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| Benefits |
You Pay |
| In-Network Preventive Care-Well Adult and Well Child office visits and exams, immunizations and screenings |
Nothing
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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 |
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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
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- 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
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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: |
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In-network - $4,500 Self Only/Self and Family |
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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.
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