APWU Health Plan

www.apwuhp.com

Customer Service 800-222-2798

2018
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 IMPORTANT
page 8 for details. This plan is accredited. See page 13. • Rates: Back Cover
• Changes for 2018: Page 15
Sponsored and administered by: American Postal Workers Union, • Summary of benefits: Page 146
AFL-CIO
Who may enroll in this Plan: All Federal and Postal Service
employees and annuitants who are eligible to enroll in the FEHB
Program may become members of this Plan. To enroll, you must be, or
must become, a member or associate member of the American Postal
Workers Union, AFL-CIO.

To become a member or associate member: All active Membership dues: Associate members will be billed
Postal Service APWU bargaining unit employees must by the APWU for the $35 annual membership fee,
be, or must become, dues-paying members of the except where exempt by law. APWU will bill new
APWU, to be eligible to enroll in the Health Plan. All associate members for the annual dues when it receives
Federal employees, other Postal Service employees in notice of enrollment. APWU will also bill continuing
non-APWU bargaining units, and annuitants will associate members for the annual membership. Active
automatically become associate members of APWU and retiree non-associate APWU membership dues
upon enrollment in the APWU Health Plan. vary.

Enrollment codes for this Plan:

471 High Option - Self Only/473 High Option - Self Plus One/472 High Option - Self and Family
474 Consumer Driven Option - Self Only/476 Consumer Driven Option - Self Plus One/475
Consumer Driven Option - Self and Family

RI 71-004
 Important Notice from APWU Health Plan About
Our Prescription Drug Coverage and Medicare
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’s at least as good
as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1% 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 (800-633-4227), (TTY: 877-486-2048).
 Table of Contents
Introduction ...................................................................................................................................................................................4
Plain Language ..............................................................................................................................................................................4
Stop Health Care Fraud! ...............................................................................................................................................................4
Discrimination is Against the Law ................................................................................................................................................5
Preventing Medical Mistakes ........................................................................................................................................................6
FEHB Facts ...................................................................................................................................................................................8
Coverage information .........................................................................................................................................................8
• No pre-existing condition limitation...............................................................................................................................8
• Minimum essential coverage (MEC) ..............................................................................................................................8
• Minimum value standard ................................................................................................................................................8
• Where you can get information about enrolling in the FEHB Program .........................................................................8
• Types of coverage available for you and your family ....................................................................................................8
• Family Member Coverage ..............................................................................................................................................9
• Children's Equity Act ....................................................................................................................................................10
• When benefits and premiums start ...............................................................................................................................10
• When you retire ............................................................................................................................................................11
When you lose benefits .....................................................................................................................................................11
• When FEHB coverage ends ..........................................................................................................................................11
• Upon divorce.................................................................................................................................................................11
• Temporary Continuation of Coverage (TCC) ...............................................................................................................11
• Converting to individual coverage ...............................................................................................................................12
• Health Insurance Marketplace ......................................................................................................................................12
• APWU Health Plan Notice of Privacy Practices ..........................................................................................................12
Section 1. How this Plan works ..................................................................................................................................................13
General features of our High Option.................................................................................................................................13
General features of our Consumer Driven Health Plan (CDHP) ......................................................................................13
How we pay providers ......................................................................................................................................................14
Your rights and responsibilities .........................................................................................................................................14
Your medical and claims records are confidential ............................................................................................................14
Section 2. Changes for 2018 .......................................................................................................................................................15
Changes to this Plan ..........................................................................................................................................................15
Section 3. How you get care ......................................................................................................................................................16
Identification cards ............................................................................................................................................................16
Where you get covered care ..............................................................................................................................................16
• Covered providers.........................................................................................................................................................16
• Covered facilities ..........................................................................................................................................................16
• Transitional care ...........................................................................................................................................................17
• If you are hospitalized when your enrollment begins...................................................................................................17
You need prior Plan approval for certain services ............................................................................................................17
• Inpatient hospital admission .........................................................................................................................................17
• Other services ...............................................................................................................................................................18
How to request precertification for an admission or get prior authorization for Other services ......................................19
What happens when you do not follow the precertification rules.....................................................................................19
• Radiology/imaging procedures precertification ...........................................................................................................20
• How to precertify a radiology/imaging procedure .......................................................................................................20
• Non-urgent care claims .................................................................................................................................................20

2018 APWU Health Plan 1 Table of Contents

 • Urgent care claims ........................................................................................................................................................21
• Concurrent care claims .................................................................................................................................................21
• Emergency inpatient admission ....................................................................................................................................21
• Maternity care ...............................................................................................................................................................22
• If your hospital stay needs to be extended ....................................................................................................................22
• If your treatment needs to be extended .........................................................................................................................22
If you disagree with our pre-service decision ...................................................................................................................22
• To reconsider a non-urgent care claim ..........................................................................................................................22
• To reconsider an urgent care claim ...............................................................................................................................23
• To file an appeal with OPM ..........................................................................................................................................23
Section 4. Your costs for covered services .................................................................................................................................24
Cost-sharing ......................................................................................................................................................................24
Copayment ........................................................................................................................................................................24
Deductible .........................................................................................................................................................................24
Coinsurance .......................................................................................................................................................................25
If your provider routinely waives your cost ......................................................................................................................25
Waivers ..............................................................................................................................................................................25
Differences between our allowance and the bill ...............................................................................................................25
Your Catastrophic protection out-of-pocket maximum for deductibles, coinsurance and copayments............................26
Carryover ..........................................................................................................................................................................29
If we overpay you .............................................................................................................................................................29
When Government facilities bill us ..................................................................................................................................29
Section 5. Benefits .....................................................................................................................................................................30
High Option Overview ................................................................................................................................................................32
Consumer Driven Health Plan Benefits ......................................................................................................................................73
Non-FEHB benefits available to Plan members .......................................................................................................................118
Section 6. General exclusions - services, drugs and supplies we do not cover ........................................................................121
Section 7. Filing a claim for covered services .........................................................................................................................122
Section 8. The disputed claims process....................................................................................................................................125
Section 9. Coordinating benefits with Medicare and other coverage .......................................................................................128
When you have other health coverage ............................................................................................................................128
• TRICARE and CHAMPVA ........................................................................................................................................128
• Workers' Compensation ..............................................................................................................................................128
• Medicaid .....................................................................................................................................................................128
When other Government agencies are responsible for your care ...................................................................................128
When others are responsible for injuries.........................................................................................................................129
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) ........................................................131
Clinical trials ...................................................................................................................................................................131
When you have Medicare ...............................................................................................................................................131
• What is Medicare? ......................................................................................................................................................131
• Should I enroll in Medicare? ......................................................................................................................................132
• The Original Medicare Plan (Part A or Part B)...........................................................................................................132
• Tell us about your Medicare coverage ........................................................................................................................133
• Private contract with your physician ..........................................................................................................................133
• Medicare Advantage (Part C) .....................................................................................................................................133
• Medicare prescription drug coverage (Part D) ...........................................................................................................134
When you are age 65 or over and do not have Medicare ................................................................................................136
When you have the Original Medicare Plan (Part A, Part B, or both) ............................................................................137
Section 10. Definitions of terms we use in this brochure ........................................................................................................138

2018 APWU Health Plan 2 Table of Contents

Section 11. Other Federal Programs .........................................................................................................................................143
The Federal Flexible Spending Account Program - FSAFEDS ......................................................................................143
The Federal Employees' Dental and Vision Insurance Program - FEDVIP ...................................................................144
The Federal Long Term Care Insurance Program - FLTCIP ..........................................................................................145
The Federal Employees' Group Life Insurance Program - FEGLI .................................................................................145
Summary of benefits for the High Option of the APWU Health Plan - 2018...........................................................................146
Summary of benefits for the CDHP of the APWU Health Plan - 2018 ....................................................................................148
Index..........................................................................................................................................................................................150
2018 Rate Information for the APWU Health Plan ..................................................................................................................154

2018 APWU Health Plan 3 Table of Contents

 Introduction
This brochure describes the benefits of APWU Health Plan under our contract (CS 1370) with 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 and
Family coverage, each eligible family member is also entitled to these benefits. If you are enrolled in Self Plus One coverage,
you and one eligible family member that you designate when you enroll are entitled to these benefits. You do not have a right
to benefits that were available before January 1, 2018, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2018, and changes are
summarized on page 15. Rates are shown at the end of this brochure.
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.
The ACA establishes a minimum value for the standard of benefits of a health plan. The minimum value standard is 60%
(actuarial value). The health coverage of this plan does meet the minimum value standard for benefits the plan provides.

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 or family member;
“we” means APWU Health Plan.
• We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the 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 Health Care Fraud!

Fraud increases the cost of health care 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 telephone or to people you do not know, except for your health
care provider, authorized health benefits plan, or OPM representative.
• Let only the appropriate medical professionals review your medical record or recommend services.
• Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to
get it paid.

2018 APWU Health Plan 4 Introduction/Plain Language/Advisory

• 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 that 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 HEALTH CARE 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 he/she was disabled and incapable of self-support prior to age 26).
• 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, to include both Title VII of the Civil Rights
Act of 1964 and Section 1557 of the Affordable Care Act. Pursuant to Section 1557 the APWU Health Plan does not
discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex.

2018 APWU Health Plan 5 Introduction/Plain Language/Advisory

 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 health care 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 medicines you take.
• Bring the actual medicines or give your doctor and pharmacist a list of all the medicines and dosage that you take,
including non-prescription (over-the-counter) medicines 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 medicine is what the doctor ordered. Ask the pharmacist about your medicine if it looks different than you
expected.
• Read the label and patient package insert when you get your medicine, including all warnings and instructions.
• Know how to use your medicine. Especially note the times and conditions when your medicine 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 health care 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?”

2018 APWU Health Plan 6 Introduction/Plain Language/Advisory

 - “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 health care 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 health care providers and improve
the quality of care you receive.
• www.npsf.org. The National Patient Safety Foundation has information on how to ensure safer health care 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 medicines.
• 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 health care professionals working
to improve patient safety.

Preventable Healthcare Acquired Conditions ("Never Events")

When you enter the hospital for treatment of one medical problem, you don’t 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 health care 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 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.

2018 APWU Health Plan 7 Introduction/Plain Language/Advisory

 FEHB Facts

Coverage information

• No pre-existing We will not refuse to cover the treatment of a condition you had before you enrolled in
condition limitation this Plan solely because you had the condition before you enrolled.

• Minimum essential Coverage under this plan qualifies as minimum essential coverage (MEC) and satisfies the
coverage (MEC) 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 Our health coverage meets the minimum value standard of 60% established by the ACA.
standard 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 See www.opm.gov/healthcare-insurance/healthcare for enrollment information as well as:
information about • Information on the FEHB Program and plans available to you
enrolling in the FEHB
Program • 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 don’t determine who is eligible for coverage and, in most cases, cannot change your
enrollment status without information from your employing or retirement office. For
information on your premium deductions, you must also contact your employing or
retirement office.

• Types of coverage Self Only coverage is for you alone. Self Plus One coverage is an enrollment that covers
available for you and you and one eligible family member. Self and Family coverage is for you, your spouse,
your family 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.

2018 APWU Health Plan 8 FEHB Facts

 If you have a Self Only enrollment, you may change to a Self and Family or Self Plus One
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.

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, that person may
not be enrolled in or covered as a family member by 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 www.opm.gov/healthcare-insurance/life-events/. If you need
assistance, please contact your employing agency, Tribal Benefits Officer, personnel/
payroll office, or retirement office.

• Family Member Family members covered under your Self and Family enrollment are your spouse
Coverage (including a valid common law marriage) 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.

Children Coverage
Natural children, adopted children, and Natural, adopted children and stepchildren
stepchildren are covered until their 26th birthday.
Foster children 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 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 Married children (but NOT their spouse or
their own children) are covered until their
26th birthday.
Children with or eligible for employer- Children who are eligible for or have their
provided health insurance 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.

2018 APWU Health Plan 9 FEHB Facts

 • 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 Blue Cross and Blue Shield
Service Benefit Plan’s Basic Option;
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves
the area where your children live, your employing office will change your enrollment
to Self 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 Blue Cross and Blue Shield Service Benefit Plan’s Basic
Option.

As long as the court/administrative order is in effect, and you have at least one child
identified in the order who is still eligible under the FEHB Program, you cannot cancel
your enrollment, change to Self Only, or change to a plan that doesn’t serve the area in
which your children live, unless you provide documentation that you have other coverage
for the children.

If the court/administrative order is still in effect when you retire, and you have at least one
child still eligible for FEHB coverage, you must continue your FEHB coverage into
retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to
a plan that doesn’t 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 The benefits in this brochure are effective January 1. If you joined this Plan during Open
premiums start 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 paid according to the 2018 benefits of your old plan or
option except 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 2018 but any unused PCA benefits from 2017 will be available to
you. However, if your old plan left the FEHB Program at the end of the year, you are
covered under that plan’s 2017 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.

2018 APWU Health Plan 10 FEHB Facts

 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

• When FEHB coverage You will receive an additional 31 days of coverage, for no additional premium, when:
ends • Your enrollment ends, unless you cancel your enrollment; or
• You are 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.

• Temporary If you leave Federal service, Tribal employment, or if you lose coverage because you no
Continuation of longer qualify as a family member, you may be eligible for Temporary Continuation of
Coverage (TCC) 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.

2018 APWU Health Plan 11 FEHB Facts

 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 If you leave Federal or Tribal service, your employing office will notify you of your right
individual coverage 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, and 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 If you would like to purchase health insurance through the Affordable Care Act's Health
Marketplace 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 The APWU Health Plan's Notice of Privacy Practices describes how medical information
Notice of Privacy about you may be used by the Health Plan, your rights concerning your health information
Practices 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 e-mail through the website, www.apwuhp.com, or by calling
800-222-2798.

2018 APWU Health Plan 12 FEHB Facts

 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.ncqa.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 health care 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 health care
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. However, if
surgical services are rendered at a PPO hospital or a PPO freestanding ambulatory facility by a PPO primary surgeon, we will
pay the services of anesthesiologists and surgical assistants who are not preferred providers at the PPO rate, based on Plan
allowance. If the covered services are performed at a PPO hospital or a PPO freestanding ambulatory facility, we will pay
the services of radiologists and pathologists who are not preferred providers at the PPO rate, based on the Plan allowance.
High Option PPO Network: Contact APWU Health Plan at 800-222-2798 to request a High Option PPO directory. You can
also go to our website, www.apwuhp.com. 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, Cigna 800-582-1314. For providers in the U.S. Virgin Islands call V.I. Equicare 340-774-5779 and for hospitals in
the U.S. Virgin Islands call Cigna 800-582-1314. For mental health/substance misuse disorder treatment providers (all
states), call Beacon Health Options toll-free 888-700-7965.
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.
This Plan offers you access to certain non-PPO health care providers that have agreed to discount their charges. Covered
services by these providers are considered at the negotiated rate subject to applicable deductibles, copayments and
coinsurance. Since these providers are not PPO providers, non-PPO benefit levels will apply. Contact Cigna at
800-582-1314, prompt 8, for more information.

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.

2018 APWU Health Plan 13 Section 1

• 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.
Non-PPO providers: We determine our allowance for covered charges by using health care charge data prepared by
Context4Healthcare for the High Option and Fair Health for the Consumer Driven Health Plan, including our own data, when
necessary. We apply this charge data under the High Option at the 70th percentile and under the Consumer Driven Option at
the 80th percentile.

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 of 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 personal health information (PHI). For more information regarding access to PHI,
visit our website APWU Health Plan at www.apwuhp.com to obtain a Notice of our 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.

2018 APWU Health Plan 14 Section 1

 Section 2. Changes for 2018
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 Postal premium will increase for (Category 1) or decrease for (Category 2) Self Only, Self Plus One and
Self and Family (see page 154).
• Your share of the non-Postal premium will decrease for Self Only, Self Plus One and Self and Family (see page 154).
• The Plan will add coverage for 3D mammograms under preventive and diagnostic and treatment services (see pages 34
and 35).
• The Plan will add coverage for Transcranial Magnetic Stimulation (TMS) for the treatment of depressive disorders not
responsive to other mental health interventions (see page 60).
• High technology imaging (CAT/CT, MRI, MRA, Nuclear Cardiology and PET) at an Urgent Care Center are subject to
deductible and coinsurance in Section 5(a) and require precertification (see page 58).
• The Plan's Diabetes Management Program will apply regular cost-sharing to in-network medical visits and lab tests;
syringes, pen needles and Insulin Pump supplies; and in-network Insulin Pump. The Program will continue to offer 100%
coverage for formulary generic drugs and blood glucose test strips and lancets by mail order (see pages 70-71).
• The Plan will eliminate the Hypertension Management Program.
• The catastrophic out-of-pocket maximum costs will increase for Self Plus One and Self and Family: In-network will be
$9,000 and out-of-network will be $15,000 (see pages 26-28).
• Prior approval/pre-notification will not be required for physical and occupational therapy (see page 40).
• Acupuncture procedures will be limited to 26 procedures per person per year (see page 44).
• The Plan will increase the coinsurance for non-preferred brand name drugs to 45% (see page 64).
• The in-network copayment to see a physician, including specialists, will be $25 (see pages 33-34 and 59-60).
Changes to our Consumer Driven Health Plan only
• Your share of the Postal premium will increase for Self Only, Self Plus One and Self and Family (see page 154).
• Your share of the non-Postal premium will increase for Self Only, Self Plus One and Self and Family (see page 154).
• The Plan will add coverage for 3D mammograms under preventive and diagnostic and treatment services (see pages 77
and 85).
• The Plan will add coverage for Transcranial Magnetic Stimulation (TMS) for the treatment of depressive disorders not
responsive to other mental health interventions (see page 107).
• The Plan will eliminate the Diabetes Management Program 100% incentives, but will continue to offer health coaching for
diabetes (see page 116).
• The Plan will add a 40% coinsurance for non-preferred brand name drugs (see page 109).
• The Plan will add to the Step therapy program asthma, hemophilia, hepatitis C, high cholesterol, and methotrexate (see
page 112).

2018 APWU Health Plan 15 Section 2

 Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID
card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your 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 or write to us at P.O. Box 1358, Glen Burnie,
MD 21060-1358 or through our website at www.apwuhp.com.
• Consumer Driven Option: Call UnitedHealthcare at 800-718-1299 or write to us at
P.O. Box 740810, Atlanta, GA 30374-0810 or request replacement cards through the
website at www.myuhc.com.

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

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

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 health care services in the normal course of
business. Covered services must be provided in the state in which the practitioner is
licensed or certified.

• 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 misuse disorder treatment.
• Hospital
1. An institution which is accredited as a hospital under the Hospital Accreditation
Program of the Joint Commission on Accreditation of Healthcare Organizations, or
2. Any other institution which is operated pursuant to law, under the supervision of a
staff of doctors and twenty-four hour a day nursing service, and which is primarily
engaged in providing: a) general inpatient care and treatment of sick and injured
persons through medical, diagnostic and major surgical facilities, all of which must be
provided on its premises or under its control, or b) specialized inpatient medical care
and treatment of sick or injured persons through medical and diagnostic facilities
(including X-ray and laboratory) on its premises, under its control, or through a
written agreement with a hospital (as defined above) or with a specialized provider of
those facilities.

2018 APWU Health Plan 16 Section 3

 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 continue until the end of your postpartum care, even if it is beyond the
90 days.

• If you are hospitalized We pay for covered services from the effective date of your enrollment. However, if you
when your enrollment are in the hospital when your enrollment in our High Option begins, call our Customer
begins 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 The pre-service claim approval processes for inpatient hospital admissions (called
approval for certain precertification) and for other services, are detailed in this Section. A pre-service claim is
services 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 or $100 for certain outpatient radiology/imaging
procedures.

• Inpatient hospital Precertification is the process by which – prior to your inpatient hospital admission – we
admission 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.

2018 APWU Health Plan 17 Section 3

 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 they have contacted us.

Warning We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us
for precertification. If the stay is not medically necessary, we will 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 (High Option) and some require pre-
notification (Consumer Driven Option):
• Prior approval/pre-notification is required for organ transplantation. Call before your
first evaluation as a potential candidate.
• Prior approval/pre-notification is required for surgical procedures which may be
cosmetic in nature such as eyelid surgery (blepharoplasty) or varicose vein surgery
(sclerotherapy).
• Prior approval/pre-notification is required for services and supplies which may be
experimental/investigational.
• Prior approval/pre-notification is required for recognized surgery for morbid obesity
(bariatric surgery) or for organic impotence.
• Prior approval/pre-notification is required for Applied Behavioral Analysis (ABA).
• Prior approval/pre-notification is required for home health care such as nursing visits,
infusion therapy, growth hormone therapy (GHT), rehabilitative and habilitative
therapy (speech therapy - High Option only) and pulmonary rehabilitation programs.
• Prior approval/pre-notification is required for durable medical equipment such as
wheelchairs, oxygen equipment and supplies, artificial limbs (prosthetic devices) and
braces.
• Prior approval is required for genetic testing including BRCA testing (High Option
only). See Definitions, Section 10.
• Prior approval is required for 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: trigger point injections, epidural steroid injections,
facet joint injections, sacroiliac joint injections (High Option only).
• Prior approval for the High Option for outpatient services at Veterans Administration
facilities is not needed.

High Option: Call Cigna/CareAllies at 800-582-1314 if you need any of the services
listed above.

Consumer Driven Option: Call UnitedHealthcare at 800-718-1299 if you need any of

the services listed above. UnitedHealthcare requires prior authorization for certain
covered health services.

2018 APWU Health Plan 18 Section 3

 • Prior approval/pre-notification 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 67 and Optum Rx at 800-718-1299 for the Consumer Driven Option
(Section 5(f), page 112).
• Prior approval is also required for mental health and substance misuse disorder
benefits, inpatient, in-network or out-of-network. Prior approval is required for
psychological and neuropsychological testing, Electroconvulsive therapy, Transcranial
Magnetic Stimulation (TMS), and services such as partial or full day hospitalization or
facility-based intensive outpatient treatment (Beacon Health Options). Under the High
Option and the Consumer Driven Option, call Beacon Health Options at
888-700-7965.

How to request • High Option: First you, your representative, your physician, or your hospital must
precertification for an call Cigna/CareAllies at 800-582-1314 at least 2 business days before admission or
admission or get prior services requiring prior authorization are rendered. For mental health and substance
authorization for Other misuse disorder inpatient treatment, your physician or your hospital must call Beacon
services Health Options at 888-700-7965 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 misuse disorder inpatient treatment, your doctor or your hospital must call
Beacon Health Options at 888-700-7965 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 • If no one contacts us, we will decide whether the hospital stay was medically
do not follow the necessary.
precertification rules • If we determine that the stay was medically necessary, we will pay the inpatient
charges, less the $500 penalty.

2018 APWU Health Plan 19 Section 3

 If we determine that it was not medically necessary for you to be an inpatient, we will not
pay inpatient hospital benefits. We will only pay for any covered medical supplies and
services that are otherwise payable on an outpatient basis.

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

When we precertified the admission but you remained in the hospital beyond the number
of days we approved and did not get the additional days precertified, then:
• For the part of the admission that was medically necessary, we will pay inpatient
benefits, but
• For the part of the admission that was not medically necessary, we will pay only
medical services and supplies otherwise payable on an outpatient basis and will not
pay inpatient benefits.

• Radiology/imaging High Option: Radiology precertification is required prior to scheduling specific imaging
procedures procedures. We evaluate the medical necessity of your proposed procedure to ensure that
precertification 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:

• CAT/CT – Computerized Axial Tomography
• MRI – Magnetic Resonance Imaging
• MRA – Magnetic Resonance Angiography
• PET – Positron Emission Tomography

• How to precertify a For these outpatient studies, you, your representative or doctor must call Cigna/CareAllies
radiology/imaging before scheduling the procedure. The toll free number is 800-582-1314.
procedure • 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 inpatient hospital
• The procedure is performed as an emergency

• Non-urgent care For non-urgent care claims, we will tell the physician and/or hospital the number of
claims 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.

2018 APWU Health Plan 20 Section 3

 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 it is an urgent care claim by
applying the judgment of a prudent layperson who 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 OPM's Health Insurance 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, then we will
make a decision within 24 hours after we receive the claim.

• Emergency inpatient If you have an emergency admission due to a condition that you reasonably believe puts
admission 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.

2018 APWU Health Plan 21 Section 3

 • 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,
then 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 his or her own right. If the newborn
is eligible for coverage, regular medical or surgical benefits apply rather than maternity
benefits.

• If your hospital stay High Option: If your hospital stay – including for maternity care – needs to be extended,
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.

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

If you disagree with our If you have a pre-service claim and you do not agree with our decision regarding
pre-service decision 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- Within 6 months of our initial decision, you may ask us in writing to reconsider our initial
urgent care claim 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 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 health care 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.

2018 APWU Health Plan 22 Section 3

 You or your provider must send the information so that we receive it within 60 days of our
request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the
date the information was due. We will base our decision on the information we already
have. We will write to you with our decision.

3. Write to you and maintain our denial.

• To reconsider an In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial
urgent care claim 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 After we reconsider your pre-service claim, if you do not agree with our decision, you
OPM may ask OPM to review it by following Step 3 of the disputed claims process detailed in
Section 8 of this brochure.

2018 APWU Health Plan 23 Section 3

 Section 4. Your costs for covered services
This is what you will pay out-of-pocket for covered care:
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 $350 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 $350. 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 $700. 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 $700. If you use non-PPO providers, your calendar year deductible
increases to a maximum of $500 per person ($1,000 per Self Plus One and Self and
Family). Whether or not you use PPO providers, your calendar year deductible will
not exceed $500 per person ($1,000 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 ($350) 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 old
plan between January 1 and the effective date of your new plan. If you change plans at
another time during the year, you must begin a new deductible under your new plan.

2018 APWU Health Plan 24 Section 4

 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 your bridge between your Personal Care
Account (PCA) and your Traditional Health Coverage. After you have exhausted your
PCA, you must pay your Deductible before your Traditional Health Coverage begins.
Your Deductible is generally $800 for a Self Only enrollment or $1,600 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 Deductible of $800, Traditional Health Coverage
begins for that individual. Once the other covered members meet the additional $800
Deductible, Traditional Health Coverage begins for them. 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). Also, there is no separate Deductible for
mental health and substance misuse disorder benefits under the Consumer Driven Option.

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 30% 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 If your provider routinely waives (does not require you to pay) your copayments,
waives your cost deductibles, or coinsurance, the provider is misstating the fee and may be violating the
law. In this case, when we calculate our share, we will reduce the provider’s fee by the
amount waived.

For example, if your physician ordinarily charges $100 for a service but routinely waives
your 30% coinsurance, the actual charge is $70. We will pay $49 (70% of the actual
charge of $70).

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 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 High Option: Our “Plan allowance” is the amount we use to calculate our payment for
allowance and the bill 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.

2018 APWU Health Plan 25 Section 4

 • PPO providers agree to limit what they will bill you. Because of that, when you use a
preferred provider, your share of covered charges consists only of your deductible and
coinsurance or copayment. Here is an example about coinsurance: You see a PPO
physician who charges $150, but our allowance is $100. If you have met your
deductible, you are only responsible for your coinsurance. That is, you pay just -- 10%
of our $100 allowance ($10). Because of the agreement, your PPO physician will not
bill you for the $50 difference between our allowance and his/her bill.
• Non-PPO providers, on the other hand, have no agreement to limit what they will bill
you. When you use a non-PPO provider, you will pay your deductible and coinsurance
-- plus any difference between our allowance and charges on the bill. Here is an
example: You see a non-PPO physician who charges $150 and our allowance is again
$100. Because you’ve met your deductible, you are responsible for your coinsurance,
so you pay 30% of our $100 allowance ($30). Plus, because there is no agreement
between the non-PPO physician and us, the physician can bill you for the $50
difference between our allowance and his/her bill.

The following table illustrates the examples of how much you have to pay out-of-pocket
for services from a PPO physician vs. a non-PPO physician. The table uses our example of
a service for which the physician charges $150 and our allowance is $100. The table
shows the amount you pay if you have met your calendar year deductible.

EXAMPLE PPO physician Non-PPO physician

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

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.

Your Catastrophic There is a limit to the amount you must pay out-of-pocket for combined medical and
protection out-of-pocket prescription drug coinsurance for the year for certain charges. When you have reached this
maximum for limit, you pay no coinsurance for covered services for the remainder of the calendar year.
deductibles, coinsurance
and copayments High Option:

PPO benefit: Your out-of-pocket maximum is $5,500 for combined medical and
prescription drugs for Self Only enrollment or $9,000 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.

2018 APWU Health Plan 26 Section 4

 Non-PPO benefit: Your out-of-pocket maximum is $10,000 for combined medical and
prescription drugs for Self Only enrollment, or $15,000 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 10% 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 misuse disorder treatment; and the medical
deductible
• The 30% you pay for non-PPO; 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 misuse disorder treatment,
dental; and the medical deductible
• The copayment of $25 for outpatient visits to PPO physicians and virtual visits
• The copayment of $40 for outpatient facility charges in an Urgent Care Center
• The 25% you pay for in-network preferred brand name prescription drugs, 45% for in-
network non-preferred brand name prescription drugs and the $10 and $20 you pay for
in-network generic prescription drugs, and 25% for generic specialty drugs

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)
• The $300 per admission for non-PPO inpatient hospital charges
• Expenses in excess of visit maximums for physical, occupational and speech therapy
(see page 40), and acupuncture (see page 44)
• Expenses incurred in excess of the $90 per day provided under home nursing care (see
pages 43-44); and
• 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:

2018 APWU Health Plan 27 Section 4

 In-network benefit: Your out-of-pocket maximum is $5,000 for combined medical and
prescription drugs for a Self Only enrollment or $10,000 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 $10,200 for combined medical

and prescription drugs for a Self Only enrollment or $13,700 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 40% you pay for out-of-network inpatient and outpatient hospital charges,
surgical, medical, maternity and emergency services under the Traditional Health
Coverage; and the Deductible
• The 25% you pay for in-network generic and preferred brand name prescription drugs;
and 40% for in-network non-preferred brand name 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)
• 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

2018 APWU Health Plan 28 Section 4

 Carryover If you changed to this Plan during Open Season from a plan with a catastrophic protection
benefit and the effective date of the change was after January 1, any expenses that would
have applied to that plan’s catastrophic protection benefit during the prior year will be
covered by your old plan if they are for care you received in January before your effective
date of coverage in this Plan. If you have already met your old 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 old plan will first
apply your covered out-of-pocket expenses until the prior year’s catastrophic level is
reached and then apply the catastrophic protection benefit to covered out-of-pocket
expenses incurred from that point until the effective date of your coverage in this Plan.
Your old 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 of the Department of Veterans Affairs, the Department of Defense, and the
facilities bill us 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.

2018 APWU Health Plan 29 Section 4

 Section 5. Benefits
See page 15 for how our benefits changed this year. Page 146 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.
High Option Overview ................................................................................................................................................................32
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals ................................33
Diagnostic and treatment services.....................................................................................................................................33
TeleHealth Services...........................................................................................................................................................34
Lab, X-ray and other diagnostic tests................................................................................................................................34
Preventive care, adult ........................................................................................................................................................34
Preventive care, children ...................................................................................................................................................36
Maternity care ...................................................................................................................................................................37
Family planning ................................................................................................................................................................38
Infertility services .............................................................................................................................................................39
Allergy care .......................................................................................................................................................................39
Treatment therapies ...........................................................................................................................................................39
Physical and occupational therapies .................................................................................................................................40
Applied behavioral analysis (ABA) ..................................................................................................................................40
Speech therapy ..................................................................................................................................................................40
Hearing services (testing, treatment, and supplies)...........................................................................................................41
Vision services (testing, treatment, and supplies) .............................................................................................................41
Foot care ............................................................................................................................................................................41
Orthopedic and prosthetic devices ....................................................................................................................................42
Durable medical equipment (DME) ..................................................................................................................................42
Home health services ........................................................................................................................................................43
Chiropractic .......................................................................................................................................................................44
Alternative treatments .......................................................................................................................................................44
Educational classes and programs.....................................................................................................................................44
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals ...........................46
Surgical procedures ...........................................................................................................................................................46
Reconstructive surgery ......................................................................................................................................................47
Oral and maxillofacial surgery ..........................................................................................................................................48
Organ/tissue transplants ....................................................................................................................................................49
Anesthesia .........................................................................................................................................................................52
Section 5 (c). Services provided by a hospital or other facility, and ambulance services ..........................................................53
Inpatient hospital ...............................................................................................................................................................53
Cancer Centers of Excellence ...........................................................................................................................................55
Outpatient hospital or ambulatory surgical center ............................................................................................................55
Extended care benefits/Skilled nursing care facility benefits ...........................................................................................55
Hospice care ......................................................................................................................................................................55
End of life care ..................................................................................................................................................................56
Ambulance ........................................................................................................................................................................56
Section 5 (d). Emergency services/accidents .............................................................................................................................57
Accidental injury ...............................................................................................................................................................58
Medical emergency ...........................................................................................................................................................58
Ambulance ........................................................................................................................................................................58
Section 5 (e). Mental health and substance misuse disorder benefits .........................................................................................59
Professional services .........................................................................................................................................................59

2018 APWU Health Plan 30 High Option Section 5

 Diagnostics ........................................................................................................................................................................60
Inpatient hospital or other covered facility .......................................................................................................................60
Outpatient hospital or other covered facility.....................................................................................................................61
Section 5 (f). Prescription drug benefits ....................................................................................................................................62
Covered medications and supplies ....................................................................................................................................64
Preventive care medications..............................................................................................................................................66
Section 5 (g). Dental benefits .....................................................................................................................................................69
Accidental injury benefit ...................................................................................................................................................69
Dental benefits service ......................................................................................................................................................69
Section 5 (h). Wellness and Other Special features ...................................................................................................................70
Flexible benefits option .....................................................................................................................................................70
24-hour nurse line .............................................................................................................................................................70
Services for deaf and hearing impaired.............................................................................................................................70
Disease Management Program..........................................................................................................................................70
Diabetes Management Program ........................................................................................................................................70
Review and Reward Program ...........................................................................................................................................71
Weight Management Program...........................................................................................................................................71
Healthy Pregnancies, Healthy Babies Program ................................................................................................................71
Special Programs...............................................................................................................................................................71
Online tools and resources ................................................................................................................................................71
Health Risk Assessment (HRA) ........................................................................................................................................72
Consumer choice information ...........................................................................................................................................72
Summary of benefits for the High Option of the APWU Health Plan - 2018...........................................................................146

2018 APWU Health Plan 31 High Option Section 5

 High Option

High Option Overview

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 misuse 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 contraceptives, including prescription drug 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 misuse 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 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 Diabetes 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 eHealthRecord. 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.

2018 APWU Health Plan 32 High Option Section 5 Overview

 High Option

Section 5 (a). Medical services and supplies provided by physicians and other health
care professionals
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 - $350 per person ($700 per Self Plus One enrollment, or $700
per Self and Family enrollment); non-PPO - $500 per person ($1,000 per Self Plus One enrollment,
or $1,000 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, keep in mind that the professionals who provide services to you in
the hospital, may not all be preferred providers. If they are not, they will be paid by this Plan as non-
PPO providers. However, if surgical services are rendered at a PPO hospital or a PPO freestanding
ambulatory facility by a PPO primary surgeon, we will pay the services of anesthesiologists and
surgical assistants who are not preferred providers at the PPO rate, based on Plan allowance. If the
covered services are performed at a PPO hospital or a PPO freestanding ambulatory facility, we will
pay the services of radiologists and pathologists who are not preferred providers at the PPO rate,
based on the Plan allowance and you may be billed any difference between our allowance and the
billed amount.
• 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.
Benefit Description You Pay
After the calendar year deductible...
Note: The calendar year deductible applies to almost all benefits in this Section. We say "(No deductible)" when it
does not apply.
Diagnostic and treatment services
Professional services of physicians PPO: $25 copayment (No deductible)
• In physician’s office Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Professional services of physicians PPO: 10% of the Plan allowance
• During a hospital stay Non-PPO: 30% of the Plan allowance and any
• In a skilled nursing facility difference between our allowance and the
• Second surgical opinion billed amount

• At home

• At Cancer Centers of Excellence PPO Cancer Center of Excellence (COE): 5%

of the Plan allowance

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 High Option

Benefit Description You Pay

After the calendar year deductible...
TeleHealth Services
• Virtual visits PPO: $25 copayment (No deductible)

Please see www.AmWell.com, or call 855-818-DOCS for information Non-PPO: N/A

on virtual visits

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

Lab, X-ray and other diagnostic tests
Tests, such as: PPO: 10% of the Plan allowance
• Blood tests Non-PPO: 30% of the Plan allowance and any
• Urinalysis difference between our allowance and the
• Non-routine pap tests billed amount
• Pathology Note: If your PPO provider uses a non-PPO lab
• X-rays or radiologist, we will pay non-PPO benefits
for lab and X-ray charges billed by these non-
• Non-routine mammograms, including 3D mammograms PPO providers.
• CT Scans/MRI/MRA/NC/PET (Outpatient requires precertification –
see Section 3, except for NC)
• Ultrasound
• Electrocardiogram and EEG

If LabCorp or Quest Diagnostics performs your covered lab services, Nothing (No deductible)
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.

Not covered: All charges
• Professional fees for automated lab tests
• Genetic screening (see Definition, Section 10)

Pharmacogenomic testing to optimize prescription drug therapies for PPO: Nothing (No deductible)
certain conditions:
Non-PPO: 30% of the Plan allowance and any
• Plavix (antiplatelet) difference between our allowance and the
• Warfarin (anticoagulant) billed amount

Preventive care, adult

We provide benefits for a comprehensive range of preventive care PPO: Nothing (No deductible)
services for adults. One routine examination per person per calendar
year. Lab tests covered are: Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
• Comprehensive Metabolic Panel billed amount
• Lipid Panel
• Urinalysis
• Complete Blood Count (CBC)
• Routine Electrocardiogram (EKG)
• Chest X-ray

Preventive care, adult - continued on next page

2018 APWU Health Plan 34 High Option Section 5(a)
 High Option

Benefit Description You Pay

After the calendar year deductible...
Preventive care, adult (cont.)
• Hemoglobin A1C PPO: Nothing (No deductible)

Note: Other laboratory work, X-rays and other diagnostic tests Non-PPO: 30% of the Plan allowance and any
performed, when medically necessary, during a routine exam are subject difference between our allowance and the
to the benefits under Diagnostic and treatment services. billed amount

Routine screenings, such as: PPO: Nothing (No deductible)

• Total Blood Cholesterol – once annually Non-PPO: 30% of the Plan allowance and any
• Fasting lipoprotein profile, once every 5 years for adults age 20 or difference between our allowance and the
over billed amount
• Colorectal Cancer Screening, including:
- Fecal occult blood test, once annually, ages 40 and older
- Sigmoidoscopy screening, starting at age 50
- Colonoscopy, starting at age 50
• Shingles vaccine, starting at age 60
• HIV screening
• One-time hepatitis C test for those born from 1945-1965
• Low-dose CT scan for those at risk of lung cancer, one annually for
adults age 55-80 (Requires prior approval, see Section 3)
• Routine Prostate Specific Antigen (PSA) test, one annually for men
age 40 and older
• Abdominal Aortic Aneurysm screening, once for men between the
ages of 65 and 75 with a smoking history
• Biometric screening, once annually

Note: Biometric screening includes Body Mass Index (BMI), Lipid

Panel, Total Blood Cholesterol, blood pressure, and Comprehensive
Metabolic Panel, as listed above in Preventive care, adult.
Adult immunizations endorsed by the Centers for Disease Control and
Prevention (CDC) in a physician's office or at a select in-network retail
pharmacy: based on the Advisory Committee on Immunization
Practices (ACIP) schedule.

Note: For immunizations for shingles at a network pharmacy, age 60 or

older pay nothing; age 59 or younger, see Section 5(f), Prescription drug
benefits.
Well woman care based on current recommendations such as: PPO: Nothing (No deductible)
• One annual routine gynecological visit Non-PPO: 30% of the Plan allowance and any
• Routine mammograms, including 3D mammograms - covered for difference between our allowance and the
women age 35 and older; as follows: billed amount
- 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
• Cervical cancer screening (Pap smear)
• Human Papillomavirus (HPV) testing
• Chlamydia/Gonorrhea screening

Preventive care, adult - continued on next page

2018 APWU Health Plan 35 High Option Section 5(a)
 High Option

Benefit Description You Pay

After the calendar year deductible...
Preventive care, adult (cont.)
• Osteoporosis screening PPO: Nothing (No deductible)
• Breast cancer screening Non-PPO: 30% of the Plan allowance and any
• Counseling for sexually transmitted infections difference between our allowance and the
• Counseling and screening human immune-deficiency virus billed amount

• Contraceptives, such as surgically implanted contraceptives,

injectable contraceptive drugs, intrauterine devices, and diaphragms
(See Family planning, Section 5(a))
• Contraceptive methods and counseling
• Sterilization procedures (See Surgical procedures, Section 5(b))
• Patient education and counseling for all women with reproductive
capacity
• Screening and counseling for women for interpersonal and domestic
violence
• Genetic testing for BRCA for women whose family is associated with
increased risk of BRCA1 or BRCA2 (Preauthorization is required.
See Other Services, Section 3)

Note: In-network prescription drugs and devices approved by the FDA

for contraception can be found in Section 5(f), Prescription drug
benefits.
Note: In-network facility and lab services directly related to covered, in-
network preventive care will also be covered at 100%.
Preventive care, children
Well-child visits, examinations, and immunizations as described in the PPO: Nothing (No deductible)
Bright Future Guidelines provided by the American Academy of
Pediatrics Non-PPO: Any difference between the Plan
allowance and the billed charge (No
deductible)
• Examinations, limited to: PPO: Nothing (No deductible)
- Examinations for amblyopia and strabismus-limited to one Non-PPO: Any difference between the Plan
screening examination (age 3 through 5) allowance and the billed charge and any
- Examinations done on the day of immunizations (ages 3 up through amount above $250 per child (ages 0 through
21) 3) each year and any amount above $150 per
- One Screening Examination of Premature Infants for Retinopathy child (ages 4 through 18) each year (No
of Prematurity or infants with low birth weight or gestational age of deductible)
32 weeks or less

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 listing of services will be subject to the
applicable member copayments, coinsurance, and deductible.

Preventive care, children - continued on next page

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 High Option

Benefit Description You Pay

After the calendar year deductible...
Preventive care, children (cont.)
Note: A complete list of preventive care services recommended under
the U.S. Preventive Services Task Force (USPSTF) is available online
at www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-
recommendations.

HHS: www.healthcare.gov/preventive-care-benefits

CDC: www.cdc.gov/vaccines/schedules/index.html

Women's preventive services:

www.healthcare.gov/preventive-care-women/

For additional information:

www.healthfinder.gov/myhealthfinder/default.aspx

Note: For a complete list of the American Academy of Pediatrics Bright

Futures Guidelines go to www.brightfutures.aap.org/Pages/default.aspx

Not covered: All charges

• Adult immunizations not endorsed by the CDC
• Routine diagnostic tests associated with preventive care other than
those specified as covered
• 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

Maternity care
Complete maternity (obstetrical) care, such as: PPO: Nothing (No deductible)
• Screening for gestational diabetes for pregnant women after 24 weeks Non-PPO: 30% of the Plan allowance and any
• Prenatal care difference between our allowance and the
• Delivery billed amount

• Postnatal care
Note: For inpatient hospital care related to
• Initial examination of a newborn child covered under a Self Plus One maternity, we pay for covered services in full
or Self and Family enrollment when you use preferred providers.
• Breastfeeding support, supplies and counseling for each birth
Note: In-network facility and lab services
directly related to covered, in-network
maternity care will also be covered at 100%.

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal or cesarean delivery; see
page 22 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.

Maternity care - continued on next page

2018 APWU Health Plan 37 High Option Section 5(a)
 High Option

Benefit Description You Pay

After the calendar year deductible...
Maternity care (cont.)
• 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 his or her
own right. If the newborn is eligible for coverage, regular medical or
surgical benefits apply rather than maternity benefits.
• We will cover other care of an infant who requires non-routine PPO: 10% of the Plan allowance
treatment if we cover the infant under a Self Plus One or Self and
Family enrollment. Surgical benefits, not maternity benefits, apply to Non-PPO: 30% of the Plan allowance and any
circumcision of a covered newborn. difference between our allowance and the
billed amount
Note: To obtain the in-network breastfeeding equipment and supplies, PPO: Nothing (No deductible)
please call 877-466-0164 after 28 weeks of pregnancy. A physician's
order is required. Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered: All charges
• Amniocentesis if for diagnosing multiple births
• Genetic screening (see Definitions, Section 10)

Family planning
A range of voluntary family planning services, limited to: PPO: Nothing (No deductible)
• Contraceptive counseling for women Non-PPO: 30% of the Plan allowance and any
• Voluntary sterilization for women (See Surgical procedures Section 5 difference between our allowance and the
(b)) billed amount
• 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.
• Voluntary sterilization for men (See Surgical procedures, Section 5 PPO: 10% of the Plan allowance
(b))
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered: All charges
• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

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 High Option

Benefit Description You Pay

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

Non-PPO: 30% of the Plan allowance, any

difference between our allowance and the
billed amount and any amount over $2,500
Not covered: All charges
• 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

Allergy care
• Testing and treatment, including materials (such as allergy serum) PPO: 10% of the Plan allowance
• Allergy injections Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered: All charges
• Provocative food testing
• Sublingual allergy desensitization

Treatment therapies
• Chemotherapy and radiation therapy PPO: 10% of the Plan allowance

Note: High dose chemotherapy in association with autologous bone Non-PPO: 30% of the Plan allowance and any
marrow transplants is limited to those transplants listed on pages 49-51. difference between our allowance and the
billed amount
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)

Note: We only cover IV/Infusion therapy and GHT when we

preauthorize 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.

Treatment therapies - continued on next page

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 High Option

Benefit Description You Pay

After the calendar year deductible...
Treatment therapies (cont.)
Note: Growth hormone and any drugs used for the administration of PPO: 10% of the Plan allowance
Home Intravenous (IV) Infusion are covered under the prescription drug
benefit. If the drugs are obtained through Accredo Health Group, Non-PPO: 30% of the Plan allowance and any
Express Scripts' specialty pharmacy, they will be paid at the in-network difference between our allowance and the
prescription drug benefit. If they are not obtained through Accredo billed amount
Health Group, Express Scripts' specialty pharmacy, they will be paid at
the out-of-network prescription drug benefit. (See Prescription drug
benefits, Section 5(f)).
• Respiratory and inhalation therapies

Physical and occupational therapies

Physical therapy and occupational therapy provided by a licensed PPO: 10% of the Plan allowance
registered therapist up to a combined 60 visits per calendar year
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
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.
Not covered: All charges
• Maintenance therapies
• Exercise programs

Applied behavioral analysis (ABA)

Outpatient Applied Behavioral Analysis (ABA) services, for the PPO: 10% of the Plan allowance
treatment of Autism Spectrum Disorder. Services must be provided
under the supervision of a Board Certified Behavior Analyst who is Non-PPO: All charges
contracted with Beacon Health Options, or agrees to participate with
Beacon Health Options’ care management activities. (Preauthorization
required by Beacon Health Options)
Note: Beacon 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.
Speech therapy
Speech therapy where medically necessary and provided by a licensed PPO: 10% of the Plan allowance
therapist
Non-PPO: 30% of the Plan allowance and any
Note: Preauthorization of speech therapy is required. See Other services, difference between our allowance and the
Section 3. billed amount

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.

2018 APWU Health Plan 40 High Option Section 5(a)

 High Option

Benefit Description You Pay

After the calendar year deductible...
Hearing services (testing, treatment, and supplies)
• For treatment related to illness or injury, including evaluation and PPO: 10% of the Plan allowance
diagnostic hearing tests performed by an M.D., D.O., or audiologist
Non-PPO: 30% of the Plan allowance and any
• One examination and testing for hearing aids every 2 years difference between our allowance and the
billed amount
Note: For routine hearing screening performed during a child's
preventive care visit, see Section 5(a), Preventive care, children.

• External hearing aids Note: For benefits for the devices, see Section
• Implanted hearing-related devices, such as bone anchored hearing 5(a), Orthopedic and prosthetic devices.
aids (BAHA) and cochlear implants

Not covered: All charges

• Hearing services that are not shown as covered

Vision services (testing, treatment, and supplies)

• Internal (implant) ocular lenses and/or the first contact lenses required PPO: 10% of the Plan allowance
to correct an impairment caused by accident or illness. The services of
an optometrist are limited to the testing, evaluation and fitting of the Non-PPO: 30% of the Plan allowance and any
first contact lenses required to correct an impairment caused by difference between our allowance and the
accident or illness billed amount

Note: See Section 5(a), Preventive care, children for eye exams for
children.
Not covered: All charges
• Eyeglasses or contact lenses and examinations for them
• Eye exercises and visual training
• Radial keratotomy and other refractive surgery

Foot care
Routine foot care when you are under active treatment for a metabolic or PPO: $25 copayment for the office visit (No
peripheral vascular disease, such as diabetes deductible) plus 10% of the Plan allowance for
other services performed during the visit

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

difference between our allowance and the
billed amount
Not covered: All charges
• 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)

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 High Option

Benefit Description You Pay

After the calendar year deductible...
Orthopedic and prosthetic devices
• Artificial limbs and eyes PPO: 10% of the Plan allowance
• Stump hose Non-PPO: 30% of the Plan allowance and any
• Externally worn breast prostheses and surgical bras, including difference between our allowance and the
necessary replacements following a mastectomy billed amount
• 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.

Note: We require preauthorization of artificial limbs. See Other

services, Section 3.
Note: We will pay only for the cost of the standard item. Coverage for
specialty items, such as bionics, is limited to the cost of the standard
item.

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.
External hearing aids PPO: All charges in excess of $1,500, up to the
• Covered every 3 years limited to $1,500 PPO allowance (No deductible)

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

Note: Excluding batteries, benefits for hearing aid dispensing fees, deductible)
accessories, supplies, and repair service are included in the benefit limit
described above.
Not covered: All charges
• 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

Durable medical equipment (DME)

Durable medical equipment (DME) is equipment and supplies that: PPO: 10% of the Plan allowance
1. Are prescribed by your attending physician (i.e., the physician who is Non-PPO: 30% of the Plan allowance and any
treating your illness or injury) difference between our allowance and the
2. Are medically necessary billed amount
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

Durable medical equipment (DME) - continued on next page

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 High Option

Benefit Description You Pay

After the calendar year deductible...
Durable medical equipment (DME) (cont.)
6. Serve a specific therapeutic purpose in the treatment of an illness or PPO: 10% of the Plan allowance
injury
Non-PPO: 30% of the Plan allowance and any
We cover rental or purchase, of durable medical equipment, at our difference between our allowance and the
option, including repair and adjustment. Covered items include but are billed amount
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.
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.
Not covered: All charges
• 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

Home health services

Services for skilled nursing care up to 25 visits per calendar year, not to PPO: 10%; all charges after we pay $90 per
exceed a maximum Plan payment of $90 per day, when preauthorized day
and:
Non-PPO: 30%; all charges after we pay $90
• a registered nurse (R.N.), licensed practical nurse (L.P.N.) or licensed per day
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

Home health services - continued on next page

2018 APWU Health Plan 43 High Option Section 5(a)
 High Option

Benefit Description You Pay

After the calendar year deductible...
Home health services (cont.)
Note: Skilled nursing care must be preauthorized. See Other services, PPO: 10%; all charges after we pay $90 per
Section 3. day

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

per day
Not covered: All charges
• 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

Chiropractic
Chiropractic treatment limited to 12 visits and/or manipulations per year PPO: $25 copayment (No deductible)

Note: X-rays covered under Lab, X-ray and other diagnostic tests. Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount.
Not covered: All charges
• Massage therapy
• Maintenance therapy

Alternative treatments
Acupuncture – by a doctor of medicine or osteopathy or licensed PPO: $25 copayment (No deductible)
acupuncturist, benefits are limited to 26 procedures per person per
calendar year Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
• anesthesia billed amount
• pain relief

Not covered: All charges

• Services of any provider not listed as covered; see Covered providers
Section 3

Educational classes and programs

If you are an APWU Health Plan member, you may enroll in a Tobacco PPO: Nothing (No deductible)
Cessation Program as follows:
Non-PPO: 30% of the Plan allowance and any
• Telephonic counseling sessions with Cigna/CareAllies or; difference between our allowance and the
• Group therapy sessions or; billed amount
• 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.

Educational classes and programs - continued on next page

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 High Option

Benefit Description You Pay

After the calendar year deductible...
Educational classes and programs (cont.)
Prescription drugs (through Express Scripts by Mail only) approved by PPO: Nothing (No deductible)
the FDA to treat tobacco dependence for Tobacco Cessation.
Non-PPO: 50% of the cost with a $10
Over-the-counter drugs (through Cigna/CareAllies only) approved by minimum coinsurance per prescription for a
the FDA to treat tobacco dependence for Tobacco Cessation. 30-day supply (No deductible)

Childhood obesity education PPO: Nothing (No deductible)

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

difference between our allowance and the
billed amount
Diabetes self-management training services, up to 10 hours initial PPO: 10% of the Plan allowance
training the first year and 2 hours subsequent training annually.
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount

2018 APWU Health Plan 45 High Option Section 5(a)

 High Option

Section 5 (b). Surgical and anesthesia services

provided by physicians and other health care professionals
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 - $350 per person ($700 per Self Plus One enrollment, or $700
per Self and Family enrollment); Non-PPO - $500 per person ($1,000 per Self Plus One enrollment,
or $1,000 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, keep in mind that the professionals who provide services to you in
the hospital, may not all be preferred providers. If they are not, they will be paid by this Plan as non-
PPO providers. However, if surgical services are rendered at a PPO hospital or a PPO freestanding
ambulatory facility by a PPO primary surgeon, we will pay the services of anesthesiologists and
surgical assistants who are not preferred providers at the PPO rate, based on Plan allowance. If the
covered services are performed at a PPO hospital or a PPO freestanding ambulatory facility, we will
pay the services of radiologists and pathologists who are not preferred providers at the PPO rate,
based on the Plan allowance and you may be billed any difference between our allowance and the
billed amount.
• 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.
Benefit Description You Pay
After the calendar year deductible…
Note: The calendar year deductible applies to almost all benefits in this Section. We say “(No deductible)” when it
does not apply.
Surgical procedures
A comprehensive range of services, such as: PPO: 10% of the Plan allowance
• Operative procedures Non-PPO: 30% of the Plan allowance and any
• Treatment of fractures, including casting difference between our allowance and the
• Normal pre- and post-operative care by the surgeon billed amount

• 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)
• Insertion of internal prosthetic devices. See Section 5(a), Orthopedic
and prosthetic devices for device coverage information
• Voluntary sterilization for men (e.g., Vasectomy)

Surgical procedures - continued on next page

2018 APWU Health Plan 46 High Option Section 5(b)
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Benefit Description You Pay

After the calendar year deductible…
Surgical procedures (cont.)
• Treatment of burns PPO: 10% of the Plan allowance
• Assistant surgeons - We cover up to 20% of our allowance for the Non-PPO: 30% of the Plan allowance and any
surgeon’s charge difference between our allowance and the
billed amount
• Voluntary sterilization for women (e.g., Tubal ligation) PPO: Nothing (No deductible)
• Surgically implanted contraceptives Non-PPO: 30% of the Plan allowance and any
• Intrauterine devices (IUDs) difference between our allowance and the
billed amount.
When multiple or bilateral surgical procedures performed during the PPO: 10% of the Plan allowance for the
same operative session add time or complexity to patient care, our primary procedure and 10% of one-half of the
benefits are: Plan allowance for the secondary procedure(s)
• For the primary procedure: Non-PPO: 30% of the Plan allowance for the
- PPO: 90% of the Plan allowance; or primary procedure and 30% of one-half of the
- Non-PPO: 70% of the Plan allowance Plan allowance for the secondary procedure(s);
and any difference between our allowance and
• For the secondary procedure(s): the billed amount
- PPO: 90% of one-half of the Plan allowance or
- Non-PPO: 70% of one-half of the Plan allowance

Note: Multiple or bilateral surgical procedures performed through the

same incision are “incidental” to the primary surgery. That is, the
procedure would not add time or complexity to patient care. We do not
pay extra for incidental procedures.
Not covered: All charges
• 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))
• Surgery for the sole purpose of gender reassignment or for the sole
purpose of changing physical appearance to conform with gender
identity

Reconstructive surgery
• Surgery to correct a functional defect PPO: 10% of the Plan allowance
• Surgery to correct a condition caused by injury or illness if: Non-PPO: 30% of the Plan allowance and any
- The condition produced a major effect on the member’s appearance difference between our allowance and the
and billed amount
- The condition can reasonably be expected to be corrected by such
surgery

Reconstructive surgery - continued on next page

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Benefit Description You Pay

After the calendar year deductible…
Reconstructive surgery (cont.)
• Surgery to correct a condition that existed at or from birth and is a PPO: 10% of the Plan allowance
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft Non-PPO: 30% of the Plan allowance and any
palate; birth marks (including port wine stains); and webbed fingers difference between our allowance and the
and toes. billed amount

• 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 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.
Not covered: All charges
• 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
• Surgery for the sole purpose of gender reassignment or for the sole
purpose of changing physical appearance to conform with gender
identity

Oral and maxillofacial surgery

Oral surgical procedures, limited to: PPO: 10% of the Plan allowance
• Reduction of fractures of the jaw or facial bones Non-PPO: 30% of the Plan allowance and any
• Surgical correction of cleft lip, cleft palate or severe functional difference between our allowance and the
malocclusion billed amount
• 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

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Benefit Description You Pay

After the calendar year deductible…
Oral and maxillofacial surgery (cont.)
• Removal of foreign body, skin, subcutaneous alveolar tissue, reaction- PPO: 10% of the Plan allowance
producing foreign bodies in the musculoskeletal system and salivary
stones Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
• Incision/excision of salivary glands and ducts billed amount
• 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.
Not covered: All charges
• 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

Organ/tissue transplants
These solid organ transplants are subject to medical necessity and PPO: 10% of the Plan allowance
experimental/investigational review by the Plan. Refer to Other services
in Section 3 for prior authorization procedures. Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
Solid organ transplants are limited to: billed amount and any amount over $50,000 for
• Cornea kidney transplants or $100,000 for other listed
transplants
• 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

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Benefit Description You Pay

After the calendar year deductible…
Organ/tissue transplants (cont.)
• Autologous pancreas islet cell transplant (as an adjunct to total or near PPO: 10% of the Plan allowance
total pancreatectomy) only for patients with chronic pancreatitis
Non-PPO: 30% 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 PPO: 10% of the Plan allowance
transplants are subject to medical necessity review by the Plan. Refer
to Other services in Section 3 for prior authorization procedures. Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
• Autologous tandem transplants for billed amount and any amount over $50,000 for
- AL Amyloidosis kidney transplants or $100,000 for other listed
- Multiple myeloma (de novo and treated) transplants

- Recurrent germ cell tumors (including testicular cancer)

Blood or marrow stem cell transplants PPO: 10% of the Plan allowance

The Plan extends coverage for the diagnoses as indicated below: Non-PPO: 30% of the Plan allowance and any
• Allogeneic transplants for difference between our allowance and the
billed amount and any amount over $50,000 for
- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) kidney transplants or $100,000 for other listed
leukemia transplants
- 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 PNH, 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

Organ/tissue transplants - continued on next page

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 High Option

Benefit Description You Pay

After the calendar year deductible…
Organ/tissue transplants (cont.)
- Myelodysplasia/Myelodysplastic Syndromes PPO: 10% of the Plan allowance
- Myeloproliferative disorders Non-PPO: 30% of the Plan allowance and any
- Paroxysmal Nocturnal Hemoglobinuria difference between our allowance and the
- Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott- billed amount and any amount over $50,000 for
Aldrich syndrome) kidney transplants or $100,000 for other listed
transplants
- Severe combined immunodeficiency
- Severe or very severe aplastic anemia
- Sickle cell anemia (pediatric only)
- X-linked lymphoproliferative syndrome
• Autologous transplants for
- Acute lymphocytic or nonlymphocytic (i.e., myelogenous)
leukemia
- Advanced childhood kidney cancers
- Advanced Hodgkin's lymphoma with recurrence (relapsed)
- Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
- Amyloidosis
- Agressive 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

Mini-transplants (non-myeloablative, reduced intensity conditioning or PPO: 10% of the Plan allowance
RIC) are subject to medical necessity review by the Plan.
Non-PPO: 30% 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 PPO: 10% of the Plan allowance
National Cancer Institute or National Institutes of Health approved
clinical trial or a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.

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Benefit Description You Pay

After the calendar year deductible…
Organ/tissue transplants (cont.)
If you are a participant in a clinical trial, the Plan will provide benefits PPO: 10% of the Plan allowance
for related routine care that is medically necessary (such as doctor visits,
lab tests, X-rays and scans, and hospitalization related to treating the Non-PPO: 30% of the Plan allowance and any
patient's condition) if it is not provided by the clinical trial. Section 9 difference between our allowance and the
has additional information on costs related to clinical trials. We billed amount and any amount over $50,000 for
encourage you to contact the Plan to discuss specific services if you kidney transplants or $100,000 for other listed
participate in a clinical trial. transplants

Transplant Network PPO: 10% of the Plan allowance

The Plan uses specific Plan-designated organ/tissue transplant facilities. Non-PPO: 30% of the Plan allowance and any
Before your initial evaluation as a potential candidate for a transplant difference between our allowance and the
procedure, you or your doctor must contact the precertification vendor billed amount and any amount over $50,000 for
(see Other services, Section 3); Cigna at 1-800-668-9682; and ask to kidney transplants or $100,000 for other listed
speak to a Transplant Case Manager. You will be provided with transplants
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.
Not covered: All charges
• Donor screening tests and donor search expenses, except as shown
above
• Transplants not listed as covered

Anesthesia
Professional services for administration of anesthesia PPO: 10% of the Plan allowance

Note: If surgical services are rendered at a PPO hospital or a PPO Non-PPO: 30% of the Plan allowance and any
freestanding ambulatory facility by a PPO primary surgeon, we will pay difference between our allowance and the
the services of non-PPO anesthesiologists at the PPO rate, based on Plan billed amount
allowance.
Not covered: All Charges
• Surgery for the sole purpose of gender reassignment or for the sole
purpose of changing physical appearance to conform with gender
identity

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Section 5 (c). Services provided by a hospital or other facility, and ambulance

services
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 -
$350 per person ($700 per Self Plus One enrollment, or $700 per Self and Family enrollment); Non-
PPO - $500 per person ($1,000 per Self Plus One enrollment, or $1,000 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.
• When you use a PPO hospital, keep in mind that the professionals who provide services to you in
the hospital, may not all be preferred providers. If they are not, they will be paid by this Plan as non-
PPO providers. However, if surgical services are rendered at a PPO hospital or a PPO freestanding
ambulatory facility by a PPO primary surgeon, we will pay the services of anesthesiologists and
surgical assistants who are not preferred providers at the PPO rate, based on Plan allowance. If the
covered services are performed at a PPO hospital or a PPO freestanding ambulatory facility, we will
pay the services of radiologists and pathologists who are not preferred providers at the PPO rate,
based on the Plan allowance and you may be billed any difference between our allowance and the
billed amount.
• 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.
• When you receive hospital observation services, we apply outpatient benefits to covered services.
In only rare and exceptional cases do reasonable and necessary outpatient observation services span
more than 48 hours.
Benefit Description You Pay
Note: The calendar year deductible applies ONLY when we say below: “(calendar year deductible applies).”
Inpatient hospital
Room and board, such as: PPO: 10% of the covered charges
• Ward, semiprivate, or intensive care accommodations Non-PPO: $300 per admission and 30% of the
• General nursing care covered charges and any difference between
• Meals and special diets 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).

Inpatient hospital - continued on next page

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Benefit Description You Pay

Inpatient hospital (cont.)
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.
Other hospital services and supplies, such as: PPO: 10% of the covered charges
• Operating, recovery, maternity, and other treatment rooms Non-PPO: $300 per admission and 30% of the
• Prescribed drugs and medicines covered charges and any difference between
• Diagnostic laboratory tests and X-rays our allowance and the billed amount.
• Blood or blood plasma, if not donated or replaced Note: For inpatient hospital care related to
• Dressings, splints, casts, and sterile tray services maternity, we pay for covered services in full
when you use preferred providers, (See Section
• Medical supplies and equipment, including oxygen 5(a), Maternity care).
• Anesthetics, including nurse anesthetist services

Note: We cover appliances, medical equipment and medical supplies

provided for take-home use under Section 5(a). We cover prescription
drugs and medicines dispensed for take-home use under Section 5(f).

Note: We base payment on whether the facility or a health care

professional bills for the services or supplies. For example, when the
hospital bills for its nurse anesthetists’ services, we pay Hospital benefits
and when the anesthesiologist bills, we pay Surgery benefits.
Not covered: All charges
• Any part of a hospital admission that is not medically necessary (see
Section 10, Definitions), 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
• Non-covered facilities, such as nursing homes, skilled nursing
facilities, residential treatment facilities, day and evening care centers,
and schools
• Personal comfort items such as radio, television, air conditioners,
beauty and barber services, guest meals and beds
• Services of a private duty nurse that would normally be provided by
hospital nursing staff
• Surgery for the sole purpose of gender reassignment or for the sole
purpose of changing physical appearance to conform with gender
identity

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Benefit Description You Pay

Cancer Centers of Excellence
The Plan provides access to designated Cancer Centers of Excellence. PPO Cancer Centers of Excellence (COE): 5%
For information, you must contact Cigna/CareAllies at 800-582-1314 of the Plan allowance
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.
Outpatient hospital or ambulatory surgical center
• Operating, recovery, and other treatment rooms PPO: 10% of the Plan allowance (calendar year
• Prescribed drugs and medicines deductible applies)

• Diagnostic laboratory tests, X-rays, and pathology services Non-PPO: 30% of the Plan allowance and any
• Administration of blood, blood plasma, and other biologicals difference between our allowance and the
billed amount (calendar year deductible
• Blood and blood plasma, if not donated or replaced applies)
• 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.
Extended care benefits/Skilled nursing care facility
benefits
No benefit All charges
Hospice care
Hospice is a coordinated program of home and inpatient supportive care Any amount over the annual maximums shown
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

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 High Option

Benefit Description You Pay

End of life care
End of life care Any amount over the annual maximums shown
• See Hospice care benefit, which includes advance care planning, on
page 55.

