How the APWU High Option Health Plan works with Medicare

In general, if you or your spouse are working and are covered by the APWU High Option Health Plan, APWU Health Plan is your primary health plan and Medicare is secondary.

If both you and your spouse are retired, Medicare is your primary coverage and APWU Health Plan is secondary.

When you are part of Medicare and the APWU High Option Health Plan, your provider will submit the claim to Medicare. After Medicare pays, they will submit the paperwork directly to the APWU Health Plan. As a member, there is no need for you to complete any paperwork.

APWU High Option Plan and Medicare Part A
Hospital services

In general, members with Medicare Part A as their primary insurance do not need to pre-certify hospital stays with the Health Plan. See the Health Plan Brochure below for rules about pre-certification.

Worldwide coverage

Medicare generally does not pay for hospital or medical services outside of the United States. But APWU Health Plan's High Option coverage travels with you around the world. When you have services outside the U.S., you will probably have to pay the bill at the time of service, then submit a bill directly for reimbursement.

APWU High Option Plan and Medicare Part B

When an APWU High Option Plan member is enrolled in Medicare Part B, Medicare pays first and the Plan is billed the remaining cost. Generally, with the High Option, most of your medical expenses are covered.

Medicare participating doctors and suppliers

Medicare will pay the provider directly and usually pays for covered services at 80% after satisfaction of Medicare Part B's annual deductible. As long as services represent a covered benefit, the APWU Health Plan High Option will pay the Part B deductible, then pay the 20% coinsurance and $18 copayment.

If the provider accepts Medicare's assignment, the provider will reduce his or her charge to no more than the Medicare allowance. You pay nothing for the covered charges up to our allowance.

APWU High Option Plan and Medicare Part C

Medicare Part C – or Medicare Advantage Plans – are private health plans that are Medicare approved. As a member of the APWU High Option Plan, there is no need to take Medicare Part C.

APWU High Option Plan and Medicare Part D

This is Medicare's prescription drug program. Prescription coverage is an integral part of your total health benefits package with APWU Health Plan. As a member of the APWU High Option Plan, the prescription drug benefit you receive can exceed that of Medicare Part D. There is no need to take part in Medicare D.

The amount that APWU Health Plan covers and/or its share of the cost of prescription drugs is the same or more than that of the standard Medicare Part D prescription drug benefits. There is an additional premium for Medicare Part D.

  • There is no prescription drug deductible for either the Network Mail Order or Retail program. The Plan offers a Mail Order pharmacy to receive up to a 90-day supply of maintenance medications.
  • For generic prescriptions, members pay $15, or 25% for brand name prescriptions (minimum $12), and a maximum of $600 per prescription.
  • With the Retail Pharmacy program, members pay $8 for up to a 30-day supply plus one refill of generic medication, or 25% for brand name medications (minimum $8).
  • There is a maximum of $200 out-of-pocket expense per prescription when network retail pharmacies are used. You pay 50% of the cost with a minimum $8 at a non-plan pharmacy.

For more information on prescription coverage with the High Option, call Express Scripts at: