APWU Health Plan

www.apwuhp.com

Customer Service 800-222-2798

2024

A Fee-for-Service Plan (High Option) and a Consumer Driven Health

Plan with Preferred Provider Organizations

IMPORTANT

• Rates: Back Cover

• Changes for 2024: Page 15

• Summary of Benefits: Page 154

This plan's health coverage qualifies as minimum essential coverage

and meets the minimum value standard for the benefits it provides. See

page 8 for details. This plan is accredited. See page 13.

Sponsored and administered by: American Postal Workers Union,

AFL-CIO

Who may enroll in this Plan: All Federal and Postal Service

employees and annuitants who are eligible to enroll in the FEHB

Program. To enroll, you must be, or must become, a member or

associate member of the American Postal Workers Union, AFL-CIO.

To become a member or associate member: All active

Postal Service APWU bargaining unit employees must

be, or must become, dues-paying members of the

APWU, to be eligible to enroll in the Health Plan. All

Federal and other Postal members and annuitants must

become associate member of APWU, see page 127 for

details.

Membership dues: Associate members will be billed

by the APWU for the $35 annual membership fee,

except where exempt by law. APWU will bill new

associate members for the annual dues when it receives

notice of enrollment. APWU will also bill continuing

associate members for the annual membership. APWU

will bill Retirees Department members $36 annual

membership. Active and retiree non-associate APWU

membership dues vary.

Enrollment codes for this Plan:

High Option: 471 Self Only, 473 Self Plus One, 472 Self and Family

Consumer Driven Option: 474 Self Only, 476 Self Plus One, 475 Self and Family

RI 71-004

Important Notice from APWU Health Plan About

Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that the APWU Health Plan prescription drug coverage is, on

average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all Plan participants

and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for

prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late

enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will

coordinate benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good

as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1% per month for every

month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug

coverage, your premium will always be at least 19% higher than what many other people pay. You will have to pay this

higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next

Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available.

Information regarding this program is available through the Social Security Administration (SSA) online at www.

socialsecurity.gov, or call the SSA at 800-772-1213, (TTY: 800-325-0778).

Potential Additional Premium for Medicare’s High Income Members

Income-Related Monthly Adjustment Amount (IRMAA)

The Medicare Income-Related Monthly Adjustment Amount (IRMAA) is an amount you may pay in addition to your FEHB

premium to enroll in and maintain Medicare prescription drug coverage. This additional premium is assessed only to those

with higher incomes and is adjusted based on the income reported on your IRS tax return. You do not make any

IRMAA payments to your FEHB plan. Refer to the Part D-IRMAA section of the Medicare website: https://www.medicare.

gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug-plans to see if you would be subject

to this additional premium.

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these

places:

•Visit www.medicare.gov for personalized help.

•Call 800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048).

Table of Contents

Introduction ...................................................................................................................................................................................4

Plain Language ..............................................................................................................................................................................4

Stop Healthcare Fraud! .................................................................................................................................................................4

Discrimination is Against the Law ................................................................................................................................................5

Preventing Medical Mistakes ........................................................................................................................................................6

FEHB Facts ...................................................................................................................................................................................8

Coverage information .........................................................................................................................................................8

• No pre-existing condition limitation ...............................................................................................................................8

• Minimum essential coverage (MEC) ..............................................................................................................................8

• Minimum value standard ................................................................................................................................................8

• Where you can get information about enrolling in the FEHB Program .........................................................................8

• Enrollment types available for you and your family ......................................................................................................8

• Family Member Coverage ..............................................................................................................................................9

• Children's Equity Act ....................................................................................................................................................10

• When benefits and premiums start ................................................................................................................................11

• When you retire ............................................................................................................................................................11

When you lose benefits .....................................................................................................................................................11

• When FEHB coverage ends ..........................................................................................................................................11

• Upon divorce .................................................................................................................................................................11

• Temporary Continuation of Coverage (TCC) ...............................................................................................................12

• Converting to individual coverage ...............................................................................................................................12

• Health Insurance Marketplace ......................................................................................................................................12

• APWU Health Plan Notice of Privacy Practices ..........................................................................................................12

Section 1. How This Plan Works ................................................................................................................................................13

We have Preferred Provider Organizations (PPOs) ..........................................................................................................13

• General features of our High Option (HO) ...................................................................................................................13

• General features of our Consumer Driven Health Plan (CDHP) ..................................................................................13

How we pay providers ......................................................................................................................................................14

Your rights and responsibilities .........................................................................................................................................14

Your medical and claims records are confidential ............................................................................................................14

Section 2. Changes for 2024 .......................................................................................................................................................15

Section 3. How You Get Care ....................................................................................................................................................16

Identification cards ............................................................................................................................................................16

Where you get covered care ..............................................................................................................................................16

Balance Billing Protection ................................................................................................................................................16

• Covered providers .........................................................................................................................................................16

• Covered facilities ..........................................................................................................................................................17

• Transitional care ...........................................................................................................................................................17

• If you are hospitalized when your enrollment begins ...................................................................................................17

You need prior Plan approval for certain services ............................................................................................................18

• Inpatient hospital admission, inpatient residential treatment center admission or skilled nursing facility

admission ..........................................................................................................................................................................18

• Other services ...............................................................................................................................................................18

How to request precertification for an admission or get prior authorization for Other services ......................................20

What happens when you do not follow the precertification rules .....................................................................................20

• Radiology/imaging procedures precertification ...........................................................................................................21

• How to precertify a radiology/imaging procedure .......................................................................................................21

1 2024 APWU Health Plan Table of Contents

• Non-urgent care claims .................................................................................................................................................21

• Urgent care claims ........................................................................................................................................................22

• Concurrent care claims .................................................................................................................................................22

• Emergency inpatient admission ....................................................................................................................................22

• Maternity care ...............................................................................................................................................................23

• If your hospital stay needs to be extended ....................................................................................................................23

• If your treatment needs to be extended .........................................................................................................................23

If you disagree with our pre-service decision ...................................................................................................................23

• To reconsider a non-urgent care claim ..........................................................................................................................23

• To reconsider an urgent care claim ...............................................................................................................................24

• To file an appeal with OPM ..........................................................................................................................................24

Section 4. Your Costs for Covered Services ..............................................................................................................................25

Cost-sharing ......................................................................................................................................................................25

Copayment ........................................................................................................................................................................25

Deductible .........................................................................................................................................................................25

Coinsurance .......................................................................................................................................................................26

If your provider routinely waives your cost ......................................................................................................................26

Waivers ..............................................................................................................................................................................27

Differences between our allowance and the bill ...............................................................................................................27

Your Catastrophic protection out-of-pocket maximum for deductibles, coinsurance and copayments ............................28

Carryover ..........................................................................................................................................................................30

If we overpay you .............................................................................................................................................................30

When Government facilities bill us ..................................................................................................................................30

Important Notice About Surprise Billing - Know Your Rights .........................................................................................31

The Federal Flexible Spending Account Program - FSAFEDS ........................................................................................31

Section 5. High Option Health Plan Benefits ............................................................................................................................32

High Option Overview ................................................................................................................................................................34

Consumer Driven Health Plan Benefits ......................................................................................................................................78

Non-FEHB Benefits Available to Plan Members ......................................................................................................................127

Section 6. General Exclusions - Services, Drugs and Supplies We Do Not Cover ..................................................................128

Section 7. Filing a Claim For Covered Services ......................................................................................................................130

Section 8. The Disputed Claims Process ..................................................................................................................................133

Section 9. Coordinating Benefits with Medicare and Other Coverage .....................................................................................136

When you have other health coverage ............................................................................................................................136

• TRICARE and CHAMPVA ........................................................................................................................................136

• Workers' Compensation ..............................................................................................................................................137

• Medicaid .....................................................................................................................................................................137

When other Government agencies are responsible for your care ...................................................................................137

When others are responsible for injuries .........................................................................................................................137

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) ........................................................139

Clinical trials ...................................................................................................................................................................139

When you have Medicare ...............................................................................................................................................140

• The Original Medicare Plan (Part A or Part B) ...........................................................................................................140

• Tell us about your Medicare coverage ........................................................................................................................141

• Private contract with your physician ..........................................................................................................................141

• Medicare Advantage (Part C) .....................................................................................................................................141

• Medicare prescription drug coverage (Part D) ...........................................................................................................143

• Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP) ........................................................143

When you are age 65 or over and do not have Medicare ................................................................................................146

2 2024 APWU Health Plan Table of Contents

When you have the Original Medicare Plan (Part A, Part B, or both) ............................................................................147

Section 10. Definitions of Terms We Use in This Brochure ....................................................................................................148

Summary of Benefits for the High Option of the APWU Health Plan - 2024 ..........................................................................154

Summary of Benefits for the CDHP of the APWU Health Plan - 2024 ....................................................................................156

Index ..........................................................................................................................................................................................158

2024 Rate Information for the APWU Health Plan ..................................................................................................................162

3 2024 APWU Health Plan Table of Contents

Introduction

This brochure describes the benefits of APWU Health Plan under contract (CS 1370) between APWU Health Plan and the

United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. This Plan is

underwritten by the American Postal Workers Union, AFL-CIO. Customer Service may be reached at 800-222-2798 or

through our website: www.apwuhp.com. The address for the APWU Health Plan administrative office is:

APWU Health Plan

799 Cromwell Park Drive, Suites K-Z

Glen Burnie, MD 21061

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits,

limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One

or Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to

benefits that were available before January 1, 2024, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates for each plan annually. Benefit changes are effective January 1, 2024, and changes are

summarized in Section 2, page 15. Rates are shown at the end of this brochure.

Plain Language

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples:

•Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each

covered family member; “we” means APWU Health Plan.

•We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States

Office of Personnel Management. If we use others, we tell you what they mean.

•Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.

Stop Healthcare Fraud!

Fraud increases the cost of healthcare for everyone and increases your Federal Employees Health Benefits Program premium.

OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless

of the agency that employs you or from which you retired.

Protect Yourself From Fraud - Here are some things you can do to prevent fraud:

•Do not give your plan identification (ID) number over the phone or to people you do not know, except for your healthcare

provider, authorized health benefits plan, or OPM representative.

•Let only the appropriate medical professionals review your medical record or recommend services.

•Avoid using healthcare providers who say that an item or service is not usually covered, but they know how to bill us to

get it paid.

•Carefully review explanations of benefits (EOBs) statements that you receive from us.

•Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.

•Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.

4 2024 APWU Health Plan Introduction/Plain Language/Advisory

•If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or

misrepresented any information, do the following:

- Call the provider and ask for an explanation. There may be an error.

- If the provider does not resolve the matter, call the APWU Health Plan Fraud Hotline at 410-424-1515.

- If we do not resolve the issue:

CALL - THE HEALTHCARE FRAUD HOTLINE

877-499-7295

OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form

The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker response

time.

You can also write to:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC 20415-1100

•Do not maintain as a family member on your policy:

- Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or

- Your child age 26 or over (unless they were disabled and incapable of self-support prior to age 26).

•A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the

enrollee's FEHB enrollment.

•If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with

your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under

Temporary Continuation of Coverage (TCC).

•Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and

your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to

or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan

when you are no longer eligible.

•If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service)

and premiums are paid, you will be responsible for all benefits paid during the period in which premiums were not paid.

You may be billed by your provider for services received. You may be prosecuted for fraud for knowingly using health

insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family

member is no longer eligible to use your health insurance coverage.

Discrimination is Against the Law

The health benefits described in this brochure are consistent with applicable laws prohibiting discrimination.

5 2024 APWU Health Plan Introduction/Plain Language/Advisory

Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most

tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer

recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall

cost of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in

medical mistakes by their accrediting bodies. You can also improve the quality and safety of your own healthcare and that of

your family members by learning more about and understanding your risks. Take these simple steps:

1. Ask questions if you have doubts or concerns.

•Ask questions and make sure you understand the answers.

•Choose a doctor with whom you feel comfortable talking.

•Take a relative or friend with you to help you take notes, ask questions and understand answers.

2. Keep and bring a list of all the medications you take.

•Bring the actual medication or give your doctor and pharmacist a list of all the medication and dosage that you take,

including non-prescription (over-the-counter) medications and nutritional supplements.

•Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as latex.

•Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your

doctor or pharmacist says.

•Make sure your medication is what the doctor ordered. Ask the pharmacist about your medication if it looks different than

you expected.

•Read the label and patient package insert when you get your medication, including all warnings and instructions.

•Know how to use your medication. Especially note the times and conditions when your medication should and should not

be taken.

•Contact your doctor or pharmacist if you have any questions.

•Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing

from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

•Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or

Provider’s portal?

•Don’t assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your

results.

•Ask what the results mean for your care.

4. Talk to your doctor about which hospital or clinic is best for your health needs.

•Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one

hospital or clinic to choose from to get the healthcare you need.

•Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5. Make sure you understand what will happen if you need surgery.

•Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.

•Ask your doctor, “Who will manage my care when I am in the hospital?”

•Ask your surgeon:

- “Exactly what will you be doing?”

6 2024 APWU Health Plan Introduction/Plain Language/Advisory

- “About how long will it take?”

- “What will happen after surgery?”

- “How can I expect to feel during recovery?”

•Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or

nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

•www.jointcommision.org/speakup.aspx. The Joint Commission's Speak Up™ patient safety program.

•www.jointcommission.org/topics/patient_safety.aspx. The Joint Commission helps healthcare organizations to improve

the quality and safety of the care they deliver.

•www.ahrq.gov/patients-consumers/. The Agency for Healthcare Research and Quality makes available a wide-ranging list

of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve

the quality of care you receive.

•www.npsf.org. The National Patient Safety Foundation has information on how to ensure safer healthcare for you and

your family.

•www.bemedwise.org. The National Council on Patient Information and Education is dedicated to improving

communication about the safe, appropriate use of medications.

•www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.

•www.ahqa.org. The American Health Quality Association represents organizations and healthcare professionals working

to improve patient safety.

Preventable Healthcare Acquired Conditions ("Never Events")

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries,

infections or other serious conditions that occur during the course of your stay. Although some of these complications may

not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had

taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences

for patients, can indicate a significant problem in the safety and credibility of a healthcare facility. These conditions and

errors are sometimes called "Never Events" or "Serious Reportable Events."

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as

certain infections, severe bedsores and fractures; and to reduce medical errors that should never happen. When such an event

occurs, neither you nor your FEHB plan will incur costs to correct the medical error.

APWU Health Plan defines a Never Event as any unanticipated event resulting in death or serious physical or psychological

injury to a member of the APWU Health Plan, not related to the natural course of the patient’s illness. These incidents/events

include loss of a limb or gross motor function, and any event or process variation for which a recurrence would carry a risk

of a serious adverse outcome. They also include events such as actual breaches in medical care, administrative procedures or

others resulting in an outcome that is not associated with the standard of care or acceptable risks associated with the

provision of care and service for a member, including reactions to drugs and materials.

When APWU Health Plan receives notification of a potential Never Event from a member telephone call, by mail, or email

or through a claim, or vendor notification, we begin a review process with our management team. An investigation is

conducted. If the investigation reveals a Never Event, the member is notified. We conduct a root cause analysis, and provide

a final report to the management team and the delegated vendor.

7 2024 APWU Health Plan Introduction/Plain Language/Advisory

FEHB Facts

Coverage information

We will not refuse to cover the treatment of a condition you had before you enrolled in

this Plan solely because you had the condition before you enrolled.

• No pre-existing

condition limitation

Coverage under this plan qualifies as minimum essential coverage (MEC) and satisfies the

Patient Protection and Affordable Care Act's (ACA) individual shared responsibility

requirement. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/

Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more

information on the individual requirement for MEC.

• Minimum essential

coverage (MEC)

Our health coverage meets the minimum value standard of 60% established by the ACA.

This means that we provide benefits to cover at least 60% of the total allowed costs of

essential health benefits. The 60% standard is an actuarial value; your specific out-of-

pocket costs are determined as explained in this brochure.

• Minimum value

standard

See www.opm.gov/healthcare-insurance/healthcare for enrollment information as well as:

• Information on the FEHB Program and plans available to you

• A health plan comparison tool

• A list of agencies that participate in Employee Express

• A link to Employee Express

• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, give you other

plans' brochures and other materials you need to make an informed decision about your

FEHB coverage. These materials tell you:

• When you may change your enrollment

• How you can cover your family members

• What happens when you transfer to another Federal agency, go on leave without pay,

enter military service, or retire

• What happens when your enrollment ends

• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your

enrollment status without information from your employing or retirement office. For

information on your premium deductions, you must also contact your employing or

retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for

updates and questions about your benefit coverage.

• Where you can get

information about

enrolling in the FEHB

Program

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and

one eligible family member. Self and Family coverage is for the enrollee and one or more

eligible family members. Family members include your spouse and your dependent

children under age 26, including any foster children authorized for coverage by your

employing agency or retirement office. Under certain circumstances, you may also

continue coverage for a disabled child 26 years of age or older who is incapable of self-

support.

• Enrollment types

available for you and

your family

8 2024 APWU Health Plan FEHB Facts

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family

enrollment if you marry, give birth, or add a child to your family. You may change your

enrollment 31 days before to 60 days after that event. The Self Plus One or Self and

Family enrollment begins on the first day of the pay period in which the child is born or

becomes an eligible family member. When you change to Self Plus One or Self and

Family because you marry, the change is effective on the first day of the pay period that

begins after your employing office receives your enrollment form. Benefits will not be

available to your spouse until you are married. A carrier may request that an enrollee

verify the eligibility of any or all family members listed as covered under the enrollee's

FEHB enrollment.

Contact your employing or retirement office if you want to change from Self Only to Self

Plus One or Self and Family. If you have a Self and Family enrollment, you may contact

us to add a family member.

Your employing or retirement office will not notify you when a family member is no

longer eligible to receive benefits. Please tell us immediately of changes in family

member status, including your marriage, divorce, annulment, or when your child reaches

age 26. We will send written notice to you 60 days before we proactively disenroll your

child on midnight of their 26th birthday unless your child is eligible for continued

coverage because they are incapable of self-support due to a physical or mental disability

that began before age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they

cannot be enrolled in or covered as a family member by another enrollee in another

FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a

child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the

FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs,

visit the FEHB website at http://www.opm.gov/healthcare-insurance/life-events. If you

need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/

payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse

(including your spouse by a valid common-law marriage from a state that recognizes

common-law marriages) and children as described in the chart below. A Self Plus One

enrollment covers you and your spouse, or one other eligible family member as described

below.

Natural children, adopted children, and stepchildren

Coverage: Natural children, adopted children, and stepchildren are covered until their 26

birthday.

Foster children

Coverage: Foster children are eligible for coverage until their 26

birthday if you provide

documentation of your regular and substantial support of the child and sign a certification

stating that your foster child meets all the requirements. Contact your human resources

office or retirement system for additional information.

Children incapable of self-support

Coverage: Children who are incapable of self-support because of a mental or physical

disability that began before age 26 are eligible to continue coverage. Contact your human

resources office or retirement system for additional information.

Married children

Coverage: Married children (but NOT their spouse or their own children) are covered until

their 26

birthday.

• Family Member

Coverage

9 2024 APWU Health Plan FEHB Facts

Children with or eligible for employer-provided health insurance

Coverage: Children who are eligible for or have their own employer-provided health

insurance are covered until their 26

birthday.

Newborns of covered children are insured only for routine nursery care during the covered

portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000.

This law mandates that you be enrolled for Self Plus One or Self and Family coverage in

the FEHB Program, if you are an employee subject to a court or administrative order

requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in

a health plan that provides full benefits in the area where your children live or provide

documentation to your employing office that you have obtained other health benefits

coverage for your children. If you do not do so, your employing office will enroll you

involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus

One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan

option as determined by OPM;

• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves

the area where your children live, your employing office will change your enrollment

to Self Plus One or Self and Family, as appropriate, in the same option of the same

plan; or

• If you are enrolled in an HMO that does not serve the area where the children live,

your employing office will change your enrollment to Self Plus One or Self and

Family, as appropriate, in the lowest-cost nationwide plan option as determined by

OPM.

As long as the court/administrative order is in effect, and you have at least one child

identified in the order who is still eligible under the FEHB Program, you cannot cancel

your enrollment, change to Self Only, or change to a plan that does not serve the area in

which your children live, unless you provide documentation that you have other coverage

for the children.

If the court/administrative order is still in effect when you retire, and you have at least one

child still eligible for FEHB coverage, you must continue your FEHB coverage into

retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to

a plan that does not serve the area in which your children live as long as the court/

administrative order is in effect. Similarly, you cannot change to Self Plus One if the

court/administrative order identifies more than one child. Contact your employing office

for further information.

• Children's Equity Act

10 2024 APWU Health Plan FEHB Facts

The benefits in this brochure are effective January 1. If you joined this Plan during Open

Season, your coverage begins on the first day of your first pay period that starts on or after

January 1. If you changed plans or plan options during Open Season and you receive

care between January 1 and the effective date of coverage under your new plan or

option, your claims will be processed according to the 2024 benefits of your prior

plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-

of-pocket maximum under the prior plan or option, you will not pay cost-sharing for

services covered between January 1 and the effective date of coverage under your new

plan or option. When you are enrolled under this Plan's Consumer Driven Option

between January 1 and the effective date of your new plan (or change to High Option of

this Plan) you will not receive a new Personal Care Account (PCA) for 2024 but any

unused PCA benefits from 2023 will be available to you. However, if your prior plan left

the FEHB Program at the end of the year, you are covered under that plan’s 2023 benefits

until the effective date of your coverage with your new plan. Annuitants’ coverage and

premiums begin on January 1. If you joined at any other time during the year, your

employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage, (i.e. you have

separated from Federal service) and premiums are not paid, you will be responsible for all

benefits paid during the period in which premiums were not paid. You may be billed for

services received directly from your provider. You may be prosecuted for fraud for

knowingly using health insurance benefits for which you have not paid premiums. It is

your responsibility to know when you or a family member are no longer eligible to use

your health insurance coverage.

Under the Consumer Driven Option, if you joined this Plan during Open Season, you

receive the full Personal Care Account (PCA) as of your effective date of coverage. If you

joined at any other time during the year, your PCA and your Deductible for your first year

will be prorated for each full month of coverage remaining in that calendar year.

• When benefits and

premiums start

When you retire, you can usually stay in the FEHB Program. Generally, you must have

been enrolled in the FEHB Program for the last five years of your Federal service. If you

do not meet this requirement, you may be eligible for other forms of coverage, such as

Temporary Continuation of Coverage (TCC).

• When you retire

When you lose benefits

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment; or

• You or a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital

or other institution for care or treatment on the 31

day of the temporary extension is

entitled to continuation of the benefits of the Plan during the continuance of the

confinement but not beyond the 60

day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage

(TCC).

• When FEHB coverage

ends

If you are an enrollee and your divorce or annulment is final, your ex-spouse cannot

remain covered as a family member under your Self Plus One or Self and Family

enrollment. You must contact us to let us know the date of the divorce or annulment and

have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof. In

order to change enrollment type, you must contact your employing or retirement office. A

change will not automatically be made.

• Upon divorce

11 2024 APWU Health Plan FEHB Facts

If you were married to an enrollee and your divorce or annulment is final, you may not

remain covered as a family member under your former spouse’s enrollment. This is the

case even when the court has ordered your former spouse to provide health coverage for

you. However, you may be eligible for your own FEHB coverage under either the spouse

equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or

are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get

additional information about your coverage choices, http://www.opm.gov/insure. We may

request that you verify the eligibility of any or all family members listed as covered under

the enrollee's FEHB enrollment.

If you leave Federal service, Tribal employment, or if you lose coverage because you no

longer qualify as a family member, you may be eligible for Temporary Continuation of

Coverage (TCC). For example, you can receive TCC if you are not able to continue your

FEHB enrollment after you retire, if you lose your Federal job, or if you are a covered

child and you turn age 26, regardless of marital status, etc.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross

misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or

retirement office or from www.opm.gov/healthcare-insurance/healthcare/plan-

information/guides. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where,

depending on your income, you could be eligible for a tax credit that lowers your monthly

premiums. Visit www.HealthCare.gov to compare plans and see what your premium,

deductible, and out-of-pocket costs would be before you make a decision to enroll.

Finally, if you qualify for coverage under another group health plan (such as your spouse's

plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing

FEHB Program coverage.

• Temporary

Continuation of

Coverage (TCC)

If you leave Federal or Tribal service, your employing office will notify you of your right

to convert. You must contact us in writing within 31 days after you receive this notice.

However, if you are a family member who is losing coverage, the employing or retirement

office will not notify you. You must contact us in writing within 31 days after you are no

longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will

not have to answer questions about your health, a waiting period will not be imposed and

your coverage will not be limited due to pre-existing conditions. When you contact us, we

will assist you in obtaining information about health benefits coverage inside or outside

the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in

finding coverage, please contact us at 800-222-2798 or visit our website at www.apwuhp.

com.

• Converting to

individual coverage

If you would like to purchase health insurance through the ACA's Health Insurance

Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S.

Department of Health and Human Services that provides up-to-date information on the

Marketplace.

• Health Insurance

Marketplace

The APWU Health Plan's Notice of Privacy Practices describes how medical information

about you may be used by the Health Plan, your rights concerning your health information

and how to exercise them, and APWU Health Plan's responsibilities in protecting your

health information. The Notice is posted on the Health Plan's website. If you need to

obtain a copy of the Health Plan's Notice of Privacy Practices, you may either contact the

Health Plan via email through the website, www.apwuhp.com, or by calling

800-222-2798.

• APWU Health Plan

Notice of Privacy

Practices

12 2024 APWU Health Plan FEHB Facts

Section 1. How This Plan Works

This Plan is a fee-for-service (FFS) plan. OPM requires that FEHB plans be accredited to validate that plan operations and/

or care management meet or exceed nationally recognized standards. APWU Health Plan holds the following accreditations:

Accreditation Association for Ambulatory Health Care (www.aaahc.org); National Committee for Quality Assurance (www.

ncqa.org); URAC (www.urac.org). To learn more about this plan's accreditation(s), please visit the following website: www.

apwuhp.com.

You can choose your own physicians, hospitals, and other healthcare providers. We give you a choice of enrollment in a High

Option or a Consumer Driven Health Plan (CDHP).

We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The

type and extent of covered services, and the amount we allow, may be different from other plans. Read brochures carefully.

We have Preferred Provider Organizations (PPOs)

General features of our High Option (HO)

Our fee-for-service plans offer services through PPO networks. This means that certain hospitals and other healthcare

providers are “preferred providers." When you use our network providers, you will receive covered services at a reduced

cost. APWU Health Plan is solely responsible for the selection of PPO providers in your area.

The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. Provider

networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialty in all

areas. If no PPO provider is available, or you do not use a PPO provider, the standard non-PPO benefits apply.

High Option PPO Network: You can go to our website, www.apwuhp.com to access an online High Option PPO directory.

If you need assistance in identifying a participating provider, call the APWU Health Plan at 800-222-2798. The Plan uses

UnitedHealthcare as its PPO network in all states and the U.S. Virgin Islands, as well as its mental health/substance use

disorder treatment provider network (all states).

When out of your state of residence, if you do not use a UnitedHealthcare PPO provider or a UnitedHealthcare PPO provider

is not available, standard non-PPO benefits apply. For assistance in identifying a provider in the network, call the APWU

Health Plan at 800-222-2798.

General features of our Consumer Driven Health Plan (CDHP)

Consumer Driven Option PPO Network: If you need assistance identifying a participating provider or to verify their

continued participation, call the Plan's Consumer Driven Option administrator, UnitedHealthcare, at 800-718-1299 or you

can go to their website, whyuhc.com/apwu, for a full nationwide online provider directory. UnitedHealthcare is the PPO

network for all states and Puerto Rico, and the U.S. Virgin Islands. Printed provider directories are not available.

•Preventive benefits: Preventive care services are generally covered with no cost-sharing and are not subject to

copayments, deductibles or annual limits when received from a network provider.

•For mental health/substance use disorder treatment providers (all states), call UnitedHealthcare Behavioral Health

Solutions toll-free 800-718-1299.

•Personal Care Account (PCA) benefits: This component is used first to provide first dollar coverage for covered

medical, dental and vision care services until the account balance is exhausted.

•Traditional benefits: After you have used up your Personal Care Account and satisfied a Deductible, the Plan starts paying

benefits under the Traditional Health Coverage as described in Section 5 CDHP.

13 2024 APWU Health Plan Section 1

How we pay providers

PPO Providers: Allowable benefits are based upon charges and discounts which we or our PPO administrators have

negotiated with participating providers. PPO provider charges are always within our Plan allowance.

For non-PPO providers, we base the Plan allowance on the lesser of the provider's actual charges or the allowed amount for

the service you received. We determine the allowed amount by using healthcare charge guides which compare charges of

other providers for similar services in the same geographical area. We update these charge guides at least once a year. For

surgery, doctor's services, X-ray, lab and therapies (physical, speech and occupational), we use the following:

•For the High Option Plan we use guides specifically prepared by Context4Healthcare at the 60

percentile.

•For the Consumer Driven Option we use guides specifically prepared by Fair Health at the 80

percentile.

•If this information is not available, we will use other credible sources including our own data.

Your rights and responsibilities

OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us,

our networks, and our providers. OPM’s FEHB website, www.opm.gov/insure lists the specific types of information that we

must make available to you. Some of the required information is listed below.

•The American Postal Workers Union Health Plan is a not-for-profit Voluntary Employee’s Beneficiary Association

(VEBA) formed in 1972.

•We meet applicable State and Federal licensing and accreditation requirements for fiscal solvency, confidentiality and

transfer of medical records.

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan.

You can view the complete list of these rights and responsibilities by visiting our website APWU Health Plan, www.apwuhp.

com. You can also contact us to request that we mail a copy to you by calling 800-222-2798, or write to APWU Health Plan,

P.O. Box 1358, Glen Burnie, MD 21060-1358. You may also contact us by fax at 410-424-1564.

By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI,

visit our website APWU Health Plan at www.apwuhp.com to obtain our Notice of Privacy Practices. You can also contact us

to request that we mail you a copy of that Notice.

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims

information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.

14 2024 APWU Health Plan Section 1

Section 2. Changes for 2024

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5

Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a

clarification that does not change benefits.

Changes to High Option Only

•Your share of the premium will increase for Self Only, Self Plus One and Self and Family (see page 162).

•The Preferred Provider Network (PPO) will change to the UnitedHealthcare (UHC) network of over 1.7 million providers

(see page 13).

•Preauthorization requirements for some services have changed (see page 18).

•Telehealth services will now be covered under Teladoc (see page 36).

•Members can now access breastfeeding supplies from any in-network provider (see page 39).

•Artificial insemination (AI) is now covered as well as coverage for infertility medications, including IVF related drugs

(see page 40).

•Skilled nursing visits have increased from 25 visits per calendar year to 50 visits per calendar year (see page 45).

•Reduced requirements for gender affirming care (see page 50).

•Special Programs have been changed or added under Section 5(h) to include a pregnancy support program, new mother

program, cancer support program, kidney resources program, a One Pass gym program and UnitedHealthcare Hearing

program (see page 77).

•The Plan will remove coverage for the following programs: Healthy Pregnancies, Healthy Babies; Weight Management;

Tobacco Cessation discounts; Healthy rewards discounts for fitness, vision, and dental; and Incentive (CignaPlus Savings)

discount program for Health Risk Assessment (HRA) completion.

•The APWU Health Plan will participate in a Medicare Part D plan administered by Express Scripts called Express Scripts

Medicare (PDP) (see page 143).

Changes to Consumer Driven Option only

•Your share of the premium will increase for Self Only, Self Plus One and Self and Family (see page 162).

•Artificial insemination (AI) is now covered as well as coverage for infertility medications, including IVF related drugs

(see page 93).

•Skilled nursing visits have increased from 25 visits per calendar year to 50 visits per calendar year (see page 98).

•Reduced requirements for gender affirming care (see page 102).

•One Pass gym program has been added to our Special Programs in Section 5(h) (see page 125)

15 2024 APWU Health Plan Section 2

Section 3. How You Get Care

We will send you an identification (ID) card when you enroll. You should carry your ID

card with you at all times. You must show it whenever you receive services from a Plan

provider; or fill a prescription at a Plan pharmacy. Until you receive your ID card, use

your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment

confirmation (for annuitants), or your electronic enrollment system (such as Employee

Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your

enrollment, or if you need replacement cards, contact us as follows:

• High Option: Call us at 800-222-2798 (TTY 800-622-2511) or write to us at P.O.

Box 1358, Glen Burnie, MD 21060-1358 or through our website at www.apwuhp.

com. You may print or request an Identification Card via the Member Portal at www.

myAPWUHP.com.

• Consumer Driven Option: Call UnitedHealthcare at 800-718-1299 or write to us at

P.O. Box 740800, Atlanta, GA 30374-0800 or request replacement cards through the

website at www.myuhc.com.

Identification cards

You can get care from any “covered provider” or “covered facility.” How much we pay –

and you pay – depends on the type of covered provider or facility you use. If you use our

preferred providers, you will pay less.

Where you get covered

care

FEHB Carriers must have clauses in their in-network (participating) providers agreements.

These clauses provide that, for a service that is a covered benefit in the plan brochure or

for services determined not medically necessary, the in-network provider agrees to hold

the covered individual harmless (and may not bill) for the difference between the billed

charge and the in-network contracted amount. If an in-network provider bills you for

covered services over your normal cost share (deductible, copay, coinsurance) contact

your Carrier to enforce the terms of its provider contract.

Balance Billing

Protection

Covered providers are medical practitioners who perform covered services when acting

within the scope of their license or certification under applicable state law and who

furnish, bill, or are paid for their healthcare services in the normal course of business.

Covered services must be provided in the state in which the practitioner is licensed or

certified.

Benefits are provided under this Plan for the services of covered providers, in accordance

with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not

determined by your state’s designation as a medically underserved area.

We list network-contracted covered providers in our network provider directory, which we

update periodically, and make available on our website.

This plan recognizes that transgender, non-binary, and other gender diverse members

require healthcare delivered by healthcare providers experienced in gender affirming

health. Benefits described in this brochure are available to all members meeting medical

necessity guidelines regardless of race, color, national origin, age, disability, religion, sex

or gender.

This plan provides Care Coordinators for complex conditions through UnitedHealthcare

and can be reached at 866-569-2064 for the High Option Plan and 800-718-1299 for the

Consumer Driven Option Plan.

• Covered providers

16 2024 APWU Health Plan Section 3

Covered facilities include:

• Freestanding ambulatory facility: An out-of-hospital facility such as a medical,

cancer, dialysis, or surgical center or clinic, and licensed outpatient facilities

accredited by the Joint Commission on Accreditation of Healthcare Organizations for

treatment of substance use disorder treatment.

• Hospital

- An institution which is accredited as a hospital under the Hospital Accreditation

Program of the Joint Commission on Accreditation of Healthcare Organizations, or

- Any other institution which is operated pursuant to law, under the supervision of a

staff of doctors and twenty-four hour a day nursing service, and which is primarily

engaged in providing: a) general inpatient care and treatment of sick and injured

persons through medical, diagnostic and major surgical facilities, all of which must

be provided on its premises or under its control, or b) specialized inpatient medical

care and treatment of sick or injured persons through medical and diagnostic

facilities (including X-ray and laboratory) on its premises, under its control, or

through a written agreement with a hospital (as defined above) or with a specialized

provider of those facilities.

The term "hospital" shall not include a skilled nursing facility, a convalescent

nursing home or institution or part thereof which 1) is used principally as a

convalescent facility, rest facility, residential treatment center, nursing facility or

facility for the aged; or 2) furnishes primarily domiciliary or custodial care,

including training in the routines of daily living.

• Covered facilities

Specialty care: If you have a chronic or disabling condition and

• lose access to your specialist because we drop out of the Federal Employees Health

Benefits (FEHB) Program and you enroll in another FEHB plan, or

• lose access to your PPO specialist because we terminate our contract with your

specialist for reasons other than cause,

You may be able to continue seeing your specialist and receiving any PPO benefits for up

to 90 days after you receive notice of the change. Contact us, or if we drop out of the

Program, contact your new plan.

If you are pregnant and you lose access to your specialist based on the above

circumstances, you can continue to see your specialist and your PPO benefits will

continue until the end of your postpartum care, even if it is beyond the 90 days.

• Transitional care

We pay for covered services from the effective date of your enrollment. However, if you

are in the hospital when your enrollment in our High Option begins, call our Customer

Service Department immediately at 800-222-2798. For the Consumer Driven Option,

please call UnitedHealthcare at 800-718-1299. If you are new to the FEHB Program, we

will reimburse you for your covered services while you are in the hospital beginning on

the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital

stay until:

• you are discharged, not merely moved to an alternative care center;

• the day your benefits from your former plan run out; or

• the 92

day after you become a member of this Plan, whichever happens first.

• If you are hospitalized

when your enrollment

begins

17 2024 APWU Health Plan Section 3

These provisions apply only to the benefits of the hospitalized person. If your plan

terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment

change, this continuation of coverage provision does not apply. In such cases, the

hospitalized family member’s benefits under the new plan begin on the effective date of

enrollment.

The pre-service claim approval processes for inpatient hospital admissions (called

precertification) and for other services, are detailed in this Section. A pre-service claim is

any claim, in whole or in part, that requires approval from us in advance of obtaining

medical care or services. In other words, a pre-service claim for benefits 1) requires

precertification or prior approval and 2) will result in a reduction of benefits if you do not

obtain precertification or prior approval.

You must get prior approval for certain services. Failure to do so will result in a minimum

$500 penalty for inpatient hospital (High Option and Consumer Driven Option) or $100

for certain outpatient radiology/imaging procedures (for High Option only).

You need prior Plan

approval for certain

services

Precertification is the process by which – prior to your inpatient hospital admission – we

evaluate the medical necessity of your proposed stay and the number of days required to

treat your condition. Unless we are misled by the information given to us, we won’t

change our decision on medical necessity.

In most cases, your physician or hospital will take care of requesting precertification.

Because you are still responsible for ensuring that your care is precertified, you should

always ask your physician or hospital whether or not they have contacted us.

• Inpatient hospital

admission, inpatient

residential treatment

center admission or

skilled nursing facility

admission

We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us

for precertification. If the stay is not medically necessary, we will only pay for any

covered medical services and supplies that are otherwise payable on an outpatient basis.

Warning

You do not need precertification in these cases:

• You are admitted to a hospital outside the United States and Puerto Rico.

• You have another group health insurance policy that is the primary payor for the

hospital stay.

• Medicare Part A is the primary payor for the hospital stay. Note: If you exhaust your

Medicare hospital benefits and do not want to use your Medicare lifetime reserve

days, then we will become the primary payor and you do need precertification.

Exceptions

Some services and outpatient surgeries require prior approval.

