Customer Service or responding to any questionnaires or surveys inquiring about benefit claims paid by the Plan. We or our subrogation representatives will communicate with you about whether you owe the Plan any reimbursement. Failure to provide information related to reimbursements may delay the processing of your benefits.
  • If you or your representatives, heirs, administrators, successors or assignees make a claim or demand on a third party for compensation for an injury or illness for which the Plan has paid benefits, notify us immediately. We will communicate with you to keep the status of the claim or demand updated in our systems so that there is no delay in processing your claims. We may seek a first priority lien on the proceeds of your claim in order to ensure that the Plan is reimbursed for the benefits we paid or will pay. We may also require you to assign to us (1) your claim or demand or (2) your right to the proceeds of your claim or demand. In all cases, we may enforce our right of recovery and reimbursement by offsetting any undisputed amount owed the Plan as a result of recovering money from a third party against future benefit payments by the Plan.

If you need more information  or wish to report or discuss a subrogation or reimbursement matter, please contact Customer Service or our subrogation representatives.

High Option:  ODSA, P.O. Box 34188, Washington, DC  20043-4188; or subroinfo@odsalaw.com, 877-535-1075 or 202-898-1075

Consumer Driven Option: UnitedHealthcare, 800-718-1299

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP)

Some FEHB plans already cover some dental and vision services.  When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage.  FEDVIP coverage pays secondary to that coverage.  When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 877-888-3337, (TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits.  Providing your FEHB information may reduce your out-of-pocket cost.

Clinical trials

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally-funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

  • Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy
  • Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care
  • Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This Plan does not cover these costs



TermDefinition

When you have Medicare

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at  www.medicare.gov.

  • 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.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.

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 will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan. When we are the primary payor, we process the claim first. In this case, we do not waive any out-of-pocket costs.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-222-2798 or see our website at www.apwuhp.com.

We waive some costs if the Original Medicare Plan is your primary payor.

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, we will waive the deductible and coinsurance.
  • Medical services and supplies provided by physicians and other healthcare professionals. If you are enrolled in Medicare Part B, we will waive the deductible, coinsurance and copayment.
  • We offer a Medicare Advantage plan, UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan for Federal members.  Please review the information on coordinating benefits with Medicare Advantage plans below.

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.

Note: We do not waive our deductible, copayments or coinsurance for prescription drugs or for services and supplies that Medicare does not cover. Also, we do not waive benefit limitations, such as the 24-visit limit for chiropractic services or the 60-visit limit for physical, occupational or speech therapy.

You can find more information about how our Plan coordinates benefits with Medicare in APWU Health Plan's Blueprint to Medicare at www.apwuhp.com. We do not waive any costs if the Original Medicare Plan is your primary carrier.

Please review the information on page 140.  It illustrates your cost share if you are enrolled in Medicare Part B. Medicare will be primary for all Medicare eligible services. Members must use providers who accept Medicare's assignment.

  • Tell us about your Medicare coverage
You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask.  You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

Medicare Part B Premium Reimbursement

We offer a plan designed to help members with their Medicare Part B premium.  This plan is called UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan.  If you have Medicare Parts A and B and enroll in the UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan, you will be reimbursed $50.00 of your Medicare Part B monthly premium.  This will be sent from Centers for Medicare & Medicaid Services (CMS) directly to your Social Security.

To learn more about this plan and how to enroll, call us at 1-855-383-8793, 8 a.m. to        8 p.m., local time, Monday through Friday. For TTY for the deaf, hard of hearing, or speech impaired, call 711.  We will send you additional information and an application for enrollment.

  • Private contract with your physician

If you are enrolled in Medicare Part B, 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.  You may be responsible for paying the difference between the billed amount and the amount we paid.

  • Medicare Advantage (Part C)

If you are eligible for Medicare, you may choose to enroll and get your Medicare benefits from a Medicare Advantage plan.  These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country.  To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227), (TTY: 877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage plan:  You may enroll in our Medicare Advantage plan and also remain enrolled in our FEHB plan.  For more information on our Medicare Advantage plan, please contact 855-383-8793.  Enrollment in UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is voluntary.  Members must complete an application for enrollment.  Eligible enrollees voluntarily opt into UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan and may opt out at any time.  You may enroll in the UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan, if:

  • You are a retiree or annuitant enrolled in the High Option and have both Medicare Part A and Part B.
  • You are a United States citizen or are lawfully present in the United States.
  • You do NOT have End-Stage Renal Disease (ESRD).  Enrollees who have ESRD cannot enroll until after the 30-month grace period has expired.  Members diagnosed with ESRD while enrolled in UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan may remain enrolled and ESRD services will be covered.
  • You complete an application for enrollment in the UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan.

Medicare B Premium Reimbursement

  • We offer a plan designed to help members with their Medicare Part B premium.  This plan is called UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan.  If you have Medicare Part A and B and enroll in this plan, you will be reimbursed $50.00 of your Medicare Part B monthly premium.  This will be sent from Centers for Medicare and Medicaid Services (CMS) directly to your Social Security.  Please review the information below.  It illustrates your cost share if you are enrolled in the High Option only, the High Option with Medicare Part B or the UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan.  Medicare will be primary for all Medicare eligible services.  Members must use providers who accept Medicare's assignment. 

Benefit Description: Deductible
High Option You Pay without Medicare (In-Network): $450 Self Only/$800 Family 
High Option You Pay with Medicare B (In-Network): $0
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $0

Benefit Description: Out-of-Pocket Maximum
High Option
You Pay without Medicare (In-Network): $6,500 Self Only/$13,000 Family 
High Option You Pay with Medicare B (In-Network): $6,500 Self Only/$13,000 Family 
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $0

Benefit Description: Part B Premium Reimbursement Offered
High Option You Pay without Medicare (In-Network): N/A
High Option You Pay with Medicare B (In-Network): N/A
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $50 per month

Benefit Description: Primary Care Physician
High Option You Pay without Medicare (In-Network): $25
High Option You Pay with Medicare B (In-Network): $0
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $0

Benefit Description: Specialist
High Option You Pay without Medicare (In-Network): $25 
High Option You Pay with Medicare B (In-Network): $0
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $0

Benefit Description: Inpatient Hospital 
High Option You Pay without Medicare (In-Network): 15%
High Option You Pay with Medicare B (In-Network): $0
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $0

Benefit Description: Outpatient Hospital
High Option You Pay without  Medicare (In-Network): 15%
High Option You Pay with Medicare B (In-Network): $0
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $0

Benefit Description: Incentives offered
High Option You Pay without Medicare (In-Network): N/A
High Option You Pay with Medicare B (In-Network): Waive deductible, coinsurance and copayment
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -  (UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): Silver Sneakers, Podiatry, Hearing aids, Nationwide network

To learn more about the UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan and how to enroll, call us at 855-383-8793, 8 a.m. to 8 p.m., local time, Monday through Friday. For TTY for the deaf, hard of hearing, or speech impaired, call 711.  We will send you additional information and an application for enrollment.

This Plan and another plan’s Medicare Advantage plan:  You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan.  We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers).  For the High Option, we waive some costs if Medicare Advantage is your primary payor.  We will waive our copayments, coinsurance, or deductibles. For the Consumer Driven Option, we will not waive any of our copayments, coinsurance, or deductibles.  If you enroll in a Medicare Advantage plan, tell us.  We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium.  (OPM does not contribute to your Medicare Advantage 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 Advantage plan’s service area.

  • Medicare prescription drug coverage (Part D)
When we are the primary payor, we process the claim first.  If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan.



Primary Payor Chart

A. When you – or your covered spouse are age 65 or over and have Medicare and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant
3) Have FEHB through your spouse who is an active employee
4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above
5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and...
  • You have FEHB coverage on your own or through your spouse who is also an active employee
  • You have FEHB coverage through your spouse who is an annuitant
6) 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) and you are not covered under FEHB through your spouse under #3 above
7) Are enrolled in Part B only, regardless of your employment status ✓ for Part B services ✓ for other services
8) Are a Federal employee receiving Workers' Compensation ✓ *
9) Are a Federal employee receiving disability benefits for six months or more


B. When you or a covered family member...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have Medicare solely based on end stage renal disease (ESRD) and..
  • It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)
  • It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
  • This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)
  • Medicare was the primary payor before eligibility due to ESRD
3) Have Temporary Continuation of Coverage(TCC) and...
  • Medicare based on age and disability
  • Medicare based on ESRD (for the 30-month coordination period)
  • Medicare based on ESRD (after the 30-month coordination period)


C. When either you or a covered family member are eligible for Medicare solely due to disability and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant
D. When you are covered under the FEHB Spouse Equity provision as a former spouse

*Workers' Compensation is primary for claims related to your condition under Workers’ Compensation.