Ambulance
• Local professional ambulance service when medically appropriate PPO: 10% of the Plan allowance
immediately before or after an inpatient admission
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Not covered: All charges
• Ambulance service used for routine transport

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 High Option

Section 5 (d). Emergency services/accidents

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 - $350 per person ($700 per Self Plus One enrollment, or $700
per Self and Family enrollment); Non-PPO - $500 per person ($1,000 per Self Plus One enrollment,
or $1,000 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, keep in mind that the professionals who provide services to you in
the hospital, may not all be preferred providers. If they are not, they will be paid by this Plan as non-
PPO providers. However, if surgical services are rendered at a PPO hospital or a PPO freestanding
ambulatory facility by a PPO primary surgeon, we will pay the services of anesthesiologists and
surgical assistants who are not preferred providers at the PPO rate, based on Plan allowance. If the
covered services are performed at a PPO hospital or a PPO freestanding ambulatory facility, we will
pay the services of radiologists and pathologists who are not preferred providers at the PPO rate,
based on the Plan allowance and you may be billed any difference between our allowance and the
billed amount.
• 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.
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.

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 High Option

Benefit Description You Pay

After the calendar year deductible…
Note: The calendar year deductible applies to almost all benefits in this Section. We say "(No deductible)" when it
does not apply.
Accidental injury
If you receive care for your accidental injury within 24 hours, we cover: PPO: Nothing (No deductible)
• Physician services and supplies Non-PPO: Only the difference between our
• Related outpatient hospital services allowance and the billed amount
• Professional ambulance service (No 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

Note: See Section 5(c) for hospital benefits if you are admitted.
Services received after 24 hours are considered the same as any other
illness and regular Plan benefits will apply.
Medical emergency
Outpatient facility charges including medical or surgical services and PPO: $40 copayment (No deductible)
supplies in an Urgent Care Center
Non-PPO: $40 copayment
Note: High technology radiology/imaging services including CAT/CT, (No deductible)
MRI, MRA, Nuclear Cardiology and PET are subject to coinsurance and
deductible (outpatient requires precertification except for Nuclear Note: For Non-PPO benefits, members may be
Cardiology), see Section 5(a). billed the difference between the Plan
allowance and the billed amount.
Outpatient medical or surgical services and supplies, other than an PPO: 10% of the Plan allowance
Urgent Care Center
Non-PPO: 10% of the Plan allowance

Note: For Non-PPO benefits, members may be

billed the difference between the Plan
allowance and the billed amount.
Ambulance
• Professional ambulance service within 24 hours of a medical PPO: 10% of the Plan allowance
emergency (No deductible)
• Air ambulance to nearest facility where necessary treatment is Non-PPO: 30% of the Plan allowance and any
available is covered if no emergency ground transportation is difference between our allowance and the
available or suitable and the patient's condition warrants immediate billed amount (No deductible)
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) for non-emergency service.

Not covered: All charges

• 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

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Section 5 (e). Mental health and substance misuse disorder benefits

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 - $350 per person ($700 per Self Plus One enrollment, or $700
per Self and Family enrollment); Non-PPO - $500 per person ($1,000 per Self Plus One enrollment,
or $1,000 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 misuse disorder
treatment, call Beacon Health Options at 888-700-7965.
• 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 misuse disorder
treatment providers. Beacon Health Options will provide you with a choice of network providers at
888-700-7965 or visit our website at www.apwuhp.com.
• Residential Treatment Facilities, schools or other educational institutions are not covered.
Benefit Description You Pay
After the calendar year deductible…
Note: The calendar year deductible applies to almost all benefits in this Section. We say “(No deductible)” when it
does not apply.
Professional services
We cover professional services by licensed professional mental Your cost-sharing responsibilities are no greater than
health and substance misuse disorder treatment practitioners when for other illnesses or conditions.
acting within the scope of their license, such as psychiatrists,
psychologists, clinical social workers, licensed professional PPO: $25 (No deductible)
counselors, or marriage and family therapists. Non-PPO: 30% of the Plan allowance and any
• In a physician's office difference between our allowance and the billed
• Treatment and counseling (including individual or group charges
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 alcoholism and substance misuse
disorder treatment (outpatient)

Professional services - continued on next page

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Benefit Description You Pay

After the calendar year deductible…
Professional services (cont.)
• Diagnosis and treatment of psychiatric conditions, mental Your cost-sharing responsibilities are no greater than
illness, or mental disorders. Services include: for other illnesses or conditions.
- Diagnostic evaluation PPO: $25 (No deductible)
- Crisis intervention and stabilization for acute episodes
Non-PPO: 30% of the Plan allowance and any
- Medication evaluation and management (pharmacotherapy) difference between our allowance and the billed
• Repetitive Transcranial Magnetic Stimulation, TMS, for the charges
treatment of depressive disorders which have not been
responsive to other interventions such as psychotherapy and
antidepressant medications (preauthorization required by
Beacon Health Options)
• Professional charges for intensive outpatient treatment in a
provider's office or other professional setting (preauthorization
required by Beacon Health Options)

Inpatient professional services for the diagnosis and treatment of PPO: 10% of the Plan allowance
psychiatric conditions, mental illness or mental disorders:
Non-PPO: 30% of the Plan allowance and any
• Psychological and neuropsychological testing necessary to difference between our allowance and the billed
determine the appropriate psychiatric treatment charges
(preauthorization required by Beacon Health Options)
• Diagnosis and treatment of alcoholism and substance misuse
disorder treatment, including detoxification, treatment and
counseling (inpatient)
• Electroconvulsive therapy (preauthorization required by Beacon
Health Options)

Diagnostics
• Outpatient diagnostic tests provided and billed by a licensed PPO: 10% of the Plan allowance
mental health and substance misuse disorder treatment
practitioner Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
• Outpatient diagnostic tests provided and billed by a laboratory, charges
hospital or other covered facility

Inpatient hospital or other covered facility

Inpatient services provided and billed by a hospital or other PPO: 10% of the Plan allowance (No deductible)
covered facility (preauthorization required by Beacon Health
Options) Non-PPO: After $300 per admission, 30% of our
allowance and any difference between our allowance
• Room and board, such as semiprivate or intensive and the billed charges (No deductible)
accommodations, general nursing care, meals and special diets,
and other hospital services
• Inpatient diagnostic tests provided and billed by a hospital or
other covered facility

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Benefit Description You Pay

After the calendar year deductible…
Outpatient hospital or other covered facility
Outpatient services provided and billed by a hospital or other PPO: 10% of the Plan allowance
covered facility
Non-PPO: 30% of the Plan allowance and any
• Services such as partial hospitalization, full-day hospitalization, difference between our allowance and the billed
or facility-based intensive outpatient treatment charges
(preauthorization required by Beacon Health Options)

Not covered: All charges

• Services that require preauthorization that are not part of a
preauthorized approved treatment plan
• Services that are not medically necessary
• Residential Treatment Facilities, schools or other education
facilities

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Section 5 (f). Prescription drug benefits

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 physicians 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 67 for more information about this program.
There are important features you should be aware of. These include:
• Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed or certified
Physician Assistant, Nurse Practitioner and Psychologist must prescribe your medication.
• 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.
• 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 physicians if they feel the formulary alternatives are not appropriate. Physicians may request a clinical
exception by calling 800-753-2851. During the year, the Plan's formulary may change.
• We have different payment levels for generic, preferred brand name and non-preferred brand name prescription drugs; and
specialty preferred brand name and specialty non-preferred brand name drugs. You can view a list on our website at www.
apwuhp.com/high_option_pharmacy_program.php.

Brand/Generic Drugs
• Why use generic drugs? A generic drug is a chemical equivalent of a corresponding name brand drug. The US Food and
Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality
and strength as brand name drugs. Generic drugs are less expensive than brand drugs, therefore, you may reduce your out-
of-pocket-expenses by choosing to use a generic drug.

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• A generic equivalent will be dispensed if it is available, unless your physician specifically requires a brand name drug. If
you receive a brand name drug when a Federally-approved generic drug is available, and your physician has not received a
preauthorization, you have to pay the difference in cost between the name brand drug and the generic, in addition to your
coinsurance. However, if your doctor obtains preauthorization because it is medically necessary that a brand name drug be
dispensed, you will not be required to pay this cost difference. Your doctor may seek preauthorization by calling
800-753-2851.
• 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 physician 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
submit it to the mail order program. If you do not, we will pay the non-network pharmacy benefit level. To receive
maximum savings you must present your card at the time of each purchase, and your enrollment information must be
current and correct. In most cases, you simply present the card together with the prescription to the pharmacist. Refills
cannot be obtained until 75% of the drug has been used.
• 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.

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Benefit Description You Pay

Note: The calendar year deductible does not apply to this section.
Covered medications and supplies
Each new enrollee will receive a description of our prescription drug • Network Retail: $10 generic. 25% preferred
program, a combined prescription drug/Plan identification card, a mail brand name with a $10 minimum
order form/patient profile and a pre-addressed reply envelope. coinsurance up to a maximum of $200
coinsurance per prescription for a 30-day
You may purchase the following medications and supplies prescribed by supply. 45% non-preferred brand name with
a physician from either a pharmacy or by mail: a $20 minimum coinsurance up to a
• Drugs and medicines, for use at home that are obtainable only upon a maximum of $300 coinsurance per
doctor’s prescription and listed in official formularies prescription for a 30-day supply
• Drugs and medicines (including those administered during a non- • Non-network Retail: 50% of cost with a $10
covered admission or in a non-covered facility) that by Federal law of minimum coinsurance for a 30-day supply
the United States require a physician’s prescription for their purchase, • Network Mail Order: $20 generic. 25%
except those listed as not covered preferred brand name with a $20 minimum
• Insulin and test strips for known diabetics coinsurance up to a maximum of $300
• Disposable needles and syringes for the administration of covered coinsurance per prescription for a 90-day
medications supply. 45% non-preferred brand name with
a $30 minimum coinsurance up to a
• Approved drugs for organic impotence such as Viagra and Levitra are maximum of $500 coinsurance per
subject to Coverage Authorization, see Other services, Section 3 and prescription for a 90-day supply
Section 5(f), page 67
• Drugs that could be used for cosmetic purposes such as: Retin A or
Botox (requires Coverage Authorization), see Other services, Section
3 and Section 5(f), page 67
• FDA approved drugs for weight management. Coverage Authorization
is required, see page 67

Specialty Prescription Drugs • Network Retail: 25% generic with up to a

maximum of $300 per prescription for a 30-
Note: See page 67 for definition. day supply. 25% preferred brand name with
a $40 minimum coinsurance up to a
maximum of $600 coinsurance per
prescription for a 30-day supply. 45% non-
preferred brand name with a $60 minimum
coinsurance up to a maximum of $1,000
coinsurance per prescription for a 30-day
supply
• Non-network Retail: 50% of cost with a $10
minimum coinsurance for a 30-day supply
• Network Mail Order: 25% generic with a
maximum of $150 coinsurance per
prescription for a 90-day supply. 25%
preferred brand name with a $20 minimum
coinsurance up to a maximum of $300
coinsurance per prescription for a 90-day
supply. 45% non-preferred brand name with
a $30 minimum coinsurance up to a
maximum of $500 coinsurance per
prescription for a 90-day supply

In-network devices approved by the FDA for contraception for women Nothing

Covered medications and supplies - continued on next page

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Benefit Description You Pay

Covered medications and supplies (cont.)
In-network prescription drugs approved by the FDA for contraception • Network Retail: $0 generic. 25% preferred
for women brand name with a $10 minimum
coinsurance up to a maximum of $200
Note: If your physician receives preauthorization because it is medically coinsurance per prescription for a 30-day
necessary that a brand name contraceptive drug be dispensed, you will supply. 45% non-preferred brand name with
pay $0. Your physician may seek preauthorization by calling a $20 minimum coinsurance up to a
800-841-2734. maximum of $300 for a 30-day supply
• Network Mail Order: $0 generic. 25%
preferred brand name with a $20 minimum
coinsurance up to a maximum of $300
coinsurance per prescription for a 90-day
supply. 45% non-preferred brand with a $30
minimum coinsurance up to a maximum of
$500 coinsurance per prescription for a 90-
day supply
• Non-network Retail: 50% of the cost with a
$10 minimum coinsurance for a 30-day
supply

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 preauthorization, 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 67 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: Specific covered medications and supplies for patients engaged

and compliant with the Plan's Disease Management Programs may have
enhanced benefits. See Disease Management, Section 5(h), Special
features.
Note: Over-the-counter or prescription drugs approved by the FDA to
treat tobacco dependence are covered under the Tobacco
Cessation Program (See Educational classes and programs, page 44).
Personalized medicine (voluntary program) Nothing
• Pharmacogenomic testing to optimize prescription drug therapies for
certain conditions:
- Warfarin (anticoagulant)
- Plavix (antiplatelet)

Not covered: All charges

• Drugs and supplies for cosmetic purposes
• Vitamins, nutrients and food supplements not listed as a covered
benefit even if a physician prescribes or administers them

Covered medications and supplies - continued on next page

2018 APWU Health Plan 65 High Option Section 5(f)
 High Option

Benefit Description You Pay

Covered medications and supplies (cont.)
• Medical supplies such as dressings and antiseptics All charges
• 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 physician and
purchased at a network pharmacy
- Over-the-counter FDA-approved female birth control methods are
covered at no cost if prescribed by a physician and purchased at a
network pharmacy

Benefit Description You Pay

Note: The calendar year deductible does not apply to this section.
Preventive care medications
Medications to promote better health as recommended by ACA. Network Retail: Nothing

Preventive Medications with a USPSTF recommendation of A or B are Non-network Retail: 50% of cost with a $10
covered without cost-share when prescribed by a health care minimum coinsurance for a 30-day supply
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.uspreventiveservestaskforce.org/BrowseRec/Index/browse-
recommendations.

Personalized Medicine (voluntary program)

The Personalized Medicine Program combines a Pharmacogenomic test (genetic lab test) with a clinical program to optimize
prescription drug therapies for patients taking Warfarin (anticoagulant) and Plavix (anti-platelet). This program focuses on
giving physicians information, on an individual level, on patients who have already been diagnosed with a disease or
condition.
The benefits of this testing, done with a simple cheek swab are:
- Greater patient safety and efficacy through more precise dosing for Warfarin and Plavix
- Elimination of adverse events since the patient will be taking the appropriate dose of Warfarin or Plavix from the early
onset of therapy

Pharmacogenomic testing gives physicians personalized information they can use to make more precise prescribing and
dosing decisions to help their patients receive the critical care they need. The Personalized Medicine Program is available to
you at no additional cost. If your medication history indicates that the testing could be beneficial for you, a pharmacist will
contact your physician to discuss the program. If your doctor agrees that the test results would be helpful, you will be
contacted by a pharmacist to let you know that the testing is available. If you agree to participate, you will receive a cheek
swab test that you can administer on your own.
The results of your test will be sent to your doctor and to an Express Scripts pharmacist who has received special training in
personalized medicine. The pharmacist is available to help your doctor interpret the results of your test. Your participation is
voluntary, and your doctor is still solely responsible for deciding which drug and dose is right for you.

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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). 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, 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, 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. One method that has proved effective
in saving members money is “preferred drug step therapy.” Step therapy ensures that a generic alternative or brand
alternative within a therapeutic category is used as a first-line treatment, before the use of a similar but more expensive
drug. Specific therapeutic categories are identified as appropriate for preferred drug step therapy. 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 and Topical Immunomodulator medications. In situations where the
targeted drug is prescribed, doctors are notified of lower-cost generics and preferred brands. If the doctor approves, the
cost-effective medication is dispensed. If the doctor disapproves, a coverage review is initiated. If the coverage review is
approved, the member is responsible for the normal coinsurance found on page 64. 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 Plan’s approval, they will pay
the full cost of the drug. If approval is obtained after filling the prescription, the member may be reimbursed for any
amount they paid minus their coinsurance. 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, hypercholesterolemia, 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.

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Many of the Specialty Drugs covered by the Plan fall under the Coverage Authorization program mentioned. Specialty
medications for long-term therapy can 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 are encouraged to ask your physician if a specialty medication that you are receiving from the physician's office or
outpatient setting can be obtained at Accredo and administered at home using Accredo nursing services. Contact Express
Scripts at 800-922-8279 to speak to an Accredo representative to inquire how your medication can be obtained through
Accredo services.
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, prescribing physician’s name, date of purchase and charge for the drug. Mail the claim form
and receipt(s) to:

APWU Health Plan

P. O. Box 1358
Glen Burnie, MD 21060-1358

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Section 5 (g). Dental benefits

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 - $350 per person ($700 per Self Plus One enrollment, or $700
per Self and Family enrollment); Non-PPO - $500 per person ($1,000 per Self Plus One enrollment,
or $1,000 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 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 You Pay
Accidental injury benefit
We cover restorative services and supplies necessary to repair (but not Within 24 hours of accident:
replace) sound natural teeth. The need for these services must result
from an accidental injury (a blow or fall) and must be performed within PPO: Nothing (No deductible)
two years of the accident. See also Section 5(d), Accidental injury. Non-PPO: Only the difference between our
allowance and the billed amount (No
deductible)

More than 24 hours after accident:

PPO: 10% of the Plan allowance

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

difference between our allowance and the
billed amount
Dental benefits service
Office visits (routine limited to 2 visits per year) 30% of the Plan allowance and any difference
between our allowance and the billed amount
Restorative care (No deductible)
(fillings)
Note: No in-network dental providers; choose
X-rays of all types (limited to 2 per year) any provider.
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.

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Section 5 (h). Wellness and Other Special features

Special feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide
services.
• We may identify medically appropriate alternatives to 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).

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 health care
issues.

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

Disease Management A voluntary program that provides a variety of services to help you manage a chronic
Program condition with outpatient treatment and avoid unnecessary emergency care or inpatient
admissions. Some examples of conditions that can be managed through this program are:
diabetes and cardiac conditions. 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.

Diabetes Management If you are an APWU Health Plan primary member enrolled in the Cigna/CareAllies
Program Diabetes Disease Management Program and participate as required by the program, you
may be eligible for the following incentives for in-network services only:
• $0 copay for Formulary Generic drugs from Express Scripts by Mail for the specific
purpose of lowering your blood sugar
• $0 copay for Formulary blood glucose test strips and lancets, covered on the Express
Scripts National Preferred Formulary from Express Scripts by Mail

Note: Enrollment in this program must be initiated by member after effective date of
Health Plan enrollment. To enroll contact Cigna/CareAllies at 800-582-1314.

2018 APWU Health Plan 70 High Option Section 5(h)

 High Option

Note: If you have other primary pharmacy insurance, you must use your primary
insurance first and then send the payment information from the primary insurance to
APWU Health Plan for coordination of benefits.

Note: You must remain in compliance with the program requirements in order to be
eligible for the $0 copay incentives. In order to remain compliant with the program,
enrollees must complete a call with their health coach at least every 90 days. During these
calls, you will discuss such topics as understanding of your disease process, knowledge of
your recent lab results, doctor visits and self-care goals.

If you are an APWU Health Plan member who has other primary insurance (i.e. Medicare
primary), you do not have to enroll in the Diabetes Disease Management Program, you
may be eligible for the following incentives:
• $0 copay for Formulary Generic drugs from Express Scripts by Mail for the specific
purpose of lowering your blood sugar
• $0 copay for Formulary blood glucose test strips and lancets, covered on the Express
Scripts National Preferred Formulary, from Express Scripts by Mail

Review and Reward If you send us a corrected hospital billing, we will credit 20% of any hospital charge over
Program $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 If you are an APWU Health Plan primary member enrolled in the Cigna/CareAllies
Program Weight Management Program and participate as required by the program, you may be
eligible for the following incentives for in-network services only:
• $0 copay for in-network office visit to a registered Dietician/Nutritionist (see Special
Programs)

Healthy Pregnancies, Enroll in this program and you take the first step toward giving your baby a healthy start
Healthy Babies Program 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 Online tools are available at www.apwuhp.com:

resources

2018 APWU Health Plan 71 High Option Section 5(h)

 High Option

• eHealthRecord - 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
• HealthAssessment - answer questions about your health and receive a personalized
health program through MyCigna

Health Risk Assessment A Health Risk Assessment (HRA) is available at www.apwuhp.com, click MyCigna and
(HRA) My Health Assessment tab. 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 Access by Internet (www.apwuhp.com) is provided to support your important health and
information 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

2018 APWU Health Plan 72 High Option Section 5(h)

 CDHP

Consumer Driven Health Plan Benefits

See page 15 for how our benefits changed this year and page 148 for a benefits summary.
Consumer Driven Health Plan Overview....................................................................................................................................75
Section 5. In-network preventive care ........................................................................................................................................76
Preventive care, adult ........................................................................................................................................................76
Preventive care, children ...................................................................................................................................................78
Section 5. Personal Care Account (PCA)....................................................................................................................................79
Personal Care Account (PCA)...........................................................................................................................................80
Section 5. Traditional Health Coverage Overview .....................................................................................................................82
Deductible before Traditional Health Coverage begins ....................................................................................................82
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals ................................84
Diagnostic and treatment services.....................................................................................................................................84
TeleHealth Services...........................................................................................................................................................85
Lab, X-ray and other diagnostic tests................................................................................................................................85
Maternity care ...................................................................................................................................................................85
Family planning ................................................................................................................................................................86
Infertility services .............................................................................................................................................................87
Allergy care .......................................................................................................................................................................87
Treatment therapies ...........................................................................................................................................................87
Physical and occupational therapies .................................................................................................................................88
Applied behavioral analysis (ABA) ..................................................................................................................................88
Speech therapy ..................................................................................................................................................................88
Hearing services (testing, treatment, and supplies)...........................................................................................................89
Vision services (testing, treatment, and supplies) .............................................................................................................89
Foot care ............................................................................................................................................................................89
Orthopedic and prosthetic devices ....................................................................................................................................90
Durable medical equipment (DME) ..................................................................................................................................90
Home health services ........................................................................................................................................................91
Chiropractic .......................................................................................................................................................................92
Alternative treatments .......................................................................................................................................................92
Educational classes and programs.....................................................................................................................................92
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals ............................93
Surgical procedures ...........................................................................................................................................................93
Reconstructive surgery ......................................................................................................................................................94
Oral and maxillofacial surgery ..........................................................................................................................................95
Organ/tissue transplants ....................................................................................................................................................96
Anesthesia .........................................................................................................................................................................99
Section 5 (c). Services provided by a hospital or other facility, and ambulance services ........................................................100
Inpatient hospital .............................................................................................................................................................100
Cancer Centers of Excellence .........................................................................................................................................101
Outpatient hospital or ambulatory surgical center ..........................................................................................................102
Extended care benefits/Skilled nursing care facility benefits .........................................................................................102
Hospice care ....................................................................................................................................................................102
End of life care ................................................................................................................................................................102
Ambulance ......................................................................................................................................................................103
Section 5 (d). Emergency services/accidents ............................................................................................................................104
Accidental injury .............................................................................................................................................................105

2018 APWU Health Plan 73 CDHP Section 5

 CDHP

Medical emergency .........................................................................................................................................................105

Ambulance ......................................................................................................................................................................105
Section 5 (e). Mental health and substance misuse disorder benefits .......................................................................................106
Professional services .......................................................................................................................................................106
Diagnostics ......................................................................................................................................................................107
Inpatient hospital or other covered facility .....................................................................................................................107
Outpatient hospital or other covered facility...................................................................................................................107
Section 5 (f). Prescription drug benefits ...................................................................................................................................108
Covered medications and supplies ..................................................................................................................................109
Preventive care medications ............................................................................................................................................110
Personalized medicine (voluntary program) ...................................................................................................................111
Section 5 (g). Dental benefits ....................................................................................................................................................114
Section 5 (h). Wellness and Other Special features...................................................................................................................115
Section 5 (i). Health education resources and account management tools ...............................................................................116
Online tools and resources ..............................................................................................................................................116
Consumer choice information .........................................................................................................................................116
Care support ....................................................................................................................................................................116
Special Programs .............................................................................................................................................................116
Health Risk Assessment (HRA) ......................................................................................................................................117
Summary of benefits for the CDHP of the APWU Health Plan - 2018 ....................................................................................148

2018 APWU Health Plan 74 CDHP Section 5

 CDHP

Consumer Driven Health Plan Overview

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 health care consumer, and gives you greater control in how you use your health care 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 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 60% 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 misuse 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 health care and manage your expenses. There is also care support and a 24-hour nurse advisory service,
and $50 for Self Only and $50 for the member, spouse, and each covered dependent age 18 or older for a Self Plus One or
Self and Family added to your PCA when a Health Risk Assessment is completed.

