 |
| |
| Benefits |
You Pay |
| In-Network Preventive Care-Well Adult and Well Child office visits and exams, immunizations and screenings |
Nothing
|
|
Personal Care Account
Up to $1,200 for Self Only or $2,400 for Self and Family for medical, surgical, hospital, mental health and substance abuse services and prescription drugs plus certain dental and vision care
The PCA must be used first for eligible expenses, except that covered in-network preventive care does not count against the PCA |
Nothing up to $1,200 for Self Only or $2,400 for Self and Family |
|
Deductible
When the PCA is exhausted, you must pay your Deductible before Traditional Health Coverage begins |
In-network/out-of-network: $600 for Self Only or $1,200 for Self and Family |
Traditional Health Coverage -after Personal Care Account is exhausted
- Medical/surgical services and supplies provided by a physician and other health care professionals
- Services provided by a hospital or other facility, and ambulance service
- Mental Health and substance abuse
- Prescription Drugs Network-Retail
- Prescription Drugs Network-Mail Order
|
- In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
- In-network: 15% of the Plan allowance
Out-of-network: 40% of the Plan allowance
- In-network: 15% of the Plan allowance
Out-of-network: 15% of the Plan allowance
- In-network: Regular cost sharing
Out-of-network: Benefits are limited
- 25% of charge with minimum of $10, maximum of $200 per prescription
- 25% of charge with minimum of $15, maximum of $600 per prescription
|
|
Dental Care/Vision Care
Covered only under Personal Care Account |
Any amount over $400 per Self Only or $800 per Family (see Section 5(b) Extra PCA Expenses) |
|
Special features
|
Online tools and resources, Consumer choice information,
Services for deaf and hearing-impaired, 24-hour nurse
advisory service and Care support |
|
Protection against catastrophic costs
Out-of-pocket maximum |
In-network: Nothing after $3,000 Self Only or
$4,500 Family enrollment per year
Out-of-network: Nothing after $9,000/Self
Only or Family enrollment per year
Some costs do not count toward this
protection |
|
|
 |
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.
An asterisk (*) means the item is subject to the Deductible, generally $600 per Self Only and $1,200 per Self and
Family, once your Personal Care Account has been spent. And, after we pay, you generally pay any difference between our
allowance and the billed amount if you use an out-of-network physician or other health care professional.
Special features: Online tools and resources, consumer choice information, services for the deaf and hearing-impaired, and a 24-hour nurse advisory
Under the Consumer Driven Health Plan, there is no calendar year deductible
| Annual Out-of-pocket maximum: |
|
In-network - $4,500 Self Only/Self and Family |
| |
|
Out-of-network - $9,000 Self Only/Self and Family |
This is a summary of the features of 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 set forth in the Plan's Federal Brochure.
|
