High Option Benefits

Click here to download the APWU Health Plan’s 2014 Brochure.

This is a summary of benefits and features offered by the APWU Health Plan.  All benefits are subject to the definitions, limitations and exclusions as set forth in the Plan’s Brochure (RI 71-004).

The APWU Health Plan High Option features the CIGNA Healthcare provider network.

Member Benefits

High Option Preventive Care

As a member of the High Option the following preventive care are at zero out-of-pocket costs to you:

FOR ADULTS

One routine examination per person per calender year after age 12. Lab tests covered are:

  • Comprehensive Metabolic Panel
  • Lipid Panel
  • Urinalysis

Routine Screenings, limited to:

  • Total Blood Cholesterol-once annually
  • Fasting lipoprotein profile, once every 5 years for adults age 20 or over
  • Osteoporosis screeening, once very two years, for women age 65 and older
  • Chlamydial infection
  • Colorectal Cancer Screening, including
    • Fecal occult bloot test, once annually, ages 40 and older
    • Sigmoidoscopy, screening- every five years starting at age 50
    • Colonoscopy, once every 10 years starting at age 50
    • Double Contrast Barium Enema (DCBE), once every 5 years starting at age 50
  • Routine Prostate Specific Antigen (PSA) test- one annually for men age 40 and older
  • Routine pap test (lab charge), one anually, women age 18 and older
  • Abdominal Aortic Aneurysm screening, once for men betweeen the ages 65 and 75 with a smoking history
  • Mammograms covered for women age 35 and older
    • From age 35 thorugh 39, one during this five year period
    • From age 40 through 64, one every calendar year
    • At age 65 and older, one every two conecutive calenday years.

FOR CHILDREN

Childhood immunizations recommended by the American Academy of Pediatrics.

Examinations, limited to:

  • Well-child care charges for physical examinations and laboratory tests through age 12
  • Examinations for amblyopia and strbismus-limited to one screenin examination (age 2 through 6)
  • One screening Examination of Premature Infants for Retinopathy of Prematurity or infants with low birth weight or gestational age of 32 weeks or less

High Option Inpatient Hospital Benefits

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.

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High Option Outpatient Hospital Benefits

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.

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High Option Home and Office Physician Visits and Chiropractic Care

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.

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High Option Outpatient Care for Mental Health and Substance Abuse Benefits

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 $500 per person / $1,000 per family calendar year deductible, the Plan pays 70% of the Plan allowance. 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.

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High Option Maternity Benefits

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.

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High Option Inpatient Care for Mental Health and Substance Abuse Benefits

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)

$300 per admission and the Plan pays 70% of the Plan allowance if preauthorized.

PPO Benefit
(Substance Abuse)

The Plan will pay for inpatient hospital treatment at 90%, if preauthorized.

Non-PPO Benefit
(Substance Abuse)

$300 per admission and the Plan pays 70% of the Plan allowance. Must be preauthorized.

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High Option Accidental Injury Benefits

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.

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High Option Surgery Benefits

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.

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High Option Dental Care Benefits

Refer to the Plan’s Brochure for listing of covered oral surgery procedures. Dental benefits:

Office visits*

The Plan pays 70% of the Plan allowance. No deductible.

Restorative care (fillings)

The Plan pays 70% of the Plan allowance. No deductible.

Simple extractions

The Plan pays 70% of the Plan allowance. No deductible.

There is no deductible for dental.

* Includes exam, cleanings, x-rays, and flouride treatment.

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

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.

Over 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); maximum of $600

All charges

Retail Pharmacy

$8 copay per generic drug

25% coinsurance per brand name drug
(or a minimum of $8); maximum of $200

50%

Personalized Medicine (voluntary program) - Available at no additional cost, pharmacogenomic testing to optomize prescription drug therapies for patients taking Warafin (anticoagulant) and Tamoxifen (for breast cancer).

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

Health Management Programs

For information regarding and enrolling in the Diabetes Management Program and the Hypertension Management Program please visit our Health Management Programs page.

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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 800/582-1314 and reach registered nurses to discuss an existing medical concern or to receive information about numerous health care issues.

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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