2008 High Option Benefits Information for Members

Click here to download the APWU Health Plan's 2008 Brochure.

This is a summary of benefits and features offered by the APWU Health Plan. Before making a final decision, please read the Plan's Federal Brochure (RI 71-004). All benefits are subject to the definitions, limitations and exclusions as set forth in the Plan's Brochure.

• Medical Inpatient Hospital Benefits
• Outpatient Hospital Benefits
• Home and Office Physician and Chiropractic Care
• Outpatient Care for Mental Health and Substance Abuse Benefits
• Maternity Benefits
• Inpatient Care for Mental Health and Substance Abuse Benefits
• Accidental Injury Benefits
• Surgery Benefits
• Dental Care Benefits
• Prescription Drug Benefits
• Special Features

Member Services

High Option Inpatient Hospital Benefits
A077407321I - Benefit Description ID - Please retain for future reference/inquiries.

For inpatient medical or maternity hospital admissions, the Health Plan's precertification guidelines are as follows:

• For elective (planned) medical admissions, precertification is required at least 48 hours prior to admission.
• For emergency admissions, the stay must be certified within 48 hours of admission, even if the patient has been discharged at that time.
• Failure to precertify a stay, or to precertify on a timely basis, will result in a $500 penalty.
• To precertify a hospital stay, call the precertification vendor for your area - click here.

PPO benefit	90% of negotiated rate for covered medical hospital stays in a PPO hospital. No deductible.
Non-PPO benefit	70% of semiprivate and intensive/cardiac care unit charge, 70% of other hospital charges after a $300 per admission deductible.

High Option Outpatient Hospital Benefits
A077407422I - Benefit Description ID - Please retain for future reference/inquiries.

Outpatient hospital and diagnostic services for covered medical or maternity diagnoses are subject to an annual $275 PPO ($500 Non-PPO) per person deductible. See the Health Plan's Federal Brochure (RI 71-004) for services that are covered at the outpatient department of a hospital.

PPO benefit	90% of covered charges of the negotiated rate.
Non-PPO benefit	70% of Plan allowance for covered services.

High Option Home and Office Physician Visits and Chiropractic Care
A077407523I - Benefit Description ID - Please retain for future reference/inquiries.

NOTE: For PPO the annual deductible is $275. For non-PPO, the annual deductible is $500 per person, with a $1,000 family maximum.

PPO Doctor	No deductible and $18 copay for home and office visits to physicians, including visits for chiropractic and accupuncture treatment. Other covered services applied to calendar year deductible, then paid at 90% of negotiated rate.
Non-PPO Doctor	After satisfaction of the annual calendar year deductible, 70% of Plan allowance.
Chiropractic services - PPO	No deductible and $18 copay for visits and/or manipulations. Limit of 12 visits/manipulations per person per year.
Chiropractic services - Non-PPO	After satisfaction of the calendar year deductible, covered services are reimbursed at 70% of Plan allowance. Limit of 12 visits/manipulations per person per year.

High Option Outpatient Care for Mental Health and Substance Abuse Benefits
A077407624I - Benefit Description ID - Please retain for future reference/inquiries.

The APWU Health Plan provides benefits for Mental Health and Substance Abuse that are the same as those for medical care. The Health Plan has contracted with ValueOptions, the nation's largest mental health/substance abuse Preferred Provider Organization (PPO). The Health Plan offers separate benefit levels depending upon whether or not PPO providers are used.

PPO benefit	There is a $18 copay for each outpatient visit. Outpatient care must be preauthorized by ValueOptions (1-888/700-7965).
Non-PPO benefit	After satisfaction of a $750 per person calendar year deductible, the Plan pays 50% for up to 15 visits per person per calendar year. Outpatient care must be preauthorized by ValueOptions (1-888/700-7965).

Related drug costs are covered under the Plan's "Prescription Drug" benefits.

NOTE: All outpatient care for mental conditions and/or substance abuse must be preauthorized by ValueOptions, whether or not you are using a Preferred Provider. Call them toll-free at 1-888/700-7965. You can also call this number to locate a covered PPO provider near you.

High Option Maternity Benefits
A077407725I - Benefit Description ID - Please retain for future reference/inquiries.

Maternity care is covered under regular medical (inpatient and outpatient) and surgical benefits.

Infertility diagnosis and treatment

Up to $2,500 per enrollment each calendar year.

Please refer to the Health Plan's Brochure for more information regarding this benefit.

High Option Inpatient Care for Mental Health and Substance Abuse Benefits
A077407826I - Benefit Description ID - Please retain for future reference/inquiries.

If the ValueOptions mental health network is used, members receive in-patient benefits for Mental Health and Substance Abuse that are identical to those for medical care. For inpatient mental condition/substance abuse hospital admissions, the Health Plan's precertification guidelines are as follows: For elective (planned) admissions, precertification is required 48 hours prior to admission. For emergency admissions, the stay must be certified within 48 hours of admission, even if the patient has been discharged at that time. Failure to precertify a stay, or to precertify on a timely basis, will result in a $500 penalty. To precertify a hospital stay, call ValueOptions, toll-free at 1-888/700-7965, whether or not you use a PPO facility. ValueOptions' certification line is available 24 hours-a-day, 7 days a week.