Under the High Option, call UnitedHealthcare at 866-569-2064 if you need any of the

services listed below:

• Applied Behavioral Analysis (ABA)

• Bariatric surgery (severe obesity)

• Chemotherapy

• Durable medical equipment such as wheelchairs, oxygen equipment and supplies,

artificial limbs (prosthetic devices) and braces

• Gender affirming surgery

• Gene Therapy

• Genetic testing, including BRCA testing (see

Definitions

, Section 10)

• Hysterectomy

• Functional endoscopic sinus surgery

• Iatrogenic fertility preservation procedures

• Intensive outpatient treatment

• Other services

18 2024 APWU Health Plan Section 3

• Minimally invasive treatment of back and neck pain. This requirement applies to both

the physician services and the facility. The following services require prior approval:

epidural steroid injections and sacroiliac joint injections.

• Orthognathic surgery (Oral maxillofacial surgery)

• Organ transplantation - call before your first evaluation as a potential candidate

• Organic impotence

• Procedures which may be cosmetic in nature such as eyelid surgery (blepharoplasty),

varicose vein surgery (sclerotherapy), or Botox injections for medical diagnosis

• Radiation Therapy - Intensity-Modulated Radiation Therapy, Proton Beam Radiation

Therapy and Stereotactic Radiation Therapy

• Residential Treatment Center (RTC)

• Services and supplies which may be experimental/investigational

• Skilled Nursing Facilities (SNF)

• Prior approval for outpatient services at Veterans Administration facilities is not

needed

Under the Consumer Driven Option, call UnitedHealthcare at 800-718-1299 if you need

any of the services listed below:

• Air Ambulance - Non emergent

• Applied Behavioral Analysis (ABA)

• Bariatric surgery (severe obesity)

• Clinical Trials

• Chemotherapy - outpatient

• Congenital Heart Disease

• Durable Medical Equipment (including Insulin pumps)

• Functional endoscopic sinus surgery

• Gender affirming surgery

• Genetic testing

• Home healthcare - nursing visits, home infusion therapy

• Hospice - inpatient

• Hysterectomy

• Iatrogenic fertility preservation procedures

• Organ transplantation

• Orthognathic surgery

• Potential cosmetic procedures

• Residential Treatment Center (RTC)

• Services and supplies which may be experimental/investigational

• Sinuplasty

• Skilled Nursing Facilities (SNF)

• Sleep apnea procedures and surgery

• Therapeutics (outpatient) dialysis, IV infusion, radiation oncology, intensity

modulated radiation therapy, MR-guided focused ultrasound

19 2024 APWU Health Plan Section 3

• Prior approval is required for certain classes of drugs and coverage authorization is

required for some medications. This authorization uses Plan rules based on FDA-

approved prescribing and safety information, clinical guidelines, and uses that are

considered reasonable, safe, and effective. For example, prescription drugs used for

cosmetic purposes such as Retin A or Botox may not be covered. Other medications

might be limited to a certain amount (such as quantity or dosage) within a specific

time period, or require authorization to confirm clinical use based on FDA labeling.

To inquire if your medication requires prior approval or authorization, call Express

Scripts Customer Service at 800-841-2734 for the High Option (see Section 5(f)), and

Optum Rx at 800-718-1299 for the Consumer Driven Option (see Section 5(f)).

• Prior approval is also required for mental health and substance use disorder benefits,

inpatient, in-network or out-of-network. Prior approval is required for psychological

and neuropsychological testing (CDHP Option only), Electroconvulsive therapy

(CDHP Option only), Transcranial Magnetic Stimulation (TMS), and services such as

partial or full day hospitalization or facility-based intensive outpatient treatment. For

questions, call UnitedHealthcare at 866-569-2064 for the High Option Plan and

800-718-1299 for the Consumer Driven Option Plan.

• High Option: You or your representative, your physician, or your hospital must call

UnitedHealthcare at 866-569-2064 at least 2 business days before admission. For other

services that require prior approval, call UnitedHealthcare at 866-569-2064 prior to

those services being rendered. For mental health and substance use disorder inpatient

treatment, your physician or your hospital must call UnitedHealthcare at

866-569-2064 at least 2 business days before admission or services requiring prior

authorization. These numbers are available 24 hours every day.

• Consumer Driven Option: First you, your representative, your physician, or your

hospital must call UnitedHealthcare at 800-718-1299 at least 2 business days before

admission or services requiring prior authorization are rendered. For mental health and

substance use disorder inpatient treatment, your doctor or your hospital must call

UnitedHealthcare Behavioral Health Solutions at 800-718-1299 at least 2 business

days before admission or services requiring prior authorization. These numbers

are available 24 hours every day.

• If you have an emergency admission due to a condition that you reasonably believe

puts your life in danger or could cause serious damage to bodily function, you, your

representative, the physician, or the hospital must telephone the above number at least

2 business days for the High Option and the Consumer Driven Option following the

day of the emergency admission, even if you have been discharged from the hospital.

• Next, provide the following information:

- enrollee’s name and Plan identification number

- patient’s name, birth date, and phone number

- reason for hospitalization, proposed treatment, or surgery

- name and phone number of admitting physician

- name of hospital or facility; and

- number of days requested for hospital stay

• We will then tell the physician and/or hospital the number of approved inpatient days

and we will send written confirmation of our decision to you, your physician, and the

hospital.

How to request

precertification for an

admission or get prior

authorization for Other

services

• If no one contacts us, we will decide whether the hospital stay was medically

necessary.

• If we determine that the stay was medically necessary, we will pay the inpatient

charges, less the $500 penalty.

What happens when you

do not follow the

precertification rules

20 2024 APWU Health Plan Section 3

If we determine that it was not medically necessary for you to be an inpatient, we will not

pay inpatient hospital benefits. We will only pay for any covered medical supplies and

services that are otherwise payable on an outpatient basis for High Option and Consumer

Driven Option out-of-network stays.

If we denied the precertification request, we will not pay inpatient hospital benefits. We

will only pay for any covered medical supplies and services that are otherwise payable on

an outpatient basis for High Option and Consumer Driven Option out-of-network stays.

When we precertified the admission but you remained in the hospital beyond the number

of days we approved and did not get the additional days precertified, then:

• For the part of the admission that was medically necessary, we will pay inpatient

benefits, but

• For the part of the admission that was not medically necessary, we will pay only

medical services and supplies otherwise payable on an outpatient basis and will not

pay inpatient benefits for High Option and Consumer Driven Option out-of-network

services.

High Option: Radiology precertification is required prior to scheduling specific imaging

procedures. We evaluate the medical necessity of your proposed procedure to ensure that

the appropriate procedure is being requested for your condition. In most cases your

physician will take care of the precertification. Because you are responsible for ensuring

that precertification is done, you should ask your doctor to contact us.

The following outpatient radiology services require precertification:

• CT/CAT Scan – Computerized Axial Tomography

• MRI – Magnetic Resonance Imaging

• MRA – Magnetic Resonance Angiography

• PET – Positron Emission Tomography

• Radiology/imaging

procedures

precertification

For these outpatient studies, you, your representative or doctor must call UnitedHealthcare

before scheduling the procedure. The toll free number is 866-569-2064.

• Provide the following information:

- patient’s name, Plan identification number, and birth date

- requested procedure and clinical support for request

- name and phone number of ordering provider

- name of requested imaging facility

• How to precertify a

radiology/imaging

procedure

We will reduce our benefits for these procedures by $100 if no one contacts us for

precertification. If the procedure is not medically necessary, we will not pay any benefits.

Warning

You do not need precertification in these cases:

• You have another health insurance policy that is primary including Medicare Parts

A&B or Part B Only

• The procedure is performed outside the United States or Puerto Rico

• You are an inpatient at a hospital

• The procedure is performed while in the Emergency Room

Exceptions

For non-urgent care claims, we will tell the physician and/or hospital the number of

approved inpatient days, or the care that we approve for other services that must have

prior authorization. We will make our decision within 15 days of receipt of the pre-service

claim.

• Non-urgent care

claims

21 2024 APWU Health Plan Section 3

If matters beyond our control require an extension of time, we may take up to an

additional 15 days for review and we will notify you of the need for an extension of time

before the end of the original 15-day period. Our notice will include the circumstances

underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you,

our notice will describe the specific information required and we will allow you up to 60

days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for your

medical care or treatment could seriously jeopardize your life, health, or ability to regain

maximum function, or in the opinion of a physician with knowledge of your medical

condition, would subject you to severe pain that cannot be adequately managed without

this care or treatment), we will expedite our review and notify you of our decision within

72 hours. If you request that we review your claim as an urgent care claim, we will

review the documentation you provide and decide whether or not it is an urgent care claim

by applying the judgment of a prudent layperson that possesses an average knowledge of

health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we

receive the claim to let you know what information we need to complete our review of the

claim. You will then have up to 48 hours to provide the required information. We will

make our decision on the claim within 48 hours of (1) the time we received the additional

information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with

written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us

and OPM. Please let us know that you would like a simultaneous review of your urgent

care claim by OPM either in writing at the time you appeal our initial decision, or by

calling us at 800-222-2798. You may also call FEHB at 202-606-3818 between 8 a.m.

and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM

so they can quickly review your claim on appeal. In addition, if you did not indicate that

your claim was a claim for urgent care, call us at 800-222-2798. If it is determined that

your claim is an urgent care claim, we will expedite our review (if we have not yet

responded to your claim).

• Urgent care claims

A concurrent care claim involves care provided over a period of time or over a number of

treatments. We will treat any reduction or termination of our pre-approved course of

treatment before the end of the approved period of time or number of treatments as an

appealable decision. This does not include reduction or termination due to benefit changes

or if your enrollment ends. If we believe a reduction or termination is warranted, we will

allow you sufficient time to appeal and obtain a decision from us before the reduction or

termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the

expiration of the approved time period and this is also an urgent care claim, we will make

a decision within 24 hours after we receive the claim.

Concurrent care claims

If you have an emergency admission due to a condition that you reasonably believe puts

your life in danger or could cause serious damage to bodily function, you, your

representative, the physician, or the hospital must telephone us within two business days

following the day of the emergency admission, even if you have been discharged from the

hospital. If you do not telephone the Plan within two business days, penalties may apply -

see

Warning

under

Inpatient hospital admissions

earlier in this Section and

If your hospital

stay needs to be extended

below.

• Emergency inpatient

admission

22 2024 APWU Health Plan Section 3

You do not need precertification of a maternity admission for a routine delivery. However,

if your medical condition requires you to stay more than 48 hours after a vaginal delivery

or 96 hours after a cesarean section, then your physician or the hospital must contact us

for precertification of additional days. Further, if your baby stays after you are discharged,

your physician or the hospital must contact us for precertification of additional days for

your baby.

Note: When a newborn requires definitive treatment during or after the mother's hospital

stay, the newborn is considered a patient in their own right. If the newborn is eligible for

coverage, regular medical or surgical benefits apply rather than maternity benefits.

• Maternity care

High Option: If your hospital stay – including for maternity care – needs to be extended,

you, your representative, your physician or the hospital must ask us to approve the

additional days by calling the precertification vendor UnitedHealthcare at 866-569-2064.

If you remain in the hospital beyond the number of days we approved and did not get the

additional days precertified, then

• For the part of the admission that was medically necessary, we will pay inpatient

benefits, but

• For the part of the admission that was not medically necessary, we will pay only

medical services and supplies otherwise payable on an outpatient basis and will not

pay inpatient benefits.

Consumer Driven Option: If your hospital stay – including for maternity care – needs to

be extended, you, your representative, your doctor or the hospital must ask us to approve

the additional days by calling UnitedHealthcare at 800-718-1299. If you remain in the

hospital beyond the number of days we approved and did not get the additional days

precertified, then

• For the part of the admission that was medically necessary, we will pay inpatient

benefits, but

• For the part of the admission that was not medically necessary, we will pay only

medical services and supplies otherwise payable on an outpatient basis and will not

pay inpatient benefits for out-of-network services only.

• If your hospital stay

needs to be extended

If you request an extension of an ongoing course of treatment at least 24 hours prior to the

expiration of the approved time period and this is also an urgent care claim, we will make

a decision within 24 hours after we receive the claim.

• If your treatment

needs to be extended

If you have a pre-service claim and you do not agree with our decision regarding

precertification of an inpatient admission or prior approval of other services, you may

request a review in accord with the procedures detailed below. If your claim is in

reference to a contraceptive, call 800-841-2734 for the High Option and 800-718-1299 for

the Consumer Driven Option.

If you have already received the service, supply, or treatment, then you have a post-

service claim and must follow the entire disputed claims process detailed in Section 8.

• If you disagree with

our pre-service

decision

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial

decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this

brochure.

In the case of a pre-service claim and that is subject to a request for additional

information, we have 30 days from the date we receive your written request for

reconsideration to:

1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give

you the care or grant your request for prior approval for a service, drug, or supply; or

2. Ask you or your provider for more information.

• To reconsider a non-

urgent care claim

23 2024 APWU Health Plan Section 3

You or your provider must send the information so that we receive it within 60 days of our

request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the

date the information was due. We will base our decision on the information we already

have. We will write to you with our decision.

3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial

decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the

disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72

hours after receipt of your reconsideration request. We will expedite the review process,

which allows oral or written requests for appeals and the exchange of information by

telephone, electronic mail, facsimile, or other expeditious methods.

• To reconsider an

urgent care claim

After we reconsider your pre-service claim, if you do not agree with our decision, you

may ask OPM to review it by following Step 3 of the disputed claims process detailed in

Section 8 of this brochure.

• To file an appeal with

OPM

24 2024 APWU Health Plan Section 3

Section 4. Your Costs for Covered Services

This is what you will pay out-of-pocket for covered care:

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible,

coinsurance, and copayments) for the covered care you receive.

Cost-sharing

High Option: A copayment is a fixed amount of money you pay to the provider, facility,

pharmacy, etc., when you receive certain services.

Example: Under the High Option, when you see your PPO physician you pay a

copayment of $25 per office visit.

Consumer Driven Option: There are no copayments under the Consumer Driven

Option.

Note: If the billed amount (or the Plan allowance that providers we contract with have

agreed to accept as payment in full), is less than your copayment, you pay the lower

amount.

Copayment

A deductible is a fixed amount of covered expenses you must incur for certain covered

services and supplies before we start paying benefits for them. Copayments and

coinsurance amounts do not count toward any deductible. When a covered service or

supply is subject to a deductible, only the Plan allowance for the service or supply counts

toward the deductible.

High Option

• If you use PPO providers, the calendar year deductible is $450 person. Under a Self

Only enrollment, the deductible is considered satisfied and benefits are payable for

you when your covered expenses applied to the calendar year deductible for your

enrollment reach $450. Under a Self Plus One enrollment, the deductible is considered

satisfied and benefits are payable for you and one other eligible family member when

the combined covered expenses applied to the calendar year deductible for your

enrollment reach $800. Under a Self and Family enrollment, the deductible is

considered satisfied and benefits are payable for all family members when the

combined covered expenses applied to the calendar year deductible for family

members reach $800. If you use non-PPO providers, your calendar year deductible

increases to a maximum of $1,000 per person ($2,000 per Self Plus One and Self and

Family). Whether or not you use PPO providers, your calendar year deductible will

not exceed $1,000 per person ($2,000 per Self Plus One and Self and Family).

If the billed amount (or the Plan allowance that providers we contract with have agreed to

accept as payment in full) is less than the remaining portion of your deductible, you pay

the lower amount.

Example: If the billed amount is $100, the provider has an agreement with us to accept

$80, and you have not paid any amount toward meeting your calendar year deductible,

you must pay $80. We will apply $80 to your deductible. We will begin paying benefits

once the remaining portion of your calendar year deductible ($450) has been satisfied.

Note: If you change plans during Open Season, and the effective date of your new plan is

after January 1 of the next year, you do not have to start a new deductible under your prior

plan between January 1 and the effective date of your new plan. If you change plans at

another time during the year, you must begin a new deductible under your new plan.

Deductible

25 2024 APWU Health Plan Section 4

If you change from Self Plus One or Self and Family to Self Only, or from Self Only to

Self Plus One or Self and Family during the year, we will credit the amount of covered

expenses already applied toward the deductible of your old enrollment to the deductible of

your new enrollment. However, if you change from High Option to Consumer Driven

Option or from Consumer Driven Option to High Option, during the year, expenses

incurred as of the effective date of the option change are subject to the benefit provisions

of your new option.

Consumer Driven Option: Your Deductible is the amount of eligible expenses you are

required to meet before Traditional Health Coverage begins. Your plan's deductible is

reduced by applying the funds in your Personal Care Account (PCA) which is funded in

January by the APWU Health Plan. Your Net Deductible is the remaining deductible

amount you have to pay once the funds in your PCA have been exhausted. By using the

funds in your PCA to pay for eligible medical expenses you decrease your total deductible

and out-of-pocket expenses. Your Net Deductible for in-network providers is generally

$1,000 for a Self Only enrollment or $2,000 for a Self Plus One or a Self and Family

enrollment. For Self Plus One or Self and Family coverage, once one individual meets the

Self Only Net Deductible of $1,000, Traditional Health Coverage begins for that

individual. Once the other covered members meet the additional $1,000 Net Deductible,

Traditional Health Coverage begins for them. If you use out-of-network providers, your

calendar year Net Deductible increases to $1,500 Self Only and $3,000 for Self Plus One

and Self and Family. Your Deductible in subsequent years may be reduced by rolling over

any unused portion of your Personal Care Account remaining at the end of the calendar

year(s).

In-Network Plan Deductible:

Self Only: $2,200

Self Plus One: $4,400

Self and Family: 4,400

In-Network PCA (APWU HP Funded)

Self Only: $1,200

Self Plus One: $2,400

Self and Family: $2,400

In-Network Net Deductible (You Pay)

Self Only: $1,000

Self Plus One: $2,000

Self and Family: $2,000

High Option: Coinsurance is the percentage of our allowance that you must pay for your

care. Coinsurance does not begin until you have met your calendar year deductible.

Example: You pay 40% of our allowance for office visits to a non-PPO physician.

Consumer Driven Option: Coinsurance is the percentage of our allowance that you

must pay for your care after you have used up your Personal Care Account (PCA) and

paid your Deductible.

Coinsurance

If your provider routinely waives (does not require you to pay) your copayments,

deductibles, or coinsurance, the provider is misstating the fee and may be violating the

law. In this case, when we calculate our share, we will reduce the provider’s fee by the

amount waived.

For example, if your physician ordinarily charges $100 for a service but routinely waives

your 40% coinsurance, the actual charge is $60. We will pay $36 (60% of the actual

charge of $60).

If your provider routinely

waives your cost

26 2024 APWU Health Plan Section 4

In some instances, an APWU Health Plan provider may ask you to sign a “waiver” prior to

receiving care. This waiver may state that you accept responsibility for the total charge for

any care that is not covered by your health plan. If you sign such a waiver, whether or not

you are responsible for the total charge depends on the contracts that the Plan has with its

providers. If you are asked to sign this type of waiver, please be aware that, if benefits are

denied for the services, you could be legally liable for the related expenses. If you would

like more information about waivers, please contact us at 800-222-2798.

Waivers

High Option: Our “Plan allowance” is the amount we use to calculate our payment for

covered services. Fee-for-service plans arrive at their allowances in different ways, so

their allowances vary. For more information about how we determine our Plan allowance,

see the definition of Plan allowance in Section 10.

Often, the provider’s bill is more than a fee-for-service plan’s allowance. Whether or not

you have to pay the difference between our allowance and the bill will depend on the

provider you use.