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 CDHP

Section 5. In-network preventive care

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) 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.
Benefit Description You Pay
Note: There is no calendar year deductible for in-network preventive care under the Consumer Driven Option.
Preventive care, adult
We provide benefits for a comprehensive range of preventive care In-network: Nothing
services for adults. One annual routine office visit and examination per
person. Lab tests covered are: Out-of-network: Uses PCA while funds
available
• Comprehensive Metabolic Panel
• Lipid Panel
• Urinalysis
• Complete Blood Count (CBC)
• Routine Electrocardiogram (EKG)
• Chest X-ray
• Hemoglobin A1C

Adult immunizations endorsed by the Centers for Disease Control and In-network: Nothing
Prevention (CDC) in a physician's office or at a select in-network retail
pharmacy: based on the Advisory Committee on Immunization Out-of-network: Uses PCA while funds
Practices (ACIP) schedule available

Routine screenings: In-network: Nothing

• Total Blood Cholesterol, once annually Out-of-network: Uses PCA while funds
• Fasting lipoprotein profile, once every 5 years for adults age 20 or available
older
• One-time hepatitis C test for those born from 1945-1965
• Low-dose CT scan for those at risk of lung cancer, one annually for
adults age 55-80
• Colorectal Cancer Screenings, member has the choice of the
following:
- Fecal occult blood test (FOBT) annually beginning at age 50; or
- Flexible sigmoidoscopy beginning at age 50; or
- Colonoscopy beginning at age 50

Preventive care, adult - continued on next page

2018 APWU Health Plan 76 CDHP Section 5 In-network preventive care
 CDHP

Benefit Description You Pay

Preventive care, adult (cont.)
• Digital Rectal Examination (DRE) and Prostate Specific Antigen In-network: Nothing
(PSA) test annually starting at age 45
Out-of-network: Uses PCA while funds
• Abdominal Aortic Aneurysm screening, once for men between the available
ages of 65 and 75 with a smoking history
• HIV screening
• Biometric screening, once annually

Note: Biometric screening includes Body Mass Index (BMI), Lipid

Panel, Total Blood Cholesterol, blood pressure, and Comprehensive
Metabolic Panel, as listed above in Preventive care, adult.
Well woman care based on current recommendations such as: In-network: Nothing
• One annual routine gynecological visit Out-of-network: Uses PCA while funds
• Routine mammograms, including 3D mammograms - covered for available
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
• Cervical cancer screening (Pap smear)
• Human Papillomavirus (HPV) testing
• Chlamydia/Gonorrhea screening
• Osteoporosis screening
• Breast cancer screening
• Counseling for sexually transmitted infections
• Counseling and screening for human immune-deficiency virus
• Contraceptives, such as surgically implanted contraceptives,
injectable contraceptive drugs, intrauterine devices, and diaphragms
(See Family planning, Section 5(a))
• Contraceptive methods and counseling
• Sterilization procedures (See Surgical procedures, Section 5(b))
• Patient education and counseling for all women with reproductive
capacity
• Screening and counseling for women for interpersonal and domestic
violence
• Genetic testing for BRCA for women whose family is associated with
increased risk of BRCA1 or BRCA2 (Preauthorization is required.
See Other Services, Section 3)
Note: In-network facility and lab services directly related to covered, in-
network preventive care will also be covered at 100%.

2018 APWU Health Plan 77 CDHP Section 5 In-network preventive care

 CDHP

Benefit Description You Pay

Preventive care, children
Well-child visits, examinations, and immunizations as described in the In-network: Nothing
Bright Future Guidelines provided by the American Academy of
Pediatrics. Out-of-network: Uses PCA while funds
available
• Examinations limited to: In-network: Nothing
- Examinations for amblyopia and strabismus-limited to one Out-of-network: Uses PCA while funds
screening examination (age 3 through 5) available
- Examinations done on the day of immunizations (ages 3 up 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

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 listing of services will be subject to the
applicable member copayments, coinsurance, and deductible.

Note: A complete list of preventive care services recommended under

the U.S. Preventive Services Task Force (USPSTF) is available online
at www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-
recommendations.

HHS: www.healthcare.gov/preventive-care-benefits

CDC: www.cdc.gov/vaccines/schedules/index.html

Women's preventive services:

www.healthcare.gov/preventive-care-women/

For additional information:

www.healthfinder.gov/myhealthfinder/default.aspx

Note: For a complete list of the American Academy of Pediatrics Bright

Futures Guidelines go to www.brightfutures.aap.org/Pages/default.aspx

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.

Not covered: All charges

• Adult immunizations not endorsed by the CDC
• Routine diagnostic tests associated with preventive care other than
those specified as covered
• 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

2018 APWU Health Plan 78 CDHP Section 5 In-network preventive care

 CDHP

Section 5. Personal Care Account (PCA)

Important things you should keep in mind about your Personal Care Account:
• All eligible health care expenses (except in-network preventive care) are paid first from your
Personal Care Account (PCA). Traditional Health Coverage (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.

2018 APWU Health Plan 79 CDHP Section 5 Personal Care Account (PCA)
 CDHP

Benefit Description You pay

There is no calendar year deductible for in-network preventive care under the Consumer Driven Option.
Personal Care Account (PCA)
A Personal Care Account (PCA) is provided by the Plan for each In-network and Out-of-network: Nothing up to
enrollment. Each year the Plan adds to your account: $1,200 for a Self Only enrollment or $2,400 for
• $1,200 per year for a Self Only enrollment or a Self Plus One or Self and Family enrollment

• $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 for a $60 visit, the
doctor will submit your claim and the cost of the visit will be deducted
automatically from your PCA; you pay nothing.

Balance in PCA or Self Only $1,200

Less: Cost of 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 misuse 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 and
must be paid up front by you. 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 generic prescriptions wherever possible; and
• Only use your PCA for Extra PCA Expenses if you expect to have an
unused balance in your PCA at the end of the calendar year

Not covered: All charges

• Orthodontia
• Dental treatment for cosmetic purposes including teeth whitening

Personal Care Account (PCA) - continued on next page

2018 APWU Health Plan 80 CDHP Section 5 Personal Care Account (PCA)
 CDHP

Benefit Description You pay

Personal Care Account (PCA) (cont.)
• Out-of-network preventive care services not included under CDHP All charges
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

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 in any given year may not exceed $5,000
per Self Only enrollment, $10,000 per Self Plus One enrollment and $10,000 per Self and Family enrollment.

2018 APWU Health Plan 81 CDHP Section 5 Personal Care Account (PCA)
 CDHP

Section 5. Traditional Health Coverage Overview

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 health care expenses.
• If your Personal Care Account has been exhausted, you must pay your 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 $66.67 per month for Self Only, $133.33 for Self Plus One or $133.33
per month for Self and Family for each full month of coverage remaining in that calendar year.
• When you use an in-network hospital, keep in mind that the professionals who provide services to
you in the hospital, may not all be preferred providers. However, if covered services are rendered at
an in-network hospital or an in-network freestanding ambulatory/facility, we will pay all physicians
and covered ancillary services that are not preferred providers at the in-network rate, based on Plan
allowance. You may be billed any difference between our allowance and the billed amount.
• 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 You Pay

Deductible before Traditional Health Coverage begins
If your Personal Care Account has been exhausted, you are responsible In-network/Out-of-network: $800 per Self
to pay your Deductible before your Traditional Health Coverage begins. Only enrollment, $1,600 for Self Plus One
enrollment or $1,600 per Self and Family
Traditional Health Coverage benefits begin after covered eligible enrollment.
expenses total $2,000 for Self Only, $4,000 for Self Plus One or $4,000
for Self and Family (the combination of eligible expenses paid out of
your PCA and your Deductible) each calendar year.

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

In year one, therefore, the Deductible is $800 for Self Only, $1,600 for
Self Plus One and $1,600 for Self and Family enrollment.

Deductible before Traditional Health Coverage begins - continued on next page

2018 APWU Health Plan 82 CDHP Section 5 Traditional Health Coverage

 CDHP

Benefit Description You Pay

Deductible before Traditional Health Coverage begins
(cont.)
Self Only Self Plus One Self and Family In-network/Out-of-network: $800 per Self
Only enrollment, $1,600 for Self Plus One
Basic PCA $1,200 $2,400 $2,400 enrollment or $1,600 per Self and Family
Expenses paid enrollment.
by PCA
Deductible paid $800 $1,600 $1,600
by you
Traditional $2,000 $4,000 $4,000
Health
Coverage starts
after
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:

Self Only Self Plus One Self and

Family
$1,200 $2,400 $2,400
PCA for year 2
+$300 +$300 +$300
Rollover from
year 1 $1,500 $2,700 $2,700
Deductible paid +$500 +$1,300 +$1,300
by you
Traditional $2,000 $4,000 $4,000
Health
Coverage starts
when eligible
expenses total
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 have 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.

2018 APWU Health Plan 83 CDHP Section 5 Traditional Health Coverage

 CDHP

Section 5 (a). Medical services and supplies provided by physicians and other health
care professionals
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 health care expenses.
• If your Personal Care Account has been exhausted, you must pay your 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 $66.67 per month for Self Only, $133.33 for Self Plus One or $133.33
per month for Self and Family for each full month of coverage remaining in that calendar year.
• When you use an in-network hospital, keep in mind that the professionals who provide services to
you in the hospital, may not all be preferred providers. However, if covered services are rendered at
an in-network hospital or an in-network freestanding ambulatory/facility, we will pay all physicians
and covered ancillary services that are not preferred providers at the in-network rate, based on Plan
allowance. You may be billed any difference between our allowance and the billed amount.
• 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 You Pay
Diagnostic and treatment services
Professional services of physicians In-network: 15% of the Plan allowance
• In physician's office Out-of-network: 40% of the Plan allowance
• At home and any difference between our allowance and
• In an urgent care center the billed amount

• During a hospital stay

• In a skilled nursing facility
• Second surgical opinion

• At a Cancer Center of Excellence PPO Cancer Center of Excellence (COE): 10%

of the Plan allowance

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Benefit Description You Pay

TeleHealth Services
• Virtual visits In-network: 15% of the Plan allowance

Please see www.apwuhp.com for information on virtual visits, or log Out-of-network: N/A
into www.myuhc.com

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

Lab, X-ray and other diagnostic tests
Tests, such as: In-network: 15% of the Plan allowance
• Blood tests Out-of-network: 40% of the Plan allowance
• Urinalysis and any difference between our allowance and
• Non-routine mammograms, including 3D mammograms the billed amount
• Pathology
• X-rays
• Non-routine pap tests
• CT 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.
Not covered: All charges
• Professional fees for automated lab tests

Pharmacogenomic testing to optimize prescription drug therapies for In-network: Nothing

certain conditions:
Out-of-network: 40% of the Plan allowance
• Plavix (antiplatelet) and any difference between our allowance and
• Warfarin (anticoagulant) the billed amount

Maternity care
Complete maternity (obstetrical) care, such as: In-network: Nothing
• Screening for gestational diabetes for pregnant women after 24 weeks Out-of-network: 40% of the Plan allowance
• Prenatal care and any difference between our allowance and
• Delivery the billed amount

• Postnatal care
Note: For inpatient hospital care related to
• Initial examination of a newborn child covered under a Self Plus One, maternity, we pay for covered services in full
or Self and Family enrollment when you use preferred providers.
• Breastfeeding support, supplies and counseling for each birth
Note: In-network facility and lab services
Note: Here are some things to keep in mind: directly related to covered, in-network
maternity care will also be covered at 100%.
• You do not need to precertify your vaginal or cesarean delivery; see
page 22 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.

Maternity care - continued on next page

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Benefit Description You Pay

Maternity care (cont.)
• We cover routine nursery care of the newborn child during the In-network: Nothing
covered portion of the mother’s maternity stay.
Out-of-network: 40% of the Plan allowance
• We pay hospitalization and surgeon services for non-maternity care, and any difference between our allowance and
as well as covering an extended stay, if medically necessary, the same the billed amount
as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Note: For inpatient hospital care related to
are covered under Section 5(b). maternity, we pay for covered services in full
when you use preferred providers.
Note: When a newborn requires definitive treatment during or after the
mother's confinement, the newborn is considered a patient in his or her Note: In-network facility and lab services
own right. If the newborn is eligible for coverage, regular medical or directly related to covered, in-network
surgical benefits apply rather than maternity benefits. maternity care will also be covered at 100%.
• We will cover other care of an infant who requires non-routine In-network: 15% of the Plan allowance
treatment if we cover the infant under a Self Plus One or Self and
Family enrollment. Surgical benefits, not maternity benefits, apply to Out-of-network: 40% of the Plan allowance
circumcision of a covered newborn. and any difference between our allowance and
the billed amount
Not covered: All charges
• Amniocentesis if for diagnosing multiple births
• Genetic screening (see Definitions, Section 10)

Family planning
A range of voluntary family services limited to: In-network: Nothing
• Contraceptive counseling for women Out-of-network: 40% of the Plan allowance
• Voluntary sterilization for women (See Surgical procedures, Section 5 and any difference between our allowance and
(b)) the billed amount
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo provera)
• Intrauterine devices (IUDs)
• Diaphragms

Note: We cover oral contraceptives under Section 5(a), Well woman.

• Voluntary sterilization for men (See Surgical procedures, Section 5 In-network: 15% of the Plan allowance
(b))
Out-of-network: 40% of the Plan allowance
and any difference between our allowance and
the billed amount
Not covered: All charges
• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

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Benefit Description You Pay

Infertility services
• Diagnosis and treatment of infertility, except as shown in Not covered In-network: 15% of the Plan allowance and
any amount over $2,500

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

and any difference between our allowance and
the billed amount and any amount over $2,500
Not covered: All charges
• 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

Allergy care
• Testing and treatment, including materials (such as allergy serum) In-network: 15% of the Plan allowance
• Allergy injections Out-of-network: 40% of the Plan allowance
and any difference between our allowance and
the billed amount
Not covered: All charges
• Provocative food testing
• Sublingual allergy desensitization

Treatment therapies
• Chemotherapy and radiation therapy In-network: 15% of the Plan allowance

Note: High dose chemotherapy in association with autologous bone Out-of-network: 40% of the Plan allowance
marrow transplants is limited to those transplants listed on pages 96-98. and any difference between our allowance and
the billed amount
• 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 under You need prior Plan approval for certain
services, Section 3.

Treatment therapies - continued on next page

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Benefit Description You Pay

Treatment therapies (cont.)
• Respiratory and inhalation therapies In-network: 15% of the Plan allowance

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

and any difference between our allowance and
the billed amount
Physical and occupational therapies
Physical therapy and occupational therapy provided by a licensed In-network: 15% of the Plan allowance
registered therapist up to a combined 60 visits per calendar year
Out-of-network: 40% of the Plan allowance
We cover rehabilitative and habilitative therapies; a physician should: and any difference between our allowance and
• Order the care; the billed amount

• 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.
Not covered: All charges
• Maintenance therapies
• Exercise programs

Applied behavioral analysis (ABA)

Outpatient Applied Behavioral Analysis (ABA) services, for the In-network: 15% of the Plan allowance
treatment of Autism Spectrum Disorder. Services must be provided
under the supervision of a Board Certified Behavior Analyst who is Out-of-network: All charges
contracted with Beacon Health Options, or agrees to participate with
Beacon Health Options’ care management activities. (Preauthorization
required by Beacon Health Options)

Note: Beacon Health Options' 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.
Speech therapy
Speech therapy where medically necessary and provided by a licensed In-network: 15% of the Plan allowance
therapist
Out-of-network: 40% of the Plan allowance
Note: Speech therapy is combined with 60 visits per calendar year for and any difference between our allowance and
the services of physical and/or occupational therapy (see above). the billed amount
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.

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 CDHP

Benefit Description You Pay

Hearing services (testing, treatment, and supplies)
• For treatment related to illness or injury, including evaluation and In-network: 15% of the Plan allowance
diagnostic hearing tests performed by an M.D., D.O., or audiologist
Out-of-network: 40% of the Plan allowance
• One examination and testing for hearing aids every 2 years and any difference between our allowance and
the billed amount
Note: For routine hearing screening performed during a child's
preventive care visit, see Section 5, Preventive care, children.
• External hearing aids Note: For benefits for the devices, see Section
• Implanted hearing-related devices, such as bone anchored hearing 5(a), Orthopedic and prosthetic devices.
aids (BAHA) and cochlear implants

Not covered: All charges

• Hearing services that are not shown as covered

Vision services (testing, treatment, and supplies)

• Internal (implant) ocular lenses and/or the first contact lenses required In-network: 15% of the Plan allowance
to correct an impairment caused by accident or illness. The services of
an optometrist are limited to the testing, evaluation and fitting of the Out-of-network: 40% of the Plan allowance
first contact lenses required to correct an impairment caused by and any difference between our allowance and
accident or illness. the billed amount

Note: See Preventive care, children, for eye exams for children.
Not covered: All charges
• Eyeglasses or contact lenses and examinations for them except under
PCA
• Eye exercises and visual training
• Radial keratotomy and other refractive surgery

Foot care
Routine foot care when you are under active treatment for a metabolic or In-network: 15% of the Plan allowance
peripheral vascular disease, such as diabetes
Out-of-network: 40% of the Plan allowance
Note: See Orthopedic and prosthetic devices for information on and any difference between our allowance and
podiatric shoe inserts. the billed amount
Not covered: All charges
• 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)

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Benefit Description You Pay

Orthopedic and prosthetic devices
• Artificial limbs and eyes In-network: 15% of the Plan allowance
• Stump hose Out-of-network: 40% of the Plan allowance
• Externally worn breast prostheses and surgical bras, including and any difference between our allowance and
necessary replacements following a mastectomy the billed amount
• 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).