The APWU Health Plan has contracted with ValueOptions, the nation's largest mental health/substance abuse Preferred Provider Organization (PPO). The Health Plan offers separate benefit levels depending upon whether or not PPO providers are used.

Mental Health and Substance Abuse Inpatient hospital benefits:

PPO benefit (Mental Conditions)	The Plan will pay for inpatient hospital treatment at 90%, if preauthorized. After $275 annual deductible, the Plan will pay for inpatient professional fees at 90%, if preauthorized.
Non-PPO benefit (Mental Conditions)	After $750 annual deductible, the Plan will pay for inpatient treatment at 50% for up to 30 days annually if preauthorized (includes professional fees).
PPO Benefit (Substance Abuse)	The Plan will pay for inpatient hospital treatment at 90%, if preauthorized.
Non-PPO Benefit (Substance Abuse)	After $750 deductible, the Plan will pay for inpatient treatment at 50%, up to a maximum payment of $3,000. There is a lifetime maximum of one treatment program per person. Must be precertified.

High Option Accidental Injury Benefits
A077407927I - Benefit Description ID - Please retain for future reference/inquiries.

PPO benefit	100% of provider's negotiated rate (no deductible), within 24 hours of onset. Applies to outpatient services.
Non-PPO benefit	100% of Plan allowance (no deductible), within 24 hours of onset. Applies to outpatient services.

High Option Surgery Benefits
A077408019I - Benefit Description ID - Please retain for future reference/inquiries.

Benefits for covered inpatient or outpatient surgery are subject to the annual $275 PPO ($500 non-PPO) per person deductible. Inpatient and outpatient surgical benefits:

PPO Benefit	90% of a negotiated fee.
Non-PPO Benefit	70% of Plan allowance.

High Option Dental Care Benefits
A077408120I - Benefit Description ID - Please retain for future reference/inquiries.

The Plan does not cover periodontics, orthodontics, endodontics, bridges or crowns. Covered Oral Surgery procedures are handled under surgical benefits. Refer to the Plan's Brochure for listing of covered oral surgery procedures. Dental benefits:

Visits, x-rays, cleanings, flouride treatments or any combination of these services	$25 twice a year
One surface filling	$13 per tooth
Multiple surface filling	$18 per tooth
Simple extraction	$13 per tooth

You can purchase a supplemental dental coverage through the APWU Voluntary Benefits Plan. APWU Health Plan members will receive a 7.5% discount on their V.B.P. Dental Insurance program. For more information, click on this link: www.voluntarybenefitsplan.com.

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High Option Prescription Drug Benefits
A077408221I - Benefit Description ID - Please retain for future reference/inquiries.

The APWU Health Plan offers the cost-savings and convenience of a Mail Order Pharmacy service for its members who use long-term or maintenance prescriptions, with prescriptions delivered right to your door.

Almost sixty thousand pharmacies are part of the Plan's Retail Pharmacy program network, including pharmacy giants such as Walgreens, Rite Aid, K-Mart, COSTCO and CVS.

	You Pay In-Network	You Pay Out of Network
Mail Order	$15 copay per generic drug 25% coinsurance per brand name drug (or a minimum of $12)	All charges
Retail Pharmacy	$8 copay per generic drug 25% coinsurance per brand name drug (or a minimum of $8)	50%

Contact the Plan for an order kit and instructions on how to use the Mail Order Prescription program, or call the Plan's Mail Order vendor at 1-800/841-2734.

Members may check the status of an order, order a refill or locate a participating retail pharmacy by clicking here.

Prospective members and visitors may check the High Option retail pharmacy network and benefit information by clicking here.

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High Option Special Features
A077408322I - Benefit Description ID - Please retain for future reference/inquiries.

Wellness Benefit

The Health Plan is the only plan in the Federal Employees Health Benefits (FEHB) Program that rewards you for staying well. We reimburse you up to $250 per Self Only enrollment and $350 per Self and Family enrollment per calendar year for routine services that are not normally covered, such as eyeglasses, orthodontics, and hearing aids. The Health Plan notifies eligible members in November and includes a Wellness Claim Form. You use the Wellness service before the end of the year. Submit a receipt or itemized bill with the Wellness Claim Form after January 1 of the following year, and the Wellness claims are paid after March 1.

Nurse Advisory 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 888/993-0333 and reach registered nurses to discuss an existing medical concern or to receive information about numerous health care issues.

Disease Management Program

A voluntary program that helps members better manage their care when they have certain chronic conditions: diabetes, coronary artery disease and heart failure.

Review and Reward Program

If you send us a corrected hospital billing, we will credit 20% of any hospital charge over $20 for covered services and supplies that were not actually provided to a covered person. The maximum amount payable under this program is $100 per person per calendar year.

Services for the Deaf and Hearing Impaired

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

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