When you are age 65 or over and do not have Medicare

Under the FEHB law, we must limit our payments for inpatient hospital care and physician care to those payments 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.  You and the FEHB benefit from these payment limits.  Outpatient hospital care and non-physician based care are not covered by this law; regular Plan benefits apply.  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 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.
  • The law prohibits a hospital from collecting more than the "equivalent Medicare amount."

And, for your physician care, the law requires us to base our payment and your coinsurance or copayment 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.

Does not participate with Medicare and is not a member of our PPO network,

your out-of-network deductibles, coinsurance, and any balance up to 115% of the Medicare approved amount.

Opts-out of Medicare via private contract,

your deductibles, coinsurance, copayments, and any balance your physician charges.

 

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.

Physicians Who Opt-Out of Medicare

A physician may have opted-out of Medicare and may or may not ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare.  This is different than a non-participating doctor, and we recommend you ask your physician if they have opted-out of Medicare.  Should you visit an opt-out physician, the physician will not be limited to 115% of the Medicare approved amount.  You may be responsible for paying the difference between the billed amount and our regular in-network/out-of-network benefits.

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. 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.  





TermDefinition

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.

We use the Department of Veterans Affairs (VA) Medicare-equivalent Remittance Advice (MRA) when the statement is submitted to determine our payment for covered services provided to you if Medicare is primary, when Medicare does not pay the VA facility.

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 up to our allowance.

Consumer Driven Option:  If your physician accepts Medicare assignment, then you pay nothing if you have unused benefits available under your Personal Care Account (PCA) 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 Deductible or the lesser of your coinsurance or the full difference if your Deductible has been met.

If your physician does not accept Medicare assignment, you pay the difference between the “limiting charge” or the physician’s charge (whichever is less) and our payment combined with Medicare’s payment.

It is important to know that a 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 the Medicare carrier that sent you the MSN form.  Call us if you need further assistance.

Please see Section 9, Coordinating benefits with Medicare and other coverage, for more information about how we coordinate benefits with Medicare.




Section 10.  Definitions of Terms We Use in This Brochure

TermDefinition
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.
Clinical trials

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally-funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application. If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

  • Routine care costs - costs for routine services such as doctors visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy 
  • Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care
  • Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis or results, and clinical tests performed only for research purposes.  These costs are generally covered by the clinical trials.  This Plan does not cover these costs.

Coinsurance

See Section 4, page 26.

Copayment

See Section 4, page 25.

Cost-sharing

See Section 4, page 25.

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

See Section 4, page 25.

Experimental or investigational service

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 protocols 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 healthcare provider or appropriate government publications such as those of the National Institutes of Health, National Cancer Institute, Food and Drug Administration, Agency for Healthcare Research and Quality, and the National Library of Medicine.

Gender Affirming Services

Healthcare that can include therapy to address feelings of gender dysphoria, as well as medical treatments that help individuals achieve physical characteristics that better align with their gender identity.

Genetic screeningThe diagnosis, prognosis, management, and prevention of genetic disease for those patients who have no current evidence or manifestation of a genetic disease and those who have not been determined to have an inheritable risk of genetic disease.
Genetic testingThe diagnosis and management of genetic disease for those patients with current signs and symptoms and for those who we have determined have an inheritable risk of genetic disease.

Group health coverage

Healthcare 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 healthcare 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.

Habilitative services

Healthcare services that help a person keep, learn or improve skills and functioning for daily living.  Examples include therapy for a child who isn't walking or talking at the expected age.  These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Healthcare professional

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

Home healthcare 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.
InfertilityInfertility is the condition of an individual who is unable to conceive or produce conception during a period of 1 year if the female is age 35 or younger or during a period of 6 months if the female is over the age of 35.
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.

Medically necessary

Services, drugs, supplies or equipment provided by a hospital or covered provider of healthcare 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.

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 charges for covered services.

For non-PPO providers, we base the Plan allowance on the lesser of the provider's actual charges or the allowed amount for the service you received.  We determine the allowed amount by using healthcare charge guides which compare charges of other providers for similar services in the same geographical area.  We update these charge guides at least once a year.  For surgery, doctor's services, X-ray, lab and therapies (physical, speech and occupational), we use the following:

  • For the High Option Plan we use guides specifically prepared by Context4Healthcare at the 70th percentile.
  • For the Consumer Driven Option we use guides specifically prepared by Fair Health at the 80th percentile.
  • If this 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.

You should also see section Important Notice About Surprise Billing - Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

Post-service claimsAny claims that are not pre-service.  In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.
Pre-service claimsThose claims (1) that require precertification, prior approval or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.
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.

Reimbursement

A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with, and not exclusive of, the right of subrogation.

Residential Treatment Center

Residential Treatment Centers (RTCs) are accredited by a nationally recognized organization and licensed by the state, district, or territory to provide short-term transitional residential treatment for medical conditions, mental health conditions, and/or substance use.  Accredited healthcare facilities (excluding hospitals, skilled nursing facilities, group homes, halfway houses, and similar types of facilities) provide 24-hour residential evaluation, treatment and comprehensive specialized services relating to the individual's medical, physical, mental health, and/or substance use therapy needs.

SubrogationA carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.
Us/We Us and We refer to APWU Health Plan.
You You refers to the enrollee and each covered family member.

Urgent care claims

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

  • Waiting could seriously jeopardize your life or health;
  • Waiting could seriously jeopardize your ability to regain maximum function; or
  • In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve pre-service claims and not post-service claims.  We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 800-222-2798.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Virtual visits
A virtual visit lets you see and talk to a doctor from your phone, tablet or computer.  A doctor can see and speak to you about minor medical concerns, provide a diagnosis and, if appropriate, a prescription can be sent to your local pharmacy.



Consumer Driven Health Plan Definitions

TermDefinition

Consumer Driven Option

A fee-for-service option under the FEHB that offers you greater control over choices of your healthcare expenditures. You decide what healthcare 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 deductible 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.

Deductible

Under the Consumer Driven Option, your plan's deductible is reduced by applying the funds in your Personal Care Account (PCA) which is funded in January by APWU Health Plan. Your Net Deductible is the remaining deductible amount you have to pay once the funds in your PCA have been exhausted. By using the funds in your PCA to pay for eligible medical expenses you decrease your total deductible and out-of-pocket expenses.  See page 25.

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).

Rollover

As long as you remain in this Plan, any unused remaining balance in your PCA at the end of the calendar year may be rolled over to subsequent years. The maximum amount allowed in your PCA may not exceed $5,000 per Self Only enrollment and $10,000 per Self Plus One or Self and Family enrollment.




Summary of Benefits for the High Option of the APWU Health Plan - 2022

Do not rely on this chart alone. This is a summary.  All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB Brochure. You can also obtain a copy of our Summary of Benefits Coverage as required by the Affordable Care Act at www.apwuhp.com.  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, $450 (PPO) or $1,000 (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 healthcare professional.




High Option BenefitsYou payPage

Medical services provided by physicians

  • Diagnostic and treatment services provided in the office*

PPO: $25 copay per visit (No deductible); 15% of Plan allowance

Non-PPO: 40% of our allowance plus amount over our allowance

35

Services provided by a hospital: 

  • Inpatient

PPO: 15% of Plan allowance

Non-PPO: $300 per admission and 40% of our allowance plus amount over our allowance

55

Services provided by a hospital: 

  • Outpatient*

PPO: 15% of Plan allowance

Non-PPO: 40% of our allowance plus amount over our allowance

57

Emergency benefits: 

  • Accidental injury

PPO: Nothing

Non-PPO: Nothing

60

  • Medical emergency* (other than an Urgent Care Center)

PPO: 15% of Plan allowance

Non-PPO:  15% of Plan allowance

60

Mental health and substance use disorder treatment:

PPO: $25 copay per visit (No deductible); 15% of Plan allowance

Non-PPO: 40% of our allowance plus amount over our allowance

63

Prescription drugs: 

  • Network pharmacy

$10 Tier 1/25% Tier 2/45% Tier 3/Specialty drugs 25% Tier 4/25% Tier 5/45% Tier 6

68

  • Non-network pharmacy

50% of cost

68

  • Mail order

$20 Tier 1/25% Tier 2/45% Tier 3 Specialty drugs 25% Tier 4/25% Tier 5/45% Tier 6

68

Dental care:

30% of Plan allowance plus amount over our allowance

73

Wellness and other special features:

Flexible benefits option, 24-hour nurse line, services for deaf and hearing-impaired, Disease Management Program, Review and Reward program, Diabetes and Weight Management Programs, online access to claims information, online Preferred Provider Organization (PPO) directories, Hospital Quality Ratings Guide, Treatment Cost Estimator, online non-FEHB savings on health and wellness products and Health Risk Assessment (HRA) savings. 