• PPO providers agree to limit what they will bill you. Because of that, when you use a

preferred provider, your share of covered charges consists only of your deductible and

coinsurance or copayment. Here is an example about coinsurance: You see a PPO

physician who charges $150, but our allowance is $100. If you have met your

deductible, you are only responsible for your coinsurance. That is, you pay just -- 15%

of our $100 allowance ($15). Because of the agreement, your PPO physician will not

bill you for the $50 difference between our allowance and the bill.

• Non-PPO providers, on the other hand, have no agreement to limit what they will bill

you. When you use a non-PPO provider, you will pay your deductible and coinsurance

-- plus any difference between our allowance and charges on the bill. Here is an

example: You see a non-PPO physician who charges $150 and our allowance is again

$100. Because you’ve met your deductible, you are responsible for your coinsurance,

so you pay 40% of our $100 allowance ($40). Plus, because there is no agreement

between the non-PPO physician and us, the physician can bill you for the $50

difference between our allowance and the bill.

The information below illustrates the examples of how much you have to pay out-of-

pocket for services from a PPO physician vs. a non-PPO physician. The information uses

our example of a service for which the physician charges $150 and our allowance is $100.

The example shows the amount you pay if you have met your calendar year deductible.

EXAMPLE

PPO physician

Physician's charge: $150

Our allowance: We set it at: $100

We pay: 85% of our allowance: $85

You owe: Coinsurance: 15% of our allowance: $15

+ Difference up to charge?: No: 0

TOTAL YOU PAY: $15

Non-PPO physician

Physician's charge: $150

Our allowance: We set it at: $100

We pay: 60% of our allowance: $60

You owe: Coinsurance: 40% of our allowance: $40

+ Difference up to charge?: Yes: $50

TOTAL YOU PAY: $90

Differences between our

allowance and the bill

27 2024 APWU Health Plan Section 4

Consumer Driven Option:

In-network providers agree to accept our Plan allowance so if you use an in-network

provider, you never have to worry about paying the difference between the Plan allowance

and the billed amount for covered services. If your covered expenses are being paid out of

your Personal Care Account or if you are receiving in-network covered preventive

services, the Plan will pay 100%. If you have exhausted your Personal Care Account, you

will be responsible for paying your Deductible and also coinsurance under the Traditional

Health Coverage.

Out-of-network providers - If you use an out-of-network provider, you will have to pay

the difference between the Plan allowance and the billed amount only if you use up

your Personal Care Account for the year. Note that it usually makes sense to use in-

network providers because it will make your Personal Care Account go much further since

money left in your Personal Care Account can be rolled over to be used in the next year.

You should also see section

Important Notice About Surprise Billing - Know Your Rights

below that describes your protections against surprise billing under the No Surprises Act.

There is a limit to the amount you must pay out-of-pocket for combined medical and

prescription drug coinsurance for the year for certain charges. When you have reached this

limit, you pay no coinsurance for covered services for the remainder of the calendar year.

High Option:

PPO benefit: Your out-of-pocket maximum is $6,500 for combined medical and

prescription drugs for Self Only enrollment or $13,000 for a Self Plus One or a Self and

Family enrollment if you are using PPO providers and in-network pharmacies. Only

eligible expenses for PPO providers and in-network pharmacies count toward this limit.

Non-PPO benefit: Your out-of-pocket maximum is $12,000 for combined medical and

prescription drugs for Self Only enrollment, or $24,000 for a Self Plus One or a Self and

Family enrollment if you are using non-PPO providers or out-of-network pharmacies.

Eligible expenses for network providers or in-network pharmacies also count toward this

limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you

use network providers.

Note: For Self Plus One or Self and Family coverage, the maximum out-of-pocket for any

individual in the family will not exceed the maximum out-of-pocket for Self Only

coverage. When an individual meets the Self Only out-of-pocket maximum, they pay no

coinsurance for covered services for the remainder of the calendar year. Once the other

covered members in the family meet the remaining out-of-pocket family maximum, then

they pay no coinsurance for covered services for the remainder of the calendar year.

Out-of-pocket expenses for the purposes of this benefit are:

• The 15% you pay (or the 5% you pay for Cancer Centers of Excellence) for PPO;

inpatient medical services and supplies, surgical and anesthesia services, services

provided by a hospital or other facility and ambulance services, emergency services/

accidents, mental health and substance use disorder treatment; and the medical

deductible

• The 40% you pay for non-PPO; medical services and supplies, surgical and anesthesia

services, services provided by a hospital or other facility and ambulance services,

mental health and substance use disorder treatment, dental (30%); and the medical

deductible

• The copayment of $25 for outpatient visits to PPO physicians and $10 for virtual visits

• The copayment of $30 for outpatient facility charges in a PPO Urgent Care Center

Your Catastrophic

protection out-of-pocket

maximum for

deductibles, coinsurance

and copayments

28 2024 APWU Health Plan Section 4

• The 25% you pay for in-network preferred brand name prescription drugs (Tier 2),

45% for in-network non-preferred brand name prescription drugs (Tier 3) and the $10

and $20 you pay for in-network generic prescription drugs (Tier 1), and 25% for

generic specialty drugs (Tier 4), 25% for preferred brand name drugs (Tier 5) and 45%

non-preferred brand name drugs (Tier 6)

The following cannot be included in the accumulation of out-of-pocket expenses:

• Expenses in excess of our allowance or maximum benefit limitations

• Any amounts you pay because benefits have been reduced for non-compliance with

this Plan's cost containment requirements, (see Section 3)

• The $300 per admission for non-PPO inpatient hospital charges or skilled nursing

facility

• Expenses in excess of visit maximums for physical, occupational and speech therapy,

and acupuncture

• Expenses in excess of Hospice care and preventive care maximums

• The difference in cost when brand name drugs are purchased and a generic is available

• Drugs reimbursed at the non-network pharmacy level

• 50% coinsurance for retail drugs after the first two fills if mail order is not used

• 100% of the cost for targeted drugs if the Plan's step therapy is not followed

• Any associated costs when you purchase medications in excess of the Plan's

dispensing limitations

• Cost associated with non-covered drugs and supplies

Consumer Driven Option:

If you have exceeded your Personal Care Account and met your Deductible the following

would apply:

In-network benefit: Your out-of-pocket maximum is $6,500 for combined medical and

prescription drugs for a Self Only enrollment or $13,000 for a Self Plus One or Self and

Family enrollment if you are using in-network providers and pharmacies. Only eligible

expenses for network providers and pharmacies count toward this limit.

Out-of-network benefit: Your out-of-pocket maximum is $12,000 for combined medical

and prescription drugs for a Self Only enrollment or $24,000 for a Self Plus One or Self

and Family enrollment if you are using out-of-network providers. Eligible expenses for

network providers and pharmacies also count toward this limit. Your eligible out-of-

pocket expenses will not exceed this amount whether or not you use network providers.

Note: For Self Plus One or Self and Family coverage, the maximum out-of-pocket for any

individual in the family will not exceed the maximum out-of-pocket for Self Only

coverage. When an individual meets the Self Only out-of-pocket maximum, they pay no

coinsurance for covered services for the remainder of the calendar year. Once the other

covered members in the family meet the remaining out-of-pocket family maximum, then

they pay no coinsurance for covered services for the remainder of the calendar year.

Out-of-pocket expenses for the purposes of this benefit are:

• The 15% you pay (or the 10% you pay for Cancer Centers of Excellence) for in-

network inpatient and outpatient hospital charges, surgical, medical, virtual visits and

emergency services under the Traditional Health Coverage; and the Deductible

• The 50% you pay for out-of-network inpatient and outpatient hospital charges,

surgical, medical, and maternity services under the Traditional Health Coverage; and

the Deductible

29 2024 APWU Health Plan Section 4

• The 25% you pay for in-network Tier 1 and Tier 2 prescription drugs; and 40% for in-

network Tier 3 drugs

• The Personal Care Account (PCA) of $1,200 for Self Only or $2,400 for Self Plus One

or Self and Family

The following cannot be included in the accumulation of out-of-pocket expenses:

• Any expenses paid by the Plan under your in-network Preventive Care benefit

• Expenses in excess of our allowance or maximum benefit limitations or expenses not

covered under the Traditional Health Coverage

• Dental care or Vision care expenses above the limitations provided under

your Personal Care Account

• Any amounts you pay because benefits have been reduced for non-compliance with

this Plan’s cost containment requirements (see Section 3)

• Expenses in excess of Hospice care maximums

• Drugs purchased at a non-network pharmacy

• The difference in cost when brand name drugs are purchased and a generic is available

• Any associated costs when you purchase medications in excess of the Plan's

dispensing limitations

• Cost associated with non-covered drugs and supplies

If you changed to this Plan during Open Season from a plan with a catastrophic protection

benefit and the effective date of the change was after January 1, any expenses that would

have applied to that plan’s catastrophic protection benefit during the prior year will be

covered by your prior plan if they are for care you received in January before your

effective date of coverage in this Plan. If you have already met your prior plan’s

catastrophic protection benefit level in full, it will continue to apply until the effective date

of your coverage in this Plan. If you have not met this expense level in full, your prior

plan will first apply your covered out-of-pocket expenses until the prior year’s

catastrophic level is reached and then apply the catastrophic protection benefit to covered

out-of-pocket expenses incurred from that point until the effective date of your coverage

in this Plan. Your prior plan will pay these covered expenses according to this year’s

benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of

covered expenses already accumulated toward the catastrophic out-of-pocket limit of your

old option to the catastrophic protection limit of your new option.

Carryover

We will make diligent efforts to recover benefit payments we made in error but in good

faith. We may reduce subsequent benefit payments to offset overpayments. We will

generally first seek recovery from the provider if we paid the provider directly, or from the

person (covered family member, guardian, custodial parent, etc.) to whom we sent our

payment.

If we overpay you

Facilities of the Department of Veterans Affairs, the Department of Defense, and the

Indian Health Service are entitled to seek reimbursement from us for certain services and

supplies they provide to you or a family member. They may not seek more than their

governing laws allow. You may be responsible to pay for certain services and charges.

Contact the government facility directly for more information.

