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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.
High Option Medical and Maternity Inpatient Hospital Benefits
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
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
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 $300 per admission, the Plan pays 70% of the Plan allowance if preauthorized for inpatient care. |
PPO Benefit
(Substance Abuse) |
The Plan will pay for inpatient hospital treatment at 90%, if preauthorized.
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Non-PPO Benefit
(Substance Abuse) |
After $300 per admission, the Plan will pay 70% of the allowance if preauthorized for in-patient care. |
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High Option Outpatient Care for Mental Health and Substance Abuse Benefits
If the Value Options mental health network is used, members receive outpatient benefits for Mental Health and Substance Abuse that are
identical to those for medical care.
| 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/$1,000 calendar year deductible, the Plan pays 70% of the Plan allowance. Outpatient care must be preauthorized by ValueOptions (1-888/700-7965). |
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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 Home and Office Physician and Chiropractic Care
| 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
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
Covered Oral Surgery procedures are handled under surgical benefits. Refer to the Plan's Brochure for listing of covered oral surgery procedures. Dental benefits:
There is no deductible for dental benefits.
|
You Pay |
| 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. |
* Includes exam, cleanings, x-rays, and flouride treatment.
For information about the Health Plan's Supplemental Dental Plan, click on this link: www.voluntarybenefitsplan.com
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High Option Prescription Drug Benefits
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; and a maximum of $200.
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 Mail Order Pharmacy prescription service for long-term or maintenance prescriptions. The
Mail Order program also has no deductible, and offers a higher rate of payment; and a maximum of $600.
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
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, $500 per person / $1,000 per family 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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High Option Special Features
| Diabetes Management Program |
APWU Health Plan primary members who are enrolled in the Care Allies Diabetes Disease Management program and participate as required by the program, may be eligible for the following incentives for in-network services only:
- $0 co-pay for in-network medical office visits for diabetes management (this does not include visits to a Podiatrist or Ophthalmologist)
- $0 coinsurance for in-network lab test related to diabetes management
- $0 co-pay for Generic drugs at mail for the treatment of diabetes
- $0 co-pay for Insulin at mail
- $0 co-pay for test strips at mail
APWU Health Plan members who have other primary insurance (i.e., Medicare primary), do not have to enroll in the Diabetes Management program. If we determine based on medical and pharmacy claims that members are eligible and compliant with diabetes management (i.e., diabetic office visits and lab tests every three months and medication refills), the member may be eligible for the following incentives:
- $0 co-pay for Generic drugs at mail for the treatment of diabetes
- $0 co-pay for Insulin at mail
- $0 co-pay for test strips at mail
- $0 coinsurance for in-network lab tests related to diabetes management
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| Hypertension (High Blood Pressure) Management Program |
APWU Health Plan primary members enrolled in the Hypertension Education and Coaching program and who participate as required by the program, may be eligible for the following incentives for in-network services only:
- $0 co-pay for in-network office visits for the treatment of hypertension
- $0 coinsurance for in-network lab tests related to the treatment of hypertension
- $0 co-pay for Generic drugs at mail for the treatment of hypertension
APWU Health Plan members who have other primary insurance (i.e., Medicare primary), do not have to enroll in the Hypertension Education and Coaching Program. Members will be eligible for the following incentives:
- $0 co-pay for Generic drugs at mail for the treatment of hypertension
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