See Section 5(h)

74

Protection against catastrophic costs (out-of-pocket maximum):

PPO: Nothing after $6,500 for Self Only or $13,000 for a Self Plus One or Self and Family enrollment per year

Non-PPO: Nothing after $12,000 for Self Only, or $24,000 for a Self Plus One or Family enrollment per year

Some costs do not count toward this protection

28




Summary of Benefits for the CDHP of the APWU Health Plan - 2022

Do not rely on this chart alone. This is a summary.  All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB Brochure. You can also obtain a copy of our Summary of Benefits Coverage as required by the Affordable Care Act at www.apwuhp.com.  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 Net Deductible, $450 (PPO) or $1,000 (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 healthcare professional.




CDHP BenefitsYou PayPage

In-network preventive care:

Nothing

80

Personal Care Account:

Up to $1,200 for Self Only or $2,400 for Self Plus One or Self and Family for medical, surgical, hospital, mental health and substance use disorder treatment services and prescription drugs plus certain dental and vision care

Nothing up to $1,200 for Self Only or $2,400 for Self Plus One or Self and Family

84

Traditional Health Coverage after Personal Care Account is exhausted

See Section 5 Traditional Health Overview (Net Deductible before Traditional Health Coverage Begins)

86

Medical/Surgical services provided by physicians: 

  • Diagnostic and treatment services provided in the office*

In-network: 15% of Plan allowance
Out-of-network: 50% of our allowance plus amount over our allowance

89

Services provided by a hospital: 

  • Inpatient*

In-network: 15% of Plan allowance
Out-of-network: 50% of our allowance plus amount over our allowance

107

  • Outpatient*

In-network: 15% of Plan allowance
Out-of-network: 50% of our allowance plus amount over our allowance

109

Emergency benefits: 

  • Accidental injury*

In-network: 15% of Plan allowance

Out-of-network:  15% of Plan allowance

112

  • Medical emergency*  (other than an Urgent Care Center)

In-network:  15% of Plan allowance

Out-of-network: 15% of Plan allowance

112

Mental health and substance use disorder treatment*:

In-network: 15% of Plan allowance
Out-of-network: 50% of our allowance plus amount over our allowance

113-114

Prescription drugs:

  • Network Retail*

25% minimum $15 Tier 1 & Tier 2/40% minimum $15 Tier 3

117

  • Network Home Delivery*

25% minimum $10 Tier 1 & Tier 2/40% minimum $10 Tier 3

117

Dental Care/Vision Care (covered only under Personal Care Account):

Any amount over $400 per Self Only or $800 per Self Plus One or Self and Family (see Section 5 Extra PCA Expenses).

84

Health education resources and account management tools:

Online tools and resources, Consumer choice information, Services for deaf and hearing-impaired, online special programs for extra support savings, $25 wellness incentive when you complete an annual physical, and Health Risk Assessment (HRA).

See Section 5(i)

123

Protection against catastrophic costs (out-of-pocket maximum):

In-network: Nothing after $6,500 Self Only or $13,000 for a Self Plus One or Self and Family enrollment per year

Out-of-network: Nothing after $12,000 Self Only or $24,000 for a Self Plus One or Self and Family enrollment per year

Some costs do not count toward this protection

29




Index

Index Entry
(Page numbers solely appear in the printed brochure)



Notes

2022 Rate Information for the APWU Health Plan

To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium.

Premiums for Tribal employees are shown under the Monthly Premium Rate column.  If you are a Tribal employee, the amount shown under “Your Share” is the maximum you will pay.  Your Tribal employer may choose to contribute a higher portion of your premium.  Please contact your Tribal Benefits Officer for exact rates.




Nationwide
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
High Option Self Only471$244.86$106.39$530.53$230.51
High Option Self Plus One473$524.63$212.96$1,136.70$461.41
High Option Self and Family472$574.13$268.83$1,243.95$582.46
CDHP Option Self Only474$208.96$69.65$452.75$150.91
CDHP Option Self Plus One476$454.15$151.38$983.99$327.99
CDHP Option Self and Family475$495.44$165.14$1,073.45$357.81