Note: We will pay only for the cost of the standard item. Coverage for
specialty items, such as bionics, is limited to the cost of the standard
item.
External hearing aids In-network: All charges in excess of $1,500
• Covered every 3 years limited to $1,500 Out-of-network: All charges in excess of
$1,500
Note: Excluding batteries, benefits for hearing aid dispensing fees,
accessories, supplies, and repair service are included in the benefit limit
described above.
Not covered: All charges
• 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

Durable medical equipment (DME)

Durable medical equipment (DME) is equipment and supplies that: In-network: 15% of the Plan allowance

1) Are prescribed by your attending physician (i.e., the physician who is Out-of-network: 40% of the Plan allowance
treating your illness or injury) and any difference between our allowance and
the billed amount
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

Durable medical equipment (DME) - continued on next page

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 CDHP

Benefit Description You Pay

Durable medical equipment (DME) (cont.)
• Dialysis equipment In-network: 15% of the Plan allowance
• Hospital beds Out-of-network: 40% of the Plan allowance
• Wheelchairs (standard and electric) and any difference between our allowance and
• Ostomy supplies (including supplies purchased at a pharmacy) the billed amount

• 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.
Not covered: All charges
• 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

Home health services

Services for skilled nursing care up to 25 visits per calendar year, not to In-network: 15% of the Plan allowance
exceed a maximum Plan payment of $90 per day, when preauthorized
and: Out-of-network: 40% of the Plan allowance
and any difference between our allowance and
• a registered nurse (R.N.), licensed practical nurse (L.P.N.) or licensed the billed amount
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.
Not covered: All charges
• 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

Home health services - continued on next page

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Benefit Description You Pay

Home health services (cont.)
• Services of nurses' aides or home health aides All charges

Chiropractic
Chiropractic treatment limited to 12 visits and/or manipulations per year In-network: 15% of the Plan allowance

Note: X-rays covered under Lab, X-ray and other diagnostic tests. Out-of-network: 40% of the Plan allowance
and any difference between our allowance and
the billed amount
Not covered: All charges
• Massage therapy
• Maintenance therapy

Alternative treatments
Acupuncture - by a doctor of medicine or osteopathy or licensed In-network: 15% of the Plan allowance
acupuncturist
Out-of-network: 40% of the Plan allowance
• anesthesia and any difference between our allowance and
• pain relief the billed amount

Not covered: All charges

• Services of any provider not listed as covered; see Covered providers,
Section 3

Educational classes and programs

If you are an APWU Health Plan member you may enroll in a Tobacco In-network: Nothing
Cessation Program as follows:
Out-of-network: 40% of the Plan allowance
• Telephonic counseling sessions with UnitedHealthcare or; and any difference between our allowance and
• Group therapy sessions or; the billed amount
• 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.
Prescription drugs (through Optum Rx by Mail only) approved by the In-network: Nothing
FDA to treat tobacco dependence for Tobacco Cessation.
Out-of-network: All charges
Over-the-counter drugs (through UnitedHealthcare only) approved by
the FDA to treat tobacco dependence for Tobacco Cessation.
Childhood obesity education In-network: Nothing

Out-of-network: 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 In-network: 15% of the Plan allowance
training the first year and 2 hours subsequent training annually.
Out-of-network: 40% of the Plan allowance
and any difference between our allowance and
the billed amount

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 CDHP

Section 5 (b). Surgical and anesthesia services provided by physicians and other
health care professionals
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 health care expenses.
• If your Personal Care Account has been exhausted, you must pay your 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 $66.67 per month for Self Only, $133.33 for Self Plus One or $133.33
per month for Self and Family for each full month of coverage remaining in that calendar year.
• When you use an in-network hospital, keep in mind that the professionals who provide services to
you in the hospital, may not all be preferred providers. However, if covered services are rendered at
an in-network hospital or an in-network freestanding ambulatory/facility, we will pay all physicians
and covered ancillary services that are not preferred providers at the in-network rate, based on Plan
allowance. You may be billed any difference between our allowance and the billed amount.
• 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 You Pay
Surgical procedures
A comprehensive range of services, such as: In-network: 15% of the Plan allowance
• Operative procedures Out-of-network: 40% of the Plan allowance
• Treatment of fractures, including casting and any difference between our allowance and
• Normal pre- and post-operative care by the surgeon the billed amount

• 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 pre-
notification. See You need prior Plan approval for certain services in
Section 3)
• Insertion of internal prosthetic devices (see Orthopedic and prosthetic
devices in Section 5(a) for device coverage information)
• Voluntary sterilization for men (e.g., Vasectomy)

Surgical procedures - continued on next page

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 CDHP

Benefit Description You Pay

Surgical procedures (cont.)
• Treatment of burns In-network: 15% of the Plan allowance
• Assistant surgeons - We cover up to 20% of our allowance for the Out-of-network: 40% of the Plan allowance
surgeon’s charge and any difference between our allowance and
the billed amount
• Voluntary sterilization for women (e.g., Tubal ligation) In-network: Nothing
• Surgically implanted contraceptives Out-of-network: 40% of the Plan allowance
• Intrauterine devices (IUDs) and any difference between our allowance and
the billed amount
When multiple or bilateral surgical procedures performed during the In-network: 15% of the Plan allowance for the
same operative session add time or complexity to patient care, our primary procedure and 15% of one-half of the
benefits are: Plan allowance for the secondary procedure(s)
• For the primary procedure: Out-of-network: 40% of the Plan allowance for
- In-network: 85% of the Plan allowance or the primary procedure and 40% of one-half of
- Out-of-network: 60% of the Plan allowance the Plan allowance for the secondary procedure
(s); and any difference between our payment
• For the secondary procedure(s): and the billed amount
- In-network: 85% of one-half of the Plan allowance or
- Out-of-network: 60% of one-half of the Plan allowance

Note: Multiple or bilateral surgical procedures performed through the

same incision are “incidental” to the primary surgery. That is, the
procedure would not add time or complexity to patient care. We do not
pay extra for incidental procedures.
Not covered: All charges
• 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))
• Surgery for the sole purpose of gender reassignment or for the sole
purpose of changing physical appearance to conform with gender
identity

Reconstructive surgery
• Surgery to correct a functional defect In-network: 15% of the Plan allowance
• Surgery to correct a condition caused by injury or illness if: Out-of-network: 40% of the Plan allowance
- The condition produced a major effect on the member’s appearance and any difference between our allowance and
and the billed amount
- The condition can reasonably be expected to be corrected by such
surgery

Reconstructive surgery - continued on next page

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Benefit Description You Pay

Reconstructive surgery (cont.)
• Surgery to correct a condition that existed at or from birth and is a In-network: 15% of the Plan allowance
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft Out-of-network: 40% of the Plan allowance
palate; birth marks (including port wine stains); and webbed fingers and any difference between our allowance and
and toes. the billed amount

• 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 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.
Not covered: All charges
• 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
• Surgery for the sole purpose of gender reassignment or for the sole
purpose of changing physical appearance to conform with gender
identity

Oral and maxillofacial surgery

Oral surgical procedures, limited to: In-network: 15% of the Plan allowance
• Reduction of fractures of the jaw or facial bones Out-of-network: 40% of the Plan allowance
• Surgical correction of cleft lip, cleft palate or severe functional and any difference between our allowance and
malocclusion the billed amount
• 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

Oral and maxillofacial surgery - continued on next page

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 CDHP

Benefit Description You Pay

Oral and maxillofacial surgery (cont.)
• Removal of foreign body, skin, subcutaneous alveolar tissue, reaction- In-network: 15% of the Plan allowance
producing foreign bodies in the musculoskeletal system and salivary
stones Out-of-network: 40% of the Plan allowance
and any difference between our allowance and
• Incision/excision of salivary glands and ducts the billed amount
• 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.
Not covered: All charges
• 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

Organ/tissue transplants
These solid organ transplants are subject to medical necessity and In-network Transplant Center of Excellence
experimental/investigational review by the Plan. Refer to Other services (COE): 10% of the Plan allowance
in Section 3 for prior authorization procedures.
In-network: 15% of the Plan allowance
Solid organ transplants are limited to:
Out-of-network: 40% of the Plan allowance
• Cornea and any difference between our allowance and
• Heart the billed amount and any amount over
• Heart/lung $100,000

• 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
• Autologous pancreas islet cell transplant (as an adjunct to total or near
total pancreatectomy) only for patients with chronic pancreatitis

Organ/tissue transplants - continued on next page

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Benefit Description You Pay

Organ/tissue transplants (cont.)
These tandem blood or marrow stem cell transplants for covered In-network Transplant Center of Excellence
transplants are subject to medical necessity review by the Plan. Refer to (COE): 10% of the Plan allowance
Other services in Section 3 for prior authorization procedures.
In-network: 15% of the Plan allowance
• Autologous tandem transplants for
- AL Amyloidosis Out-of-network: 40% of the Plan allowance
and any difference between our allowance and
- Multiple myeloma (de novo and treated) the billed amount and any amount over
- Recurrent germ cell tumors (including testicular cancer) $100,000

Blood or marrow stem cell transplants In-network Transplant Center of Excellence

(COE): 10% of the Plan allowance
The Plan extends coverage for the diagnoses as indicated below:
• Allogeneic transplants for In-network: 15% of the Plan allowance
- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) Out-of-network: 40% of the Plan allowance
leukemia and any difference between our allowance and
- Acute myeloid leukemia the billed amount and any amount over
$100,000
- 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 PNH, 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

Organ/tissue transplants - continued on next page

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Benefit Description You Pay

Organ/tissue transplants (cont.)
- Severe or very severe aplastic anemia In-network Transplant Center of Excellence
- Sickle cell anemia (pediatric only) (COE): 10% of the Plan allowance

- X-linked lymphoproliferative syndrome In-network: 15% of the Plan allowance

• Autologous transplants for Out-of-network: 40% of the Plan allowance
- Acute lymphocytic or nonlymphocytic (i.e., myelogenous) and any difference between our allowance and
leukemia the billed amount and any amount over
- Advanced childhood kidney cancers $100,000

- Advanced Hodgkin's lymphoma with recurrence (relapsed)

- Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
- Amyloidosis
- Agressive 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

Mini-transplants (non-myeloablative, reduced intensity conditioning or In-network Transplant Center of Excellence

RIC) are subject to medical necessity review by the Plan. (COE): 10% of the Plan allowance

In-network: 15% of the Plan allowance

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

and any difference between our allowance and
the billed amount and any amount over
$100,000
Blood or marrow stem cell transplants are covered only in a National In-network Transplant Center of Excellence
Cancer Institute or National Institutes of Health approved clinical trial (COE): 10% of the Plan allowance
or a Plan-designated center of excellence and if approved by the Plan's
medical director in accordance with the Plan's protocols. In-network: 15% of the Plan allowance

If you are a participant in a clinical trial, the Plan will provide benefits Out-of-network: 40% of the Plan allowance
for related routine care that is medically necessary (such as doctor visits, and any difference between our allowance and
lab tests, X-rays and scans, and hospitalization related to treating the the billed amount and any amount over
patient's condition) if it is not provided by the clinical trial. Section 9 has $100,000
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

Organ/tissue transplants - continued on next page

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Benefit Description You Pay

Organ/tissue transplants (cont.)
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.
Not covered: All charges
• Donor screening tests and donor search expenses, except as shown
above
• Transplants not listed as covered
• Implants of artificial organs

Anesthesia
Professional services for administration of anesthesia In-network: 15% of the Plan allowance

Note: If surgical services are rendered at an in-network hospital or an Out-of-network: 40% of the Plan allowance
in-network freestanding ambulatory facility by an in-network primary and any difference between our allowance and
surgeon, we will pay the services of out-of-network anesthesiologists at the billed amount
the in-network rate, based on Plan allowance.

Not covered: All charges

• Surgery for the sole purpose of gender reassignment or for the sole
purpose of changing physical appearance to conform with gender
identity

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Section 5 (c). Services provided by a hospital or other facility, and ambulance

services
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 health care expenses.
• If your Personal Care Account has been exhausted, you must pay your 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 $66.67 per month for Self Only, $133.33 for Self Plus One or $133.33
per month for Self and Family for each full month of coverage remaining in that calendar year.
• When you use an in-network hospital, keep in mind that the professionals who provide services to
you in the hospital, may not all be preferred providers. However, if covered services are rendered at
an in-network hospital or an in-network freestanding ambulatory/facility, we will pay all physicians
and covered ancillary services that are not preferred providers at the in-network rate, based on Plan
allowance. You may be billed any difference between our allowance and the billed amount.
• 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.
• When you receive hospital observation services, we apply outpatient benefits to covered services.
In only rare and exceptional cases do reasonable and necessary outpatient observation services span
more than 48 hours.
Benefit Description You Pay
Inpatient hospital
Room and board, such as: In-network: 15% of the Plan allowance
• Ward, semiprivate, or intensive care accommodations Out-of-network: 40% of the Plan allowance
• General nursing care and any difference between our allowance and
• Meals and special diets the billed amount

Note: For inpatient hospital care related to

Note: We only cover a private room when you must be isolated to maternity, we pay for covered services in full
prevent contagion. Otherwise, we will pay the hospital’s average charge when you use preferred providers (See Section
for semiprivate accommodations. If the hospital only has private rooms, 5(a), Maternity care).
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.

Inpatient hospital - continued on next page

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Benefit Description You Pay

Inpatient hospital (cont.)
Other hospital services and supplies, such as: In-network: 15% of Plan allowance
• Operating, recovery, maternity and other treatment rooms Out-of-network: 40% of the Plan allowance
• Prescribed drugs and medicines and any difference between our allowance and
• Diagnostic laboratory tests and X-rays billed amount

• Blood or blood plasma, if not donated or replaced Note: For inpatient hospital care related to
• Dressings, splints, casts, and sterile tray services maternity, we pay for covered services in full
when you use preferred providers (See Section
• Medical supplies and equipment, including oxygen 5(a), Maternity care).
• Anesthetics, including nurse anesthetist services

Note: We base payment on whether the facility or a health care

professional bills for the services or supplies. For example, when the
hospital bills for its nurse anesthetists’ services, we pay Hospital benefits
and when the anesthesiologist bills, we pay Surgery benefits.
Not covered: All charges
• 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
• Custodial care; see Definitions, Section 10
• Non-covered facilities, such as nursing homes, skilled nursing
facilities, residential treatment facilities, day and evening care centers,
and schools
• Personal comfort items such as radio, television, air conditioners,
beauty and barber services, guest meals and beds
• Services of a private duty nurse that would normally be provided by
hospital nursing staff
• Surgery for the sole purpose of gender reassignment or for the sole
purpose of changing physical appearance to conform with gender
identity

Cancer Centers of Excellence

The Plan provides access to designated Cancer Centers of Excellence. In-network Cancer Centers of Excellence
To locate a Cancer Center of Excellence, contact UnitedHealthcare at (COE): 10% of the Plan allowance
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

Cancer Centers of Excellence - continued on next page

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Benefit Description You Pay

Cancer Centers of Excellence (cont.)
• Outpatient surgery, diagnostic and therapeutic services. In-network Cancer Centers of Excellence
(COE): 10% of the Plan allowance
If you decide to use a designated Center of Excellence, you may receive
prior approval for travel and lodging costs.
Outpatient hospital or ambulatory surgical center
• Operating, recovery, and other treatment rooms In-network: 15% of Plan allowance
• Prescribed drugs and medicines Out-of-network: 40% of the Plan allowance
• Diagnostic laboratory tests, X-rays, and pathology services and any difference between our allowance and
• Administration of blood, blood plasma, and other biologicals billed amount

• Blood and blood plasma, if not donated or replaced Note: For inpatient hospital care related to
• Pre-surgical testing maternity, we pay for covered services in full
when you use preferred providers (See Section
• Dressings, casts, and sterile tray services 5(a), Maternity care).
• 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.
Extended care benefits/Skilled nursing care facility
benefits
No benefit All charges
Hospice care
Hospice is a coordinated program of home and inpatient supportive care Any amount over the annual maximums shown
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

End of life care

End of life care Any amount over the annual maximums shown
• See Hospice care benefit, which includes advance care planning,
above

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Benefit Description You Pay

Ambulance
Local professional ambulance service when medically appropriate In-network: 15% of Plan allowance
immediately before or after an inpatient admission
Out-of-network: 40% of the Plan allowance
and any difference our allowance and billed
amount
Not covered: All charges
• Ambulance service used for routine transport

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Section 5 (d). Emergency services/accidents

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 health care expenses.
• If your Personal Care Account has been exhausted, you must pay your 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 $66.67 per month for Self Only, $133.33 for Self Plus One or $133.33
per month for Self and Family for each full month of coverage remaining in that calendar year.
• When you use an in-network hospital, keep in mind that the professionals who provide services to
you in the hospital, may not all be preferred providers. However, if covered services are rendered at
an in-network hospital or an in-network freestanding ambulatory/facility, we will pay all physicians
and covered ancillary services that are not preferred providers at the in-network rate, based on Plan
allowance. You may be billed any difference between our allowance and the billed amount.
• 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.

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Benefit Description You Pay

Accidental injury
If you receive care for your accidental injury within 24 hours, we cover: In-network: 15% of the Plan allowance
• Physician services and supplies Out-of-network: 15% of the Plan allowance
• Related outpatient hospital services and any difference between our allowance and
the billed amount
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.

Medical emergency
• Outpatient facility charges in an Urgent Care Center In-network: 15% of the Plan allowance
• Outpatient medical or surgical services and supplies, other than an Out-of-network: 15% of the Plan allowance
Urgent Care Center
Note: For out-of-network benefits, members
may be billed the difference between the Plan
allowance and the billed amount.
Ambulance
• Professional ambulance service within 24 hours of an accidental In-network: 15% of the Plan allowance
injury or medical emergency
Out-of-network: 15% of the Plan allowance
• Air ambulance to nearest facility where necessary treatment is and any difference between our allowance and
available is covered if no emergency ground transportation is the billed amount
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 Hospital benefits, Section 5(c) for non-emergency service.

Not covered: All charges

• 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

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Section 5 (e). Mental health and substance misuse disorder benefits

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 Deductible for your first year
will be prorated at a rate of $66.67 per month for Self Only, $133.33 for Self Plus One or $133.33
per month for 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 misuse disorder
treatment, call Beacon Health Options at 888-700-7965.
• 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 misuse disorder
treatment providers. Beacon Health Options will provide you with a choice of network providers at
888-700-7965 or visit our website at www.apwuhp.com.
• Residential Treatment Facilities, schools or other educational institutions are not covered.
Benefits Description You Pay
Professional services
We cover professional services by licensed professional mental health Your cost-sharing responsibilities are no greater
and substance misuse disorder treatment practitioners when acting than for other illnesses or conditions.
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

Diagnosis and treatment of psychiatric conditions, mental illness, or In-network: 15% of the Plan allowance
mental disorders. Services include:
Out-of-network: 40% of the Plan allowance
• Diagnostic evaluation and any difference between our allowance and
• Crisis intervention and stabilization for acute episodes the billed amount.
• Medication evaluation and management (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine
the appropriate psychiatric treatment (preauthorization required by
Beacon Health Options)
• Treatment and counseling (including individual or group therapy
visits)

Professional services - continued on next page

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 CDHP

Benefits Description You Pay

Professional services (cont.)
• Diagnosis and treatment of alcoholism and substance misuse disorder In-network: 15% of the Plan allowance
treatment, including detoxification, treatment and counseling
Out-of-network: 40% of the Plan allowance
• Repetitive Transcranial Magnetic Stimulation, TMS, for the treatment and any difference between our allowance and
of depressive disorders which have not been responsive to other the billed amount.
interventions such as psychotherapy and antidepressant medications
(preauthorization required by Beacon Health Options)
• Electroconvulsive therapy (preauthorization required by Beacon
Health Options)
• Professional charges for intensive outpatient treatment in a provider's
office or other professional setting (preauthorization required by
Beacon Health Options)
• Diagnosis and treatment to address gender dysphoria and gender
transition (in-network only) (See Section 5(b) and 5(c) for exclusions)

Diagnostics
• Outpatient diagnostic tests provided and billed by a licensed mental In-network: 15% of the Plan allowance
health and substance misuse disorder treatment practitioner
Out-of-network: 40% of the Plan allowance
• Outpatient diagnostic tests provided and billed by a laboratory, and any difference between our allowance and
hospital or other covered facility the billed amount.
• Inpatient diagnostic tests provided and billed by a hospital or other
covered facility

Inpatient hospital or other covered facility

Inpatient services provided and billed by a hospital or other covered In-network: 15% of the Plan allowance
facility (preauthorization required by Beacon Health Options)
Out-of-network: 40% of the Plan allowance
• Room and board, such as semiprivate or intensive accommodations, and any difference between our allowance and
general nursing care, meals and special diets, and other hospital the billed amount.
services

Outpatient hospital or other covered facility

Outpatient services provided and billed by a hospital or other covered In-network: 15% of the Plan allowance
facility
Out-of-network: 40% of the Plan allowance
• Services such as partial hospitalization, or facility-based intensive and any difference between our allowance and
outpatient treatment (preauthorization required by Beacon Health the billed amount.
Options)

Not covered: All charges

• Services that require preauthorization that are not part of a
preauthorized approval treatment plan
• Services that are not medically necessary
• Residential Treatment Facilities, schools or other educational
institutions are not covered

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Section 5 (f). Prescription drug benefits

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 physicians 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 health care expenses.
• If your Personal Care Account has been exhausted, you must pay your 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 112 for more
information about this program.
• Specialty drugs must be obtained through Optum Rx specialty pharmacy.
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed or certified Physician
Assistant, Nurse Practitioner and Psychologist must prescribe your medication.
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.

Brand/Generic Drugs
• Why use generic drugs? A generic drug is a chemical equivalent of a corresponding name brand drug. The US Food and
Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality
and strength as brand name drugs. Generic drugs are less expensive than brand drugs, therefore, you may reduce your out-
of-pocket-expenses by choosing to use a generic drug.
• A generic equivalent will be dispensed if it is available, unless your physician specifically requires a brand name drug.

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Benefit Description You Pay

Covered medications and supplies
Each new enrollee will receive a combined prescription drug/Plan • Network Retail: generic and preferred brand
identification card. name 25% of charge with a minimum of $15
and a maximum per prescription of $200 for
You may purchase the following medications and supplies prescribed by a 30-day supply. $400 for a 60-day supply,
a physician from either a network pharmacy or by mail: $600 for a 90-day supply; non-preferred
• Drugs and medicines, including those for tobacco cessation, for use at brand name 40% of charge with a minimum
home that are obtainable only upon a doctor’s prescription $15 and a maximum per prescription of $200
• Drugs and medicines (including those administered during a non- for a 30-day supply, $400 for a 60-day
covered admission or in a non-covered facility) that by Federal law of supply, $600 for a 90-day supply
the United States require a physician’s prescription for their purchase, • Network Mail Order: generic and preferred
except those listed as not covered brand name 25% of charge with a minimum
• Insulin and test strips for known diabetics of $10 and a maximum per prescription of
$200 for a 30-day supply. $400 for a 60-day
• FDA approved drugs for weight management. Prior approval is supply, $600 for a 90-day supply; non-
required, see page 112 preferred brand name 40% of charge with a
• Disposable needles and syringes for the administration of covered minimum $10 and a maximum per
medications prescription of $200 for a 30-day supply,
• Prior authorization/medical necessity review is required for certain $400 for a 60-day supply, $600 for a 90-day
drugs and must be renewed periodically. Prior authorization/medical supply
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 and
page 112 for more information about this program.

• In-network prescription drugs approved by the FDA for contraception • Network Retail: $0 generic. Preferred brand
for women name 25% of charge with a minimum of $15
and a maximum per prescription of $200 for
Note: If your physician receives prior authorization because it is a 30-day supply, $400 for a 60-day supply,
medically necessary that a brand name contraceptive drug be dispensed, $600 for a 90-day supply; non-preferred
you will pay $0. Your physician may seek prior authorization by calling brand name 40% of charge with a minimum
800-718-1299. of $15 and maximum per prescription of
$200 for a 30-day supply, $400 for a 60-day
supply, $600 for a 90-day supply
• Network Mail Order: $0 generic. Preferred
brand name 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; non-
preferred brand name 40% of charge with a
minimum of $10 and maximum per
prescription of $200 for a 30-day supply,
$400 for a 60-day supply, $600 for a 90-day
supply

In-network devices approved by the FDA for contraception for women Nothing
Not covered: All charges
• Drugs and supplies for cosmetic purposes

Covered medications and supplies - continued on next page

2018 APWU Health Plan 109 CDHP Section 5(f)
 CDHP

Benefit Description You Pay

Covered medications and supplies (cont.)
• Vitamins, nutrients and food supplements not listed as a covered All charges
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 physician and
purchased at a network pharmacy
- Over-the counter FDA-approved female birth control methods are
covered at no cost if prescribed by a physician and purchased at a
network pharmacy
- Certain new prescription drug products until they are reviewed and
evaluated by Optum Rx

• Non-network retail drugs (unless for a sudden illness while traveling

outside the United States or Puerto Rico)

Note: Over-the-counter and prescription drugs approved by the FDA to

treat tobacco dependence are covered under the Tobacco Cessation
Program (See Educational classes and programs page 92).

