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What are the plan choices?

APWU Health Plan gives you two smart plans to consider. Compare them side by side.

High Option
Consumer Driven Option
High Option
With low copays, low deductibles, and a vast network of providers, this is a premiere plan in the Federal Employee Health Benefits Program.
COVERED 100%
When you choose a network doctor.
  • Preventive care and screenings
  • Maternity care
  • Accidental injury within 24 hours
  • Diabetes Management Program
  • Hypertension Management Program
  • Weight Management Program
  • Tobacco Cessation Program
  • Lab tests (when you use LabCorp and Quest Diagnostics)
In-network you pay Out-of-network you pay
Calendar year deductible :
Self
$275 $500
Self plus one $550 $1,000
Self and family $550 $1,000
Annual out-of-pocket maximum (both medical and prescription drugs) $5,000
per membership
$10,000
per membership
Office visits $18 copay** 30%
of the Plan allowance*
Specialist office visits
Maternity care
Complete maternity (obstetrical) care, such as prenatal care delivery, postnatal care, and initial examination of a newborn child covered under family enrollment $0 30% of the Plan allowance*
Preventive care
Well child care (through age 12) $0 Difference between the Plan allowance billed amount
Childhood immunizations (through age 18) $0 Difference between the Plan allowance and billed amount
Annual adult routine exams $0 30% of the Plan allowance*
Adult immunizations (shingles vaccine covered at 100% in network at age 60) $0 30% of the Plan allowance*
Preventive screenings $0 30% of the Plan allowance*
Routine dental N/A 30% of the Plan allowance*
Hospital/facility care
Diagnostics tests or imaging 10%
($0 for blood work performed at LabCorp or Quest Diagnostics)
30% of the Plan allowance*
Outpatient surgery, facility fee, lab visits, and surgeon fee 10% 30% of the Plan allowance*
Inpatient facility fee 10% 30% of the Plan allowance*
($300 per admission)
Cancer Centers of Excellence 5% N/A
Surgical and facility fee 10% 30% of the Plan allowance*
Hearing services
Diagnostic Hearing Tests (every 2 years) 10% 30% of the Plan allowance*
Hearing aid (every 3 years) All charges in excess of $1,500** All charges in excess of $1,500
Emergency care
Accidental injury (care within 24 hours of injury) $0 Difference between the Plan allowance and billed amount
Urgent care $40 copay** $40 copay**
Emergency room 10% 10% of the Plan allowance*
Ambulance 10%** 30% of the Plan allowance*
Alternative care
Chiropractic care (12 visits annually) $18 copay** 30% of the Plan allowance*
Acupuncture $18 copay** 30% of the Plan allowance*
Prescription drugs
Retail prescription drugs - non-specialty $10 for generic drugs
25% for preferred brand name drugs,
$200 maximum per RX
40% for non-preferred brand name drugs,
maximum $300 per RX
No deductible
50% ($10 minimum coinsurance),

(no deductible)
Mail-order prescription drugs - non-specialty $20 for generic drugs
25% for brand name drugs,
maximum $300 per RX
40% for non-preferred brand name drugs,
maximum $500 per RX
No deductible
N/A
Retail prescription drugs - specialty 25% for generic drugs,
maximum $300 per RX
40% for non-preferred brand name drugs,
maximum $1,000 per RX
No deductible
50% ($10 minimum coinsurance),

(no deductible)
Mail-order prescription drugs - specialty 25% for generic drugs,
maximum $150 per RX
25% for preferred brand name drugs,
maximum $500 per RX
No deductible
N/A
Mental health/substance abuse
Office visit $18 copay** 30% of the Plan allowance*
Outpatient treatment 10% 30% of the Plan allowance*
Diagnostics, inpatient, and outpatient services 10% 30% of the Plan allowance*

* If there is a difference between the allowance and billed amount, the member is responsible for that difference.
** No deductible applied

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



THIS PLAN ALSO INCLUDES:
Consumer Driven Option

This is a different model of health care that, when used properly, can save money. With the broad national network of UnitedHealthcare, this option is an excellent alternative to traditional plans.

COVERED 100%

When you choose a network doctor.

  • Preventive care and screenings
  • Maternity care
  • Diabetes Management Program
  • Healthy Pregnancy Program
  • Tobacco Cessation Program
  • Personal Care Account provides 100% coverage for the first $1,200 of your annual medical expenses for Self-Only or $2,400 for Self Plus One and Self and Family
Overall plan features
Personal Care Account (PCA) Members in this plan are given a PCA, which is an allowed amount used to pay for all medical costs at 100% until exhausted.
PCA rollover As long as you remain in this plan, any unused remaining balance in your PCA at the end of the calendar year may be rolled over to subsequent years. The maximum amount allowed in your PCA in any given year is $5,000 per self-only enrollment and $10,000 per self and family enrollment.
Self $1,200 Self plus one Self and family $2,400
Deductible When the PCA is exhausted, member must meet a deductible.
Self $600 Self plus one $1,200 Self and family $1,200
Coinsurance Once the deductible is met, member pays coinsurance for in- or out-of-network medical services and prescription drugs.
In-network you pay Out-of-network you pay
Medical services 15% 40%
Prescription drugs (retail or mail order) 25% N/A
Out-of-pocket maximum Because the unexpected happens, this plan has a built-in out-of-pocket maximum which, when reached, allows the rest of your annual health care costs to be paid at 100% (both medical and prescription drugs and PCA).
In-network you pay Out-of-network you pay
Self $4,200 Self $10,200
Self plus one $6,900 Self plus one $11,400
Self and family $6,900 Self and family $11,400
Preventive care (adults and children) In-network preventive care and screenings, such as mammograms, yearly check-ups, and child and adult immunizations are covered at 100%. No PCA dollars are used.
In-network you pay Out-of-network you pay
Preventive care
Well-child care, immunizations, well-woman care, adult routine exams, preventive screenings $0
(No PCA used)
All charges. May use PCA while funds are available.
Medical benefits
Office visits and specialist visits 15% of the Plan allowance 40% of the Plan allowance*
Maternity care
Complete maternity (obstetrical) care, such as prenatal care, delivery, postnatal care, initial examination of a newborn child covered under family enrollment $0
(No PCA used)
40% of the Plan allowance*
Hearing services
Diagnostic hearing test (every 2 years) 15% 40% of the Plan allowance*
Hearing aids (every 3 years) All charges in excess of $1,500 All charges in excess of $1,500
Hospital/facility care
Diagnostic tests or imaging 15% 40% of the Plan allowance*
Outpatient surgery, facility fee, lab visits, and surgeon fee 15% 40% of the Plan allowance*
Inpatient 15% 40% of the Plan allowance*
Cancer Centers of Excellence 10% N/A
Emergency care
Accidental injury, urgent care, emergency room, ambulance 15% 15%*
Prescription drugs
Retail prescription (up to 30-day supply) 25% coinsurance
$200 maximum per Rx
All charges
Mail-order prescription (up to 90-day supply) 25% coinsurance
$600 maximum per Rx
N/A
Mental health/substance abuse
Office visit 15% 40% of the Plan allowance*
Outpatient treatment 15% 40% of the Plan allowance*
Diagnostics, inpatient, and outpatient services 15% 40% of the Plan allowance*

* If there is a difference between allowance and billed amount, member is responsible for that difference.

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



THIS PLAN INCLUDES: