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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 Employees Health Benefits Program.
COVERED 100%
When you choose a network doctor.
  • Preventive care and screenings
  • Maternity care
  • Accidental injury outpatient services within 72 hours
  • Lab tests ($0 for covered blood work performed at LabCorp and Quest Diagnostics)
  • Visits to registered dietician/nutritionist
  • Health management programs: diabetes, weight management, pregnancy and tobacco cessation
In-network you pay Out-of-network you pay
Calendar year deductible:
Self Only		 $450 $1,000
Self Plus One $800 $2,000
Self and Family $800 $2,000
Annual out-of-pocket maximum (both medical and prescription drugs) $6,500 Self Only
$13,000 Self Plus One and Self and Family		 $12,000 Self Only
$24,000 Self Plus One and Self and Family
Medical office and specialist visits $25 copay** 40%
of the Plan allowance*
Virtual visits through American Well $15 copay** 40%
of the Plan allowance*
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 40% 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 40% of the Plan allowance*
Adult immunizations (shingles vaccine covered at 100% in network at age 60) $0 40% of the Plan allowance*
Preventive screenings $0 40% of the Plan allowance*
Routine dental N/A 40% of the Plan allowance*
Hospital/facility care
Diagnostics tests or imaging 15%
($0 for blood work performed at LabCorp or Quest Diagnostics)		 40% of the Plan allowance*
Outpatient surgery, facility fee, lab visits, and surgeon fee 15% 40% of the Plan allowance*
Inpatient facility fee 15% 40% of the Plan allowance*
($300 per admission)
Cancer Centers of Excellence 5% N/A
Surgical and facility fee 15% 40% of the Plan allowance*
Hearing services
Diagnostic hearing tests (every 2 years) 15% 40% 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 72 hours of injury) $0 Difference between the Plan allowance and billed amount
Urgent care $30 copay** 40% of the Plan allowance*
Emergency room 15% 15% of the Plan allowance*
Ambulance 15%** 40% of the Plan allowance*
Alternative care
Chiropractic care (24 visits annually) $25 copay** 40% of the Plan allowance*
Acupuncture (26 visits annually) $25 copay** 40% of the Plan allowance*
Prescription drugs
Retail prescription drugs - non-specialty (30-day supply) $10 for Tier 1 drugs
25% for Tier 2 drugs,
$200 maximum per Rx
45% for Tier 3 drugs,
maximum $300 per Rx
No deductible		 50% ($10 minimum coinsurance),

(no deductible)
Mail-order prescription drugs - non-specialty (90-day supply) $20 for Tier 1 drugs
25% for Tier 2 drugs,
maximum $300 per Rx
45% for Tier 3 drugs,
maximum $500 per Rx
No deductible		 N/A
Retail prescription drugs - specialty 25% for Tier 1 drugs,
maximum $300 per Rx
25% for Tier 2 drugs, maximum $600 per Rx
45% for Tier 3 drugs,
maximum $1,000 per Rx
No deductible		 50% ($10 minimum coinsurance),

(no deductible)
Mail-order prescription drugs - specialty 25% for Tier 1 drugs,
maximum $150 per Rx
25% for Tier 2 drugs,
maximum $300 per Rx
45% for Tier 3 drugs,
maximum $500 per Rx
No deductible		 N/A
Mental health/substance misuse disorder
Office visit $25 copay** 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 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

When used properly, this different model of health care can save money. With UnitedHealthcare’s expansive national network, this option provides low premiums and a proactive alternative to traditional health plans.

COVERED 100%

When you choose a network doctor.

  • In January, the Health Plan funds a Personal Care Account (PCA) members can use for covered medical services. Members are covered at 100% until the PCA is exhausted. The Plan funds the PCA at $1,200 for Self Only and $2,400 for Self Plus One and Self and Family.
  • Preventive care and screenings
  • Maternity care
  • Healthy Pregnancy Program
  • Tobacco Cessation Program
Overall plan features
Personal Care Account (PCA) 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.
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 Plus One and Self and Family.
Self Only
$1,200		 Self Plus One
$2,400		 Self and Family
$2,400
When the PCA is exhausted, member must meet a deductible.
Deductible
(In-network)		 Self Only
$1,000		 Self Plus One
$2,000		 Self and Family
$2,000
Deductible
(Out-of-network)		 Self Only
$1,500		 Self Plus One
$3,000		 Self and Family
$3,000
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% 50%
Prescription drugs (retail or mail order) 25% for Tier 1 and Tier 2; 40% for Tier 3 N/A
Out-of-pocket maximum (both medical and prescription drugs) 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 Only $6,500 Self Only $13,000
Self Plus One $12,000 Self Plus One $24,000
Self and Family $12,000 Self and Family $24,000
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)		 May use PCA while funds are available.
Medical benefits
Office visits, virtual visits and specialist visits 15% of the Plan allowance 50% 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)		 50% of the Plan allowance*
Hearing services
Diagnostic hearing test (every 2 years) 15% 50% 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% 50% of the Plan allowance*
Outpatient surgery, facility fee, lab visits, and surgeon fee 15% 50% of the Plan allowance*
Inpatient 15% 50% of the Plan allowance*
Cancer Centers of Excellence 10% N/A
Emergency care
Accidental injury (within 72 hours), urgent care, emergency room, ambulance 15% 15%*
Prescription drugs
Retail prescription (30-day supply) 25% for Tier 1 drugs,
$200 maximum per Rx
25% for Tier 2 drugs,
$200 maximum per Rx
40% for Tier 3 drugs,
$300 maximum per Rx		 All charges
Mail-order prescription (90-day supply) 25% for Tier 1 or Tier 2 drugs
40% for Tier 3 drugs
$600 maximum for
60-day supply
$900 maximum for
90-day supply		 N/A
Mental health/substance misuse disorder
Office visit 15% 50% of the Plan allowance*
Outpatient treatment 15% 50% of the Plan allowance*
Diagnostics, inpatient, and outpatient services 15% 50% 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: