2008 High Option Benefits Information for Providers

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 & Maternity Inpatient Hospital Benefits
• Inpatient Care for Mental Health and Substance Abuse Benefits
• Annual Deductible Information
• Outpatient Hospital and Maternity Benefits
• Accidental Injury Benefits
• Home and Office Physician and Chiropractic Care
• Surgery Benefits
• Outpatient Care for Mental Health and Substance Abuse Benefits
• Dental Care Benefits
• Retail Prescription Drug Benefits

Provider Services

High Option Medical and Maternity Inpatient Hospital Benefits
A077405824I - Benefit Description ID - Please retain for future reference/inquiries.

All inpatient hospital admissions except maternity admissions, require precertification to avoid a $500 penalty. Planned, or elective admissions must be precertified at least 48 hours prior to admission. To precertify a hospital stay, call the precertification vendor for your area - click here

Medical and maternity inpatient hospital benefits:

PPO benefit	90% of semiprivate and intensive/cardiac care unit charge; 90% of other hospital charges. 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 and Maternity Benefits
A077405925I - Benefit Description ID - Please retain for future reference/inquiries.

All outpatient services are subject to an annual $275 PPO ($500 non-PPO) per person deductible. Outpatient hospital and maternity services are paid as follows:

PPO benefit	90% of covered charges at the provider's negotiated rate.
Non-PPO benefit	70% of Plan allowance for covered services.
Infertility diagnosis and treatment	Up to $2,500 per enrollment each calendar year.

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High Option Mental Health, Alcohol and Substance Abuse - Inpatient Facility and Professional Fees
A077406017I - Benefit Description ID - Please retain for future reference/inquiries.

If the ValueOptions mental health network is used, members receive in-patient hospital benefits for Mental Health and Substance Abuse that are identical to those for medical care.

All inpatient hospital admissions require precertification to avoid a $500 penalty. Planned, or elective admissions must be precertified at least 48 hours prior to admission. Emergency admissions must be certified within 48 hours of admission. To certify a hospital stay, call ValueOptions at 1-888/700-7965.

Mental Health 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.

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High Option Outpatient Care for Mental Health and Substance Abuse Benefits
A077406118I - Benefit Description ID - Please retain for future reference/inquiries.

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).

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High Option Accidental Injury Benefits
A077406219I - 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.

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High Option Home and Office Physician and Chiropractic Care
A077406320I - Benefit Description ID - Please retain for future reference/inquiries.

PPO Doctor	No deductible and $18 copay for home and office visits. 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. Services other than visits/manipulations are reimbursed at 90% of the negotiated fee, after satisfaction of the calendar year deductible.
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 Surgery Benefits
A077406421I - Benefit Description ID - Please retain for future reference/inquiries.

All surgical benefits are subject to the annual $275 PPO ($500 non-PPO) per person deductible. Inpatient and outpatient surgical benefits:

PPO Benefit	90% of the provider's negotiated rate.
Non-PPO Benefit	70% of Plan allowance.

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High Option Dental Care Benefits
A077406522I - Benefit Description ID - Please retain for future reference/inquiries.

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

For information about the Health Plan's Supplemental Dental Plan, click on this link: www.voluntarybenefitsplan.com

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High Option Retail Prescription Drug Benefits
A077406623I - Benefit Description ID - Please retain for future reference/inquiries.

There is no prescription drug deductible for either the Plan's Retail Pharmacy or Mail Order Service programs. For generic drugs purchased at a Plan pharmacy members pay a $8 copayment, and 25% coinsurance for brand name medications. Immediate care prescriptions include the initial prescription (up to a 30 day supply), and the first refill (again, up to a 30 day supply). For the second, and subsequent refills members pay the non-Plan pharmacy rate of 50%. The Plan encourages the use of the Home Delivery Service prescription service for long-term or maintenance prescriptions. The Mail Order program also has no deductible, and offers a higher rate of payment.

For questions regarding Plan pharmacies, or the Plan's Mail Order program, call 1-800/841-2734.

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High Option Annual Deductible Information
A077406724I - Benefit Description ID - Please retain for future reference/inquiries.

All surgical benefits are subject to the annual $275 PPO ($500 non-PPO) per person deductible. Inpatient and outpatient surgical benefits:

Medical/Surgical Deductible:	Annually, if PPO providers are used, the calendar year deductible is $275 per person and $550 per family. For non-PPO providers, the deductible is $500 per person, $1,000 per family. See Brochure for services that require no deductible.
Mental Conditions/Substance Abuse:	PPO deductible: Annually, $275 per person, for in-patient professional fees for Mental Conditions/Substance Abuse. Non-PPO deductible: Annually, $750 per person for in- and/or outpatient services for Mental Conditions/Substance Abuse.
Out of Pocket Maximum - PPO benefit:	100% of covered charges if out-of-pocket expenses for coinsurance exceed $4,000 for either a Self Only or Self and Family enrollment in a calendar year.
Out of Pocket Maximum - Non-PPO benefit:	100% of covered charges if out-of-pocket expenses for coinsurance exceed $10,000 for a Self only or Self & Family enrollment in a calendar year.

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