Note: Prescription drugs approved by the FDA for contraception for

women are also noted under Well woman (See In-network preventive
care, Section 5 and for devices for birth control under Family planning
(see Section 5(a)).

Benefit Description You Pay

Preventive care medications
Medications to promote better health as recommended by ACA. • Network Retail: Nothing

Preventive Medications with a USPSTF recommendation of A or B are

covered without cost-share when prescribed by a health care
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.uspreventiveservicetaskforce.org/Browse/Rec/Index/browse-
recommendations.

Personalized Medicine (voluntary program)

The Personalized Medicine Program combines a Pharmacogenomic test (genetic lab test) with a clinical program to optimize
prescription drug therapies for patients taking Warfarin (anticoagulant) and Plavix (antiplatelet). This program focuses on
giving physicians information, on an individual level, on patients who have already been diagnosed with a disease or
condition.
The benefits of this testing, done with a simple cheek swab are:
• Greater patient safety and efficacy through more precise dosing for Warfarin and Plavix
• Elimination of adverse events since the patient will be taking the appropriate dose of Warfarin or Plavix from the early
onset of therapy

2018 APWU Health Plan 110 CDHP Section 5(f)

 CDHP

Pharmacogenomic testing gives physicians personalized information they can use to make more precise prescribing and
dosing decisions to help their patients receive the critical care they need. The Personalized Medicine Program is available to
you at no additional cost. If your medication history indicates that the testing could be beneficial for you, a pharmacist will
contact your physician to discuss the program. If your doctor agrees that the test results would be helpful, you will be
contacted by a pharmacist to let you know that the testing is available. If you agree to participate, you will receive a cheek
swab test that you can administer on your own.
The results of your test will be sent to your doctor and to an Optum Rx pharmacist who has received special training in
personalized medicine. The pharmacist is available to help your doctor interpret the results of your test. Your participation is
voluntary, and your doctor is still solely responsible for deciding which drug and dose is right for you.
Benefit Description You Pay
Personalized medicine (voluntary program)
• Pharmacogenomic testing to optimize prescription drug therapies for Nothing
certain conditions
• Warfarin (anticoagulant)
• Plavix (antiplatelet)

2018 APWU Health Plan 111 CDHP Section 5(f)

 CDHP

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 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.
• 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 prescribing physician 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 physician for
a new prescription for an FDA-approved drug before your next fill. Your compound medication may require notification/
prior authorization. The prescribing physician 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.

2018 APWU Health Plan 112 CDHP Section 5(f)

 CDHP

• 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).

2018 APWU Health Plan 113 CDHP Section 5(f)

 CDHP

Section 5 (g). Dental benefits

Benefits Description You Pay

Dental
No benefit See Personal Care Account, page 80

2018 APWU Health Plan 114 CDHP Section 5(g)

 CDHP

Section 5 (h). Wellness and Other Special features

Special features Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide
services.
• We may identify medically appropriate alternatives to 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).

2018 APWU Health Plan 115 CDHP Section 5(h)

 CDHP

Section 5 (i). Health education resources and account management tools

Special features Description
Online tools and Your Personal, private website accessible by Internet at www.myuhc.com
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

Consumer choice Each member is provided access by Internet (www.myuhc.com) or telephone

information 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

Care support A 24-hour nurse advisory service for your use. This program is strictly voluntary and
confidential. You may call toll-free at 800-718-1299 to discuss an existing medical
concern or to receive information about numerous health care and self-care issues. This
also includes health coaching with a registered nurse when you want to discuss significant
medical decisions. TTY/TDD callers, please call the National Relay Center at
800-855-2880 and ask for 800-718-1299.

Identification and notification of potential patient safety issues (e.g., drug interactions).

Individual support with a health care professional for numerous medical conditions
including maternity, asthma, diabetes, congestive heart failure, healthy back and more.

Cancer Centers of Excellence (See Section 5(c), page 101).

Special Programs Online programs and services provide extra support and savings, at www.welcometouhc.
com/apwu
• Healthy Pregnancy Program - Mothers-to-be receive support through every stage of
pregnancy and delivery.
• Healthy Back Program - Help for preventing or dealing with back pain before it
becomes a recurring or long-term issue.
• Cancer Support Program - Enroll in the program, and receive enhanced benefits at
Cancer Centers of Excellence.
• Source4Women - Resource designed for women to learn how to keep the entire
family healthy.
• Diabetes Management Program - Receive support from a health coach for managing
diabetes.

2018 APWU Health Plan 116 CDHP Section 5(i)

 CDHP

Health Risk Assessment A Health Risk Assessment (HRA) is available at www.myuhc.com, or call 800-718-1299.
(HRA) 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 online, if you have Self Only coverage, we will add $50 to
your Personal Care Account (PCA). If you have Self Plus One or Self and Family
coverage we will add $50 to the Personal Care Account (PCA) for the member, spouse,
and each covered dependent age 18 or older who completes the HRA. We will add these
amounts in the calendar year in which the HRAs were completed.

2018 APWU Health Plan 117 CDHP Section 5(i)

 Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file 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/
Conversion_Plan_Option.php.
American Hearing Benefits 888-863-7222
www.americanhearingbenefits.com
The American Hearing Benefits 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 American Hearing Benefits Plan through this offer will receive a discount on hearing aid devices
offered through Starkey Hearing Technologies. To enroll in the plan you must call American Hearing Benefits toll free at
888-863-7222. Please specify that you are an APWU Health Plan participant.
Availability: The American Hearing Benefits Plan is available to all Active, Retired, Associate and Transitional Employees,
APWU Members in all States and Territories of the United States.
Coverage Description: With this optional plan you must contact American Hearing Benefits (AHB) to activate the benefit.
AHB will locate a local provider in your area and schedule your first member visit. After the first visit with a provider,
members may schedule additional appointments with the same provider at will. Discounts are applied at the time services
are rendered.
This program is available to Group members and their immediate families without any charge. This program involves the
extension of a negotiated discount on certain products and services available from certain hearing aid providers and does not
involve the provision of insurance. The program discounts are subject to change. It is your responsibility to determine
whether the products and services you elect to purchase are covered by the program by calling AHB toll free at
888-863-7222.
Coverage Schedule:
• Free hearing consultations annually for members and their immediate family
• Referrals to local providers
• Discounts up to 40%-60% off suggested MSRP prices on Starkey digital hearing instruments
• A full two-year extended warranty included with every purchase of Starkey hearing aid at no additional cost
Benefits on this page are not part of the FEHB contract

2018 APWU Health Plan 118 Non-FEHB benefits available to Plan members Section 5
The Supplemental Discount Drug Program 800-818-6717
www.express-scripts.com
The Supplemental Discount Drug Program is a value-added program that provides members with access to discounts on
prescription drugs not covered by the prescription drug plan when ordered through Express Scripts Mail Service Pharmacies.
Specifically, the Supplemental Discount Drug Program will provide discounts to members on all FDA-approved prescription
drugs that are dispensed through Express Scripts Mail Order pharmacies, yet are not covered under the prescription drug plan
administered by Express Scripts.
Availability: The Supplemental Discount Drug Program is available to all High Option Plan members only.
Coverage Description: You pay 100% of the discounted price. You cannot file a claim for off-Plan prescriptions.
• Call Express Scripts first at 800-818-6717 to find out the price of off-Plan prescriptions.
• Obtain the prescription from your physician.
• Complete an Express Scripts Mail Order envelope and enclose your prescription along with your check or credit card
number. You must include full payment with your order for prescriptions.

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.
The Voluntary Benefits Plan
The Voluntary Benefits Plan Dental program is an optional program with an additional premium that supplements the dental
benefits in your APWU Health Plan coverage. All participants of the APWU Health Plan, either High Option or Consumer
Driven Option, who enroll in the Voluntary Benefits Plan Dental Plan automatically receive a 7.5% premium reduction off
this plan's rates. To enroll in this additional coverage, complete and sign the Voluntary Benefits Plan Dental Plan enrollment
form, which you can obtain from your APWU Health Plan representative or by calling the Voluntary Benefits Plan office at
the toll-free number listed below. Please specify that you are an APWU Health Plan participant.
Availability: The Voluntary Benefits Plan Dental Plan is available to all APWU Active, Retired, Associate, PSE and Private
Sector dues-paying members.
Coverage Description: This optional dental plan is an indemnity insurance plan underwritten by the United States Life
Insurance Company. Insured members may use any dentist they choose. If you were previously a member of a dental plan
requiring the use of a specific dentist, you may continue to use that dentist if you choose, but it is not a requirement of this
Group Dental Plan. Covered services are reimbursed as a percentage of the “Reasonable and Customary” charges for that
service in the state where the charge is incurred. Once you have satisfied the continuous coverage limitations of the program,
there are no further waiting periods as long as you remain continuously insured under the plan. Both you and your eligible
dependents (spouse and unmarried children to age 19 - full-time students to age 25) can be insured under this plan.
Coverage Schedule:
• Calendar Year Deductible:
- $100 per person - Type II and Type III benefits, combined
• Calendar Year Maximum:
- $1,500 per person for all covered services
- $500 per person for all eligible Orthodontic services, if Optional Orthodontic Coverage is selected
• Lifetime Maximum:
- $1,000 for Orthodontic services, if Optional Orthodontic Coverage is selected
(available only for insured dependent children under age 19)

Benefits on this page are not part of the FEHB contract

2018 APWU Health Plan 119 Non-FEHB benefits available to Plan members Section 5
 Benefits Schedule After the Annual Deductible, this plan will pay:
Benefit Schedule High Option Plan Low Option Plan
Type I Benefits: Preventive 100% 100%
Services of the Reasonable and Customary of the Reasonable and Customary
charges charges
Exams / X-rays / Cleanings
Type II Benefits: Basic Services 80% 50%
of the Reasonable and Customary of the Reasonable and Customary
Fillings / Oral Surgery / charges charges
Extractions
(no waiting period) (no waiting period)
Type III Benefits: Major Services 50% 50%
of the Reasonable and Customary of the Reasonable and Customary
Crowns / Bridges / Dentures / charges charges
Periodontics
(12 month waiting period) (18 month waiting period)
Type IV Benefits: (Optional 50% 50%
Coverage) of the Reasonable and Customary of the Reasonable and Customary
charges charges
Orthodontic
(24 month waiting period) (24 month waiting period)
(available only for insured
dependent children under age 19)

This is a partial summary of the terms, conditions and limitations of the Dental Plan. For more information regarding the
coverage, rates or to receive an enrollment form, please contact the Voluntary Benefits Plan office by calling our toll free
number below, going to our website or e-mailing us at voluntarybenefitsplan@gmail.com.
The Voluntary Benefits Plan
P.O. Box 12009
Cheshire, CT 06410
800-422-4492
www.voluntarybenefitsplan.com

Benefits on this page are not part of the FEHB contract

2018 APWU Health Plan 120 Non-FEHB benefits available to Plan members Section 5
 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 as shown on
pages 18, 64, 67, 109, 112.
• 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.
• 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.
• Services, drugs and supplies billed by a Residential Treatment Facility, schools or other education institutions.
• 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 136-137), doctor charges exceeding the amount specified by the
Department of Health and Human Services when benefits are payable under Medicare limiting charge (see page 136), 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.

2018 APWU Health Plan 121 Section 6

 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.
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

VI Equicare claims mail to:

• APWU Health Plan, P.O. Box 1358, Glen Burnie, MD 21060-1358, or Payor ID
44444

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 740810, Atlanta, GA 30374-0810

Mental Health/Substance Misuse Disorder Treatment for both the High Option and
Consumer Driven Option: Mail to:
• Beacon Health Options, P.O. Box 1854, Hickville, NY 11802-1854, or Payor ID FHC
&Affiliates

In most cases, providers and facilities file claims for you. Your physician 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.

2018 APWU Health Plan 122 Section 7

 • 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 physician 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 physician’s name, date, and
charge.
• We will provide translation and currency conversion services for claims for overseas
(foreign) services.

Post-service claims We will notify you of our decision within 30 days after we receive your post-service
procedures 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.

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

Deadline for filing your Send us all the documents for your claim as soon as possible. You must submit the claim
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 in hospitals outside the United States and Puerto Rico
and performed by physicians outside the United States, send a completed claim form and
the itemized bills to the following address. Also, send any written inquiries concerning the
processing of overseas claims to:
• High Option: APWU Health Plan, P.O. Box 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 Please reply promptly when we ask for additional information. We may delay processing
information 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 You may designate an authorized representative to act on your behalf for filing a claim or
Representative to appeal claims decisions to us. For urgent care claims, a health care 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.

2018 APWU Health Plan 123 Section 7

 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 health care 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.

2018 APWU Health Plan 124 Section 7

 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 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 visit www.apwuhp.com.
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 health care 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
his/her 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.
Step Description
Ask us in writing to reconsider our initial decision. You must:
1
(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 30573,
Salt Lake City, UT 84130-0573; 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.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

2018 APWU Health Plan 125 Section 8

 a) Pay the claim or
2
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, Health Insurance 2, 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 health care 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.

OPM will review your disputed claim request and will use the information it collects from you and us to
4 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.

2018 APWU Health Plan 126 Section 8

 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 OPM’s
Healthcare and Insurance office 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.

2018 APWU Health Plan 127 Section 8

 Section 9. Coordinating benefits with Medicare and other coverage
When you have other You must tell us if you or a covered family member has coverage under any other health
health coverage plan or has automobile insurance that pays health care expenses without regard to fault.
This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary
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 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 TRICARE is the health care program for eligible dependents of military persons, and
CHAMPVA 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' We do not cover services that:

Compensation • 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 We do not cover services and supplies when a local, State, or Federal government agency
agencies are responsible directly or indirectly pays for them.
for your care

2018 APWU Health Plan 128 Section 9

 When others are The terms “Reimbursement” and “Subrogation” are defined by the U.S. Office of
responsible for injuries 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 worker’s 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”).

2018 APWU Health Plan 129 Section 9

 • 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

2018 APWU Health Plan 130 Section 9

 When you have Federal Some FEHB plans already cover some dental and vision services. When you are covered
Employees Dental and by more than one vision/dental plan, coverage provided under your FEHB plan remains as
Vision Insurance Plan your primary coverage. FEDVIP coverage pays secondary to that coverage. When you
(FEDVIP) 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

When you have Medicare

• What is Medicare? Medicare is a health insurance program for:

• People 65 years of age or older
• Some people with disabilities under 65 years of age
• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a
transplant)

Medicare has four parts:

• Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or
your spouse worked for at least 10 years in Medicare-covered employment, you
should be able to qualify for premium-free Part A insurance. (If you were a Federal
employee at any time both before and during January 1983, you will receive credit for
your Federal employment before January 1983.) Otherwise, if you are age 65 or older,
you may be able to buy it. Contact 800-MEDICARE (800-633-4227), (TTY:
877-486-2048) for more information.
• Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B
premiums are withheld from your monthly Social Security check or your retirement
check.
• Part C (Medicare Advantage). You can enroll in a Medicare Advantage plan to get
your Medicare benefits. We do not offer a Medicare Advantage plan. Please review
the information on coordinating benefits with Medicare Advantage plans on page
133-134.

2018 APWU Health Plan 131 Section 9

 • Part D (Medicare prescription drug coverage). There is a monthly premium for Part D
coverage. Before enrolling in Medicare Part D, please review the important disclosure
notice from us about the FEHB prescription drug coverage and Medicare. The notice
is on the first inside page of this brochure. For people with limited income and
resources, extra help in paying for a Medicare prescription drug plan is available. For
more information about this extra help, visit the Social Security Administration online
at www.socialsecurity.gov, or call them at 800-772-1213 (TTY: 800-325-0778).

• Should I enroll in The decision to enroll in Medicare is yours. We encourage you to apply for Medicare
Medicare? benefits 3 months before you turn age 65. It’s easy. Just call the Social Security
Administration toll-free number 800-772-1213, (TTY: 800-325-0778) to set up an
appointment to apply. If you do not apply for one or more Parts of Medicare, you can still
be covered under the FEHB Program.

If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal
employees and annuitants are entitled to Medicare Part A at age 65 without cost.

When you don’t have to pay premiums for Medicare Part A, it makes good sense to obtain
the coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB,
which can help keep FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage. The Social Security
Administration can provide you with premium and benefit information. Review the
information and decide if it makes sense for you to buy the Medicare Part B coverage. If
you do not sign up for Medicare Part B when you are first eligible, you may be charged a
Medicare Part B late enrollment penalty of a 10 % increase in premium for every 12
months you are not enrolled. If you didn't take Part B at age 65 because you were covered
under FEHB as an active employee (or you were covered under your spouse's group
health insurance plan and he/she was an active employee), you may sign up for Part B
(generally without an increased premium) within 8 months from the time you or your
spouse stop working or are no longer covered by the group plan. You also can sign up at
any time while you are covered by the group plan.

If you are eligible for Medicare, you may have choices in how you get your health care.
Medicare Advantage is the term used to describe the various private health plan choices
available to Medicare beneficiaries. The information in the next few pages shows how we
coordinate benefits with Medicare, depending on whether you are in the Original
Medicare Plan or a private Medicare Advantage plan.

(Please refer to page 136 for information about how we provide benefits when you
are age 65 or older and do not have Medicare.)

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

2018 APWU Health Plan 132 Section 9

 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 health care
professionals. If you are enrolled in Medicare Part B, we will waive the deductible,
coinsurance and copayment.

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 12-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 following table 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 You must tell us if you or a covered family member has Medicare coverage, and let us
Medicare coverage 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.

• Private contract with If you are enrolled in Medicare Part B, a physician may ask you to sign a private contract
your physician 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 If you are eligible for Medicare, you may choose to enroll in and get your Medicare
(Part C) benefits from a Medicare Advantage plan. These are private health care 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:

2018 APWU Health Plan 133 Section 9

 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 When we are the primary payor, we process the claim first. If you enroll in Medicare Part
drug coverage (Part D and we are the secondary payor, we will review claims for your prescription drug costs
D) that are not covered by Medicare Part D and consider them for payment under the FEHB
plan.

2018 APWU Health Plan 134 Section 9

Medicare always makes the final determination as to whether they are the primary payor. The following chart illustrates
whether Medicare or this Plan should be the primary payor for you according to your employment status and other factors
determined by Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can
administer these requirements correctly. (Having coverage under more than two health plans may change the order of
benefits determined on this chart.)

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...
Medicare 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 for other
services services
8) Are a Federal employee receiving Workers' Compensation disability benefits for six months *
or more
B. When you or a covered family member...
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...
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.

2018 APWU Health Plan 135 Section 9

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 your deductibles, coinsurance, and copayments.
for the claim and is a member of our PPO network,

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 your out-of-network deductibles, coinsurance, and any
our PPO network, 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.

2018 APWU Health Plan 136 Section 9

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 he or she has 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.

When you have the We limit our payment to an amount that supplements the benefits that Medicare would
Original Medicare Plan pay under Medicare Part A (Hospital insurance) and Medicare Part B (Medical insurance),
(Part A, Part B, or both) 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, then 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 other coverage, for more information
about how we coordinate benefits with Medicare.

2018 APWU Health Plan 137 Section 9

 Section 10. Definitions of terms we use in this brochure
Accidental injury An injury resulting from a violent external force.

Admission The period from entry (admission) into a hospital or other covered facility until discharge.
In counting days of inpatient care, the date of entry and the date of discharge are counted
as the same day.

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

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

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 Coinsurance is the percentage of our allowance that you must pay for your care. You may
also be responsible for additional amounts. See page 25.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See
page 24.

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.

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

2018 APWU Health Plan 138 Section 10

 We determine which services are custodial care. Custodial care that lasts 90 days or more
is sometimes known as long term care.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered
services and supplies before we start paying benefits for those services. See page 24.

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

A medical treatment or procedure, or a drug, device, or biological product is experimental

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

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

Determination of experimental/investigational status may require review by a specialty

appropriate board-certified health care provider or appropriate government publications
such as those of the National Institutes of Health, National Cancer Institute, Food and
Drug Administration, Agency of Health Care Policy & Research, and the National Library
of Medicine.

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

Habilitative services Health care 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.

Health care professional A physician or other health care professional licensed, accredited, or certified to perform
specified health services consistent with state law.

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

2018 APWU Health Plan 139 Section 10

 • 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.

Infertility Infertility 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
health care services that we determine:
• Are appropriate to diagnose or treat the patient's condition, illness or injury
• Are consistent with standards of good medical practice in the United States
• Are not primarily for the personal comfort or convenience of the patient, the family, or
the provider
• Are not a part of or associated with the scholastic education or vocational training of
the patient; and
• In the case of inpatient care, cannot be provided safely on an outpatient basis

The fact that a covered provider has prescribed, recommended, or approved a service,
supply, drug or equipment does not, in itself, make it medically necessary.

Pharmacogenomics The study of a patient's genes to predict response to drugs and hence select the right drug
and the right quantity.

Plan allowance Our Plan allowance is the amount we use to determine our payment and your coinsurance
for covered services. Fee-for-service plans determine their allowances in different ways.
We determine our allowance as follows:

For PPO providers, our allowance is based on negotiated rates. PPO providers always
accept the Plan’s allowance as their charge for covered services.

For non-PPO providers, we base the Plan allowance on the lesser of the provider’s actual
charge or the allowed amount for the service you received. We determine the allowed
amount by using health care charge guides which compare charges of other providers for
similar services in the same geographical area. For surgery, doctor’s services, X-ray, lab
and therapies (physical, speech and occupational), we use guides prepared by
the Context4Healthcare and Fair Health and apply these guides under the High Option at
the 70th percentile and under the Consumer Driven Option at the 80th percentile. We
update these charge guides at least once each year. 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.

Post-service claims Any 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.

2018 APWU Health Plan 140 Section 10

 Pre-service claims Those 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.

Subrogation 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.

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 judge whether 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.

2018 APWU Health Plan 141 Section 10

 Consumer Driven Health Plan Definitions
Consumer Driven Option A fee-for-service option under the FEHB that offers you greater control over choices of
your health care expenditures. You decide what health care services will be reimbursed
under the Health Plan funded Personal Care Account (PCA). Unused funds from the PCA
will roll over at the end of the year. If you spend the entire PCA fund before the end of the
year, then you must satisfy a 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 Deductible is the amount you must pay, if you
have exhausted your Personal Care Account, before your Traditional Health Coverage
begins. 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 in any given year may not exceed $5,000 per Self Only enrollment
and $10,000 per Self Plus One or Self and Family enrollment.

2018 APWU Health Plan 142 Section 10

 Section 11. Other Federal Programs
Please note, the following programs are not part of your FEHB benefits. They are separate Federal programs that
complement your FEHB benefits and can potentially reduce your annual out-of-pocket expenses. These programs are
offered independent of the FEHB Program and require you to enroll separately with no government contribution.
Important information First, the Federal Flexible Spending Account Program, also known as FSAFEDS, lets
about four Federal you set aside pre-tax money from your salary to reimburse you for eligible dependent care
programs that and/or health care expenses. You pay less in taxes so you save money. Participating
complement the FEHB employees save an average of about 30% on products and services they routinely pay for
Program out-of-pocket.

Second, the Federal Employees' Dental and Vision Insurance Program (FEDVIP)
provides comprehensive dental and vision insurance at competitive group rates. There are
several plans from which to choose. Under FEDVIP you may choose self only, self plus
one, or self and family coverage for yourself and any eligible dependents.

Third, the Federal Long Term Care Insurance Program (FLTCIP) can help cover long
term care costs, which are not covered under the FEHB Program.

Fourth, the Federal Employees' Group Life Insurance Program (FEGLI) can help
protect your family from burdensome funeral costs and the unexpected loss of your
income.

The Federal Flexible Spending Account Program - FSAFEDS

What is an FSA? It is an account where you contribute money from your salary BEFORE taxes are
withheld, then incur eligible expenses and get reimbursed. You pay less in taxes so you
save money. Annuitants are not eligible to enroll.

There are three types of FSAs offered by FSAFEDS. Each type has a minimum annual
election of $100. The maximum annual election for a health care flexible spending
account (HCFSA) or a limited expense health care spending account (LEX HCFSA) is
$2,600 per person. The maximum annual election for a dependent care flexible spending
account (DCFSA) is $5,000 per household.
• Health Care FSA (HCFSA) – Reimburses you for eligible out-of-pocket health care
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.
• Limited Expense Health Care FSA (LEX HCFSA) – Designed for employees
enrolled in or covered by a High Deductible Health Plan with a Health Savings
Account. Eligible expenses are limited to out-of-pocket dental and vision care
expenses for you and your tax dependents including adult children (through the end of
the calendar year in which they turn 26).

2018 APWU Health Plan 143 Section 11

 • Dependent Care FSA (DCFSA) – Reimburses you for eligible non-medical day care
expenses for your children under age 13 and/or for any person you claim as a
dependent on your Federal Income Tax return who is mentally or physically incapable
of self-care. You (and your spouse if married) must be working, looking for work
(income must be earned during the year), or attending school full-time to be eligible
for a DCFSA.
• If you are a new or newly eligible employee you have 60 days from your hire date to
enroll in an HCFSA or LEX HCFSA and/or DCFSA, but you must enroll before
October 1. If you are hired or become eligible on or after October 1 you must wait
and enroll during the Federal Benefits Open Season held each fall.

Where can I get more Visit www.FSAFEDS.com or call an FSAFEDS Benefits Counselor toll-free at 877-
information about FSAFEDS, 877-372-3337 (TTY, 866-353-8058), Monday through Friday, 9 a.m. until 9 p.
FSAFEDS? m., Eastern Time.

The Federal Employees' Dental and Vision Insurance Program - FEDVIP

Important Information The Federal Employees' Dental and Vision Insurance Program (FEDVIP) is separate and
different from the FEHB Program. This Program provides comprehensive dental and
vision insurance at competitive group rates with no pre-existing condition limitations
for enrollment.

FEDVIP is available to eligible Federal and Postal Service employees, retirees, and their
eligible family members on an enrollee-pay-all basis. Employee premiums are withheld
from salary on a pre-tax basis.

Dental Insurance All dental plans provide a comprehensive range of services, including:
• Class A (Basic) services, which include oral examinations, prophylaxis, diagnostic
evaluations, sealants and X-rays.
• Class B (Intermediate) services, which include restorative procedures such as fillings,
prefabricated stainless steel crowns, periodontal scaling, tooth extractions, and denture
adjustments.
• Class C (Major) services, which include endodontic services such as root canals,
periodontal services such as gingivectomy, major restorative services such as crowns,
oral surgery, bridges and prosthodontic services such as complete dentures.
• Class D (Orthodontic) services with up to a 12-month waiting period. Most FEDVIP
dental plans cover adult orthodontia but it may be limited. Review your FEDVIP
dental plan's brochure for information on this benefit.

Vision Insurance All vision plans provide comprehensive eye examinations and coverage for lenses, frames
and contact lenses. Other benefits such as discounts on LASIK surgery may also be
available.

Additional information You can find a comparison of the plans available and their premiums on the OPM website
at www.opm.gov/dental and www.opm.gov/vision. This site also provides links to each
plan’s website, where you can view detailed information about benefits and preferred
providers.

How do I enroll? You enroll on the Internet at www.BENEFEDS.com. For those without access to a
computer, call 877-888-3337 (TTY: 877-889-5680).

2018 APWU Health Plan 144 Section 11

The Federal Long Term Care Insurance Program - FLTCIP

It's important protection The Federal Long Term Care Insurance Program (FLTCIP) can help pay for the
potentially high cost of long term care services, which are not covered by FEHB plans.
Long term care is help you receive to perform activities of daily living – such as bathing
or dressing yourself - or supervision you receive because of a severe cognitive impairment
such as Alzheimer’s disease. Long term care can be received in your home, in a nursing
home, in an assisted living facility or in adult day care. You must apply, answer health
questions (called underwriting) and be approved for enrollment. Federal and U.S. Postal
Service employees and annuitants, active and retired members of the uniformed services,
and qualified relatives are eligible to apply. Your qualified relatives can apply even if you
do not. Certain medical conditions, or combinations of conditions, will prevent some
people from being approved for coverage. You must apply to know if you will be
approved for enrollment. For more information, call 800-LTC-FEDS (800-582-3337),
(TTY: 800-843-3557), or visit www.ltcfeds.com.

The Federal Employees' Group Life Insurance Program - FEGLI

Peace of Mind for You The Federal Employees’ Group Life Insurance Program (FEGLI) can help protect your
and Your Family family from burdensome funeral costs and the unexpected loss of your income. You can
get life insurance coverage starting at one year’s salary to more than six times your salary
and many options in between. You can also get coverage on the lives of your spouse and
unmarried dependent children under age 22. You can continue your coverage into
retirement if you meet certain requirements. For more information, visit www.opm.gov/
life.

2018 APWU Health Plan 145 Section 11

 Summary of benefits for the High Option of the APWU Health Plan - 2018
Do not rely on this chart alone. All benefits are subject to the definitions, limitations, and exclusions in this brochure. On
this page we summarize specific expenses we cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on
your enrollment form.
Below, an asterisk (*) means the item is subject to the calendar year deductible, $350 (PPO) or $500 (Non-PPO). And, after
we pay, you generally pay any difference between our allowance and the billed amount if you use a Non-PPO physician or
other health care professional.
High Option Benefits You pay Page
Medical services provided by physicians:

• Diagnostic and treatment services provided in the PPO: $25 copay per visit (No deductible); 33
office* 10% of Plan allowance

Non-PPO: 30% of our allowance plus amount

over our allowance

Services provided by a hospital:

• Inpatient PPO: 10% of Plan allowance 53

Non-PPO: $300 per admission and 30% of

our allowance plus amount over our
allowance

• Outpatient* PPO: 10% of Plan allowance 55

Non-PPO: 30% of our allowance plus amount

over our allowance

Emergency benefits:

• Accidental injury PPO: Nothing 58

Non-PPO: Any amount over our allowance

• Medical emergency* PPO 10% of Plan allowance 58

Non-PPO: 10% of our allowance plus amount

over our allowance

Mental health and substance misuse disorder PPO: $25 copay per visit (No deductible); 59
treatment: 10% of Plan allowance

Non-PPO: 30% of our allowance plus amount

over our allowance

Prescription drugs:

• Network pharmacy $10 generic/25% preferred brand name/45% 64

non-preferred brand name/Specialty drugs
25% generic/25% preferred brand name/45%
non-preferred brand name

• Non-network pharmacy 50% of cost 64

• Mail order 64

2018 APWU Health Plan 146 High Option Summary

 $20 generic/25% preferred brand name/45%
non-preferred brand name/Specialty drugs
25% generic/25% preferred brand name/45%
non-preferred brand name

Dental care: 30% of Plan allowance plus amount over our 69

allowance

Wellness and other special features: See Section 5(h) 70

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.

Protection against catastrophic costs (out-of-pocket PPO: Nothing after $5,500 for Self Only or 26
maximum): $9,000 for a Self Plus One or Self and Family
enrollment per year

Non-PPO: Nothing after $10,000 for Self

Only, or $15,000 for a Self Plus One or
Family enrollment per year

Some costs do not count toward this

protection

2018 APWU Health Plan 147 High Option Summary

 Summary of benefits for the CDHP of the APWU Health Plan - 2018

• Do not rely on this chart alone. All benefits are subject to the definitions, limitations, and exclusions in this brochure. On
this page we summarize specific expenses we cover; for more detail, look inside.

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on
your enrollment form.

Below, an asterisk (*) means the item is subject to the Deductible, generally $800 per Self Only and $1,600 per Self Plus
One or Self and Family, once your Personal Care Account has been spent. And, after we pay, you generally pay any
difference between our allowance and the billed amount if you use an out-of-network physician or other health care
professional.

CDHP Benefits You Pay Page

In-network preventive care: Nothing 76
Personal Care Account:

Up to $1,200 for Self Only or $2,400 for Self Plus One or Nothing up to $1,200 for Self Only or $2,400 79
Self and Family for medical, surgical, hospital, mental for Self Plus One or Self and Family
health and substance misuse disorder treatment services
and prescription drugs plus certain dental and vision care

Traditional Health Coverage after Personal See Section 5 Traditional Health Overview 82
Care Account is exhausted (Deductible before Traditional Health
Coverage Begins)

Medical/Surgical services provided by physicians:

• Diagnostic and treatment services provided in the In-network: 15% of Plan allowance 84
office* Out-of-network: 40% of our allowance plus
amount over our allowance

Services provided by a hospital:

• Inpatient* In-network: 15% of Plan allowance 100

Out-of-network: 40% of our allowance plus
amount over our allowance

• Outpatient* In-network: 15% of Plan allowance 102

Out-of-network: 40% of our allowance plus
amount over our allowance

Emergency benefits:

• Accidental injury* In-network: 15% of Plan allowance 105

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

amount over our allowance

• Medical emergency* In-network: 15% of Plan allowance 105

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

amount over our allowance

Mental health and substance misuse disorder In-network: 15% of Plan allowance 106
treatment*: Out-of-network: 40% of our allowance plus
amount over our allowance

Prescription drugs:

2018 APWU Health Plan 148 CDHP Summary

 CDHP Benefits You Pay Page
• Network pharmacy* 25% minimum $15 generic and preferred 109
brand/40% minimum $15 non-preferred

• Mail order* 25% minimum $10 generic and preferred 109

brand/40% minimum $10 non-preferred

Dental Care/Vision Care (covered only under Personal Any amount over $400 per Self Only or $800 79
Care Account): per Self Plus One or Self and Family (see
Section 5 Extra PCA Expenses).

Health education resources and account management See Section 5(i) 116
tools:

Online tools and resources, Consumer choice information,

Services for deaf and hearing-impaired, 24-hour Nurse
Advisory Service and Care Support, online special
programs for extra support savings, and Health Risk
Assessment (HRA) savings.

Protection against catastrophic costs (out-of-pocket In-network: Nothing after $5,000 Self Only or 26
maximum): $10,000 for a Self Plus One or Self and
Family enrollment per year

Out-of-network: Nothing after $10,200 Self

Only or $13,700 for a Self Plus One or Self
and Family enrollment per year

Some costs do not count toward this

protection

2018 APWU Health Plan 149 CDHP Summary

 Index
Accidental injury Congenital anomalies Fecal occult blood test
CDHP..........................................104-105 CDHP..............................................93-95 CDHP..............................................76-77
HO............................................57-58, 69 HO..................................................46-48 HO..................................................34-36
Acupuncture Consumer Driven Option......................75-76 Federal Employees Dental and Vision
CDHP...................................................92 Contraceptive devices and drugs Insurance Plan..........................................144
HO........................................................44 CDHP...................76-77, 93-94, 109-110 Flexible benefits option
Allergy HO......................34-36, 38, 46-47, 62-69 CDHP.................................................115
CDHP...................................................87 Conversion Plan Health Insurance (non- HO........................................................70
HO........................................................39 FEHB)...............................................118-119 Foot care
Alternative treatments Coordination of benefits...................128-138 CDHP...................................................89
CDHP...................................................92 Copayment............................................24-29 HO........................................................41
HO........................................................44 Cost-sharing...............................................24 Fraud.........................................................4-5
Ambulance Covered providers......................................16 General exclusions.................................121
CDHP.........................................103, 105 Deductible............................................24-25 Health Management Programs
HO..................................................56, 58 CDHP..............................................82-83 CDHP.................................................116
American Hearing Benefits (non-FEHB) HO..................................................24-25 HO..................................................70-71
....................................................118-119 Definitions........................................138-142 Hearing services
Anesthesia Dental CDHP...................................................89
CDHP.....................................92, 99, 102 CDHP........................75, 95-96, 114-115 HO........................................................41
HO............................................44, 52, 55 HO............................................48-49, 69 High Option...............................................32
Applied Behavioral Health Diabetes Management Program Home health services
CDHP...................................................88 CDHP.................................................116 CDHP..............................................91-92
HO........................................................40 HO........................................................70 HO..................................................43-44
APWU Health Plan Diabetic supplies Hospice
Mailing Address.....................................4 CDHP..........................................109-110 CDHP.................................................102
Telephone Number.................................4 HO..................................................64-66 HO........................................................55
Biopsies Diagnostic Services Hospital
CDHP..............................................93-96 CDHP...................................................84 Inpatient CDHP..................100-101, 107
HO..................................................46-49 HO........................................................33 Inpatient HO.............................53-54, 60
Blood and blood plasma Dialysis Outpatient CDHP.......................102, 107
CDHP..........................................100-102 CDHP..............................................87-88 Outpatient HO................................55, 61
HO..................................................53-55 HO..................................................39-40 Immunizations
Breast reconstruction Disease Management Program Adult CDHP...................................76-77
CDHP..............................................94-95 CDHP.................................................116 Adult HO........................................34-36
HO..................................................47-48 HO........................................................70 Children CDHP....................................78
Cancer Centers of Excellence Disputed claims process...........................125 Children HO...................................36-37
CDHP....................................84, 101-102 Durable Medical Equipment (DME) Infertility
HO..................................................33, 55 CDHP..............................................90-91 CDHP...................................................87
Casts HO..................................................42-43 HO........................................................39
CDHP..........................................100-102 Educational classes and programs Insulin
HO..................................................53-55 CDHP...................................................92 CDHP..........................................109-110
Catastrophic protection.........................26-28 HO..................................................44-45 HO..................................................64-66
CHAMPVA..............................................128 Effective date of enrollment.................10-11 Magnetic Reasonance Imagings (MRIs)
Chemotherapy/Radiation Emergency ..............................................................20
CDHP......................................87-88, 102 CDHP..........................................104-105 CDHP...................................................85
HO............................................39-40, 55 HO..................................................57-58 HO........................................................34
Chiropractic End of Life Care Mail Order prescription drugs
CDHP...................................................92 CDHP.................................................102 CDHP..........................................109-110
HO........................................................44 HO........................................................56 HO..................................................64-66
Cholesterol tests Experimental or investigational.......121, 139 Mammograms
CDHP..............................................76-77 CDHP..............................................96-99 CDHP........................................76-77, 85
HO..................................................34-36 HO..................................................49-52 HO..................................................34-36
Claims...............................................122-123 Eyeglasses Maternity
Clinical Trials...................................131, 138 CDHP........................................80-83, 89 CDHP..............................................85-86
Coinsurance..........................................24-28 HO........................................................41 HO..................................................37-38
Colorectal cancer screening Family planning Medicaid..................................................128
CDHP..............................................76-77 CDHP...................................................86 Medical emergency
HO..................................................34-36 HO........................................................38 CDHP..........................................104-105
HO..................................................57-58

2018 APWU Health Plan 150 Index

Medically necessary.............................17-18 Precertification......................................17-23 Syringes
Medicare............................131-134, 136-137 Preferred Provider Organizations (PPO) CDHP..........................................109-110
Mental health ........................................................13-14 HO..................................................64-66
CDHP..........................................106-107 Prescription drugs Temporary Continuation of Coverage
HO..................................................59-61 CDHP..........................................108-113 (TCC).............................................11-12
Newborn care HO..................................................62-68 Therapy (Occupational, Physical, & Speech)
CDHP..............................................85-86 Preventive care CDHP..............................................87-88
HO..................................................37-38 Adult CDHP...................................76-77 HO........................................................40
Non-FEHB........................................118-119 Adult HO........................................34-36 Tobacco cessation
Nurse Children CDHP....................................78 CDHP...................................................92
CDHP..............................91-92, 100-101 Children HO...................................36-37 HO..................................................44-45
HO.......................................43-44, 53-54 Prior approval.......................................17-23 Transplants............................................96-99
Nurse help line Prostate Cancer Screening (PSA) CDHP..............................................96-99
CDHP.................................................149 CDHP..............................................76-77 HO..................................................49-52
HO......................................................147 HO..................................................34-36 Treatment therapies
Office visits Prosthetic devices CDHP........................................88, 96-99
CDHP........................33, 84-92, 106-107 CDHP...................................................90 HO..................................................39-40
HO.......................................34-44, 59-60 HO........................................................42 TRICARE................................................128
Organic impotence....................111-113, 121 Rate information....................................154 Virtual Visits
CDHP..........................................109-110 Review and reward program CDHP...................................................85
HO..................................................64-68 HO........................................................71 HO........................................................34
Orthopedic devices Rollover Vision services
CDHP...................................................90 CDHP......................................80-81, 142 CDHP...................................................89
HO........................................................42 Room and board HO........................................................41
Osteoporosis screening CDHP..................................100-101, 107 Voluntary Benefits Dental Plan (non-FEHB)
CDHP..............................................76-77 HO............................................53-54, 60 ....................................................118-120
HO..................................................34-36 Second surgical opinion Weight management program................71
Out-of-pocket expenses........................24-28 CDHP...................................................84 Well Woman
Overseas claims.......................................123 HO........................................................33 CDHP..............................................76-77
Oxygen..................................................18-19 Sigmoidoscopy HO..................................................34-36
CDHP..............................90-91, 100-102 CDHP..............................................76-77 Wheelchairs..........................................18-19
HO.......................................42-43, 53-55 HO..................................................34-36 CDHP..............................................90-91
Pap test Skilled nursing HO..................................................42-43
CDHP..............................................76-77 CDHP................................84, 91-92, 102 Workers' Compensation...........................128
HO..................................................34-36 HO......................................33, 43-44, 55 X-rays
Personal Care Account (PCA) Subrogation.......................................129-130 CDHP...................................................85
CDHP..............................................79-82 Substance misuse disorder HO........................................................34
Physical examination CDHP..........................................106-107
Adult CDHP...................................76-77 HO..................................................59-61
Adult HO........................................34-36 Supplemental Discount Drug Program (non-
Children CDHP....................................78 FEHB)......................................................118
Children HO...................................36-37 Surgery
Physician Assistant surgeon CDHP................93-94
CDHP....................................84, 106-107 Assistant surgeon HO..........................46
HO............................................33, 59-60 Cosmetic CDHP.............................93-95
Positron Emission Tomography (PET)......20 Cosmetic HO..................................46-48
CDHP...................................................85 Multiple procedures CDHP............93-94
HO........................................................34 Multiple procedures HO.................46-47
Oral CDHP.....................................95-96
Oral HO..........................................48-49
Outpatient CDHP...............................102
Outpatient HO......................................55
Reconstructive CDHP.....................94-95
Reconstructive HO.........................47-48

2018 APWU Health Plan 151 Index

 Notes

2018 APWU Health Plan 152

 Notes

2018 APWU Health Plan 153

 2018 Rate Information for the APWU Health Plan

To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

Non-Postal rates apply to most non-Postal employees. If you are in a special enrollment category, contact the agency that maintains
your health benefits enrollment.
Postal rates apply to United States Postal Service employees.
Postal Category 1 rates apply to career bargaining unit employees who are represented by the following agreements: APWU,
IT/AS, NALC, NPMHU, NPPN and NRLCA.
Postal Category 2 rates apply to career bargaining unit employees who are represented by the following agreements: PPOA.
APWU rates apply to career Postal employees represented by APWU.
Non-Postal rates apply to all career non-bargaining unit Postal Service employees.
For further assistance, Postal Service employees should call:
Human Resources Shared Service Center: 877-477-3273, Option 5, TTY: 866-260-7507
Postal rates do not apply to non-career Postal employees, Postal retirees, or associate members of any Postal employee
organization who are not career Postal employees.
Premiums for Tribal employees are shown under the monthly non-Postal column. The amount shown under employee contribution
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.

Non-Postal Premium Postal Premium

Biweekly Monthly Biweekly

Enrollment Gov’t Your Gov’t Your Category 1 Category 2 APWU

Type of Enrollment Code Share Share Share Share Your Share Your Share Your Share

High Option Self Only 471 $229.25 $93.04 $496.71 $201.59 $86.67 $80.31 $86.67

High Option Self Plus

473 $491.00 $185.79 $1,063.83 $402.55 $172.15 $158.51 $172.15
One

High Option Self and

472 $521.58 $251.90 $1,130.09 $545.78 $237.41 $222.92 $237.41
Family

CDHP Option Self Only 474 $191.92 $63.97 $415.82 $138.61 $58.21 $53.10 $12.79

CDHP Option Self Plus

476 $422.21 $140.74 $914.80 $304.93 $128.07 $116.81 $28.15
One

CDHP Option Self and

475 $460.59 $153.53 $997.94 $332.65 $139.71 $127.43 $41.83
Family

2018 APWU Health Plan 154