When Government

facilities bill us

30 2024 APWU Health Plan Section 4

The No Surprises Act (NSA) is a federal law that provides you with protections against

"surprise billing" and "balance billing" for out-of-network emergency services; out-of-

network non-emergency services provided with respect to a visit to a participating

healthcare facility; and out-of-network air ambulance services.

A surprise bill is an unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom

you receive care, or for

• non-emergency services furnished by nonparticipating providers with respect to

patient visits to participating healthcare facilities, or for

• air ambulance services furnished by nonparticipating providers of air ambulance

services.

Balance billing happens when you receive a bill from the nonparticipating provider,

facility, or air ambulance service for the difference between the nonparticipating

provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from

surprise bills.

For specific information on surprise billing, the rights and protections you have, and your

responsibilities go to www.apwuhp.com and click on Members or contact the Health Plan

at 800-222-2798.

Important Notice About

Surprise Billing -

Know Your Rights

Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare

expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs

and medications, vision and dental expenses, and much more) for you, your tax

dependents, and your adult children (through the end of the calendar year in which they

turn 26).

FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB

and FEDVIP plans. This means that when you or your provider files claims with your

FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-

pocket expenses based on the claim information it receives from your plan.

The Federal Flexible

Spending Account

Program -

FSAFEDS

31 2024 APWU Health Plan Section 4

Section 5. High Option Health Plan Benefits

See Section 2 for how our benefits changed this year. Page 154 is a benefits summary of the High Option. Make sure that you

review the benefits that are available under the option in which you are enrolled.

High Option Overview ................................................................................................................................................................34

Section 5 (a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals .............................35

Diagnostic and treatment services .....................................................................................................................................35

TeleHealth Services ...........................................................................................................................................................36

Lab, X-ray and other diagnostic tests ................................................................................................................................36

Preventive care, adult ........................................................................................................................................................37

Preventive care, children ...................................................................................................................................................38

Maternity care ...................................................................................................................................................................39

Family Planning ................................................................................................................................................................40

Infertility services .............................................................................................................................................................40

Allergy care .......................................................................................................................................................................41

Treatment therapies ...........................................................................................................................................................41

Physical and occupational therapies .................................................................................................................................42

Applied behavioral analysis (ABA) ..................................................................................................................................42

Speech therapy ..................................................................................................................................................................42

Hearing services (testing, treatment, and supplies) ...........................................................................................................43

Vision services (testing, treatment, and supplies) .............................................................................................................43

Foot care ............................................................................................................................................................................43

Orthopedic and prosthetic devices ....................................................................................................................................44

Durable medical equipment (DME) ..................................................................................................................................44

Home health services ........................................................................................................................................................45

Chiropractic .......................................................................................................................................................................46

Alternative treatments .......................................................................................................................................................46

Educational classes and programs .....................................................................................................................................46

Section 5 (b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals ........................48

Surgical procedures ...........................................................................................................................................................48

Reconstructive surgery ......................................................................................................................................................50

Oral and maxillofacial surgery ..........................................................................................................................................51

Organ/tissue transplants ....................................................................................................................................................52

Anesthesia .........................................................................................................................................................................55

Section 5 (c). Services Provided by a Hospital or Other Facility, and Ambulance Services ......................................................56

Inpatient hospital ...............................................................................................................................................................56

Cancer Centers of Excellence ...........................................................................................................................................58

Outpatient hospital or ambulatory surgical center ............................................................................................................58

Extended care benefits/Skilled nursing care facility benefits ...........................................................................................58

Hospice care ......................................................................................................................................................................59

End of life care ..................................................................................................................................................................59

Ambulance ........................................................................................................................................................................59

Section 5 (d). Emergency Services/Accidents ...........................................................................................................................60

Accidental injury ...............................................................................................................................................................61

Medical emergency ...........................................................................................................................................................61

Ambulance ........................................................................................................................................................................61

Air ambulance ...................................................................................................................................................................61

Section 5 (e). Mental Health and Substance Use Disorder Benefits ...........................................................................................63

32 2024 APWU Health Plan High Option Section 5

Professional services .........................................................................................................................................................64

TeleHealth services ...........................................................................................................................................................65

Diagnostics ........................................................................................................................................................................65

Inpatient hospital or other covered facility .......................................................................................................................65

Outpatient hospital or other covered facility .....................................................................................................................65

Section 5 (f). Prescription Drug Benefits ...................................................................................................................................67

Covered medications and supplies ....................................................................................................................................69

Preventive care medications ..............................................................................................................................................72

Section 5 (g). Dental Benefits ....................................................................................................................................................75

Accidental injury benefit ...................................................................................................................................................75

Dental benefits service ......................................................................................................................................................75

Section 5 (h). Wellness and Other Special Features ...................................................................................................................76

Healthy Pregnancies, Healthy Babies® Program ..............................................................................................................-1

Flexible benefits option .....................................................................................................................................................76

24-hour NurseLine ............................................................................................................................................................76

Services for deaf and hearing impaired .............................................................................................................................76

Disease Management Program ..........................................................................................................................................76

Review and Reward Program ...........................................................................................................................................76

Weight Management ........................................................................................................................................................76

Special Programs ...............................................................................................................................................................77

Online tools and resources ................................................................................................................................................77

Health Risk Assessment (HRA) ........................................................................................................................................77

Consumer choice information ...........................................................................................................................................77

Summary of Benefits for the High Option of the APWU Health Plan - 2024 ..........................................................................154

33 2024 APWU Health Plan High Option Section 5

High Option Overview

High Option

The Plan offers a High Option, described in this section. Make sure that you review the benefits that are available under the

benefit program in which you are enrolled.

The High Option Section 5 is divided into subsections. Please read

Important things you should keep in mind

at the

beginning of each subsection. Also read the general exclusions in Section 6; they apply to the benefits in the following

subsections. To obtain claim forms, claims filing advice, or more information about the High Option benefits, contact us at

800-222-2798 or on our website at www.apwuhp.com.

The APWU Health Plan’s High Option provides a wide range of comprehensive benefits for preventive services, doctors’

visits and services, care in a hospital, laboratory tests and procedures, accidental and emergency services, mental health and

substance use disorder treatment and prescription drugs. We have extensive networks of preferred providers for both medical

and mental health services to help lower your costs, but you may use any provider you wish, in or out of our networks.

The High Option includes:

Preventive care

The Plan emphasizes prevention by providing an extensive range of preventive benefits to help members stay well. We

include 100% coverage for an array of in-network preventive tests and screenings, routine physical exams, and a Tobacco

Cessation program to stop smoking. To keep children well, we have 100% coverage for recommended immunizations,

physical exams and laboratory tests for children. We emphasize women's wellness with our Preventive Care benefit that

provides 100% coverage for a full range of in-network preventive services, preventive tests and screenings, counseling

services and generic and single source brand FDA approved prescription contraceptives.

Medical and Surgical services

The Plan provides coverage for doctors’ visits and surgical services and supplies. You pay only a flat copayment for office

visits to a network physician, including visits for chiropractic and acupuncture treatment. In-network maternity care is

covered 100%, including breastfeeding support. Mental health and substance use disorder treatment has the same

comprehensive coverage as is provided for medical care.

Hospitalization and Emergency care

We offer extensive benefits for hospital and other inpatient healthcare services. There is no deductible or per admission

charge for in-network hospital care. You also receive 100% coverage for unexpected outpatient care when you need it most

with the Plan’s Accidental Injury benefit.

Prescription drugs

Our prescription drug program offers prescription savings with no deductible and low copayments for (Tier 1) generic drugs.

The prescription drug program is easy to use, with a huge network of pharmacies and a mail order service where medications

are delivered right to your door. The Plan’s prescription drug program provides savings and convenience for generic and

brand name drugs, and you never have to file a claim.

UnitedHealthcare Medicare Advantage (PPO)

We also offer the UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan for High Option retiree/annuitants

with primary Medicare Part A and B. Membership is voluntary and members may opt-in or out of this plan at any time.

Members have access to a nationwide PPO network and may seek care within the network or out-of-network. Members that

join will have access to certain benefit enhancements that are noted in Section 9.

Special features

Obtaining help from a medical professional is quick, confidential, and free with the Plan’s voluntary 24-hour NurseLine,

available anywhere in the country. Online access to claims information is available through the APWU Health Plan Member

Portal. We help members navigate the healthcare system with an online Preferred Provider Organization (PPO) directory,

Hospital Quality Ratings Guide, Treatment Cost Estimator, and prescription drug information. We also offer online tools and

resources.

34 2024 APWU Health Plan High Option Section 5 Overview

Section 5 (a). Medical Services and Supplies Provided by Physicians and Other

Healthcare Professionals

High Option

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in

this brochure and are payable only when we determine they are medically necessary.

•The calendar year deductible is: PPO - $450 per person ($800 per Self Plus One enrollment, or

$800 per Self and Family enrollment); non-PPO - $1,000 per person ($2,000 per Self Plus One

enrollment, or $2,000 per Self and Family enrollment). The calendar year deductible applies to

almost all benefits in this Section. We added “(No deductible)” to show when the calendar year

deductible does not apply.

•The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you

use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how

cost-sharing works. Also, read Section 9 for information about how we pay if you have other

coverage, or if you are age 65 or over.

•YOU MUST GET PRECERTIFICATION FOR CERTAIN OUTPATIENT

IMAGING PROCEDURES.FAILURE TO DO SO WILL RESULT IN A MINIMUM OF A

$100 PENALTY. Please refer to precertification information in Section 3 to be sure which

procedures require precertification.

•If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is

primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our

FEHB members. This plan enhances your FEHB coverage by reducing/eliminating cost-sharing for

services and/or adding benefits at no additional cost. This would be an enhancement to your APWU

Health Plan's High Option benefits. It includes an $85 monthly Part B reimbursement. The

UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.

(See Section 9 for additional details.)

•The coverage and cost-sharing listed below are for services provided by physicians and other

healthcare professionals for your medical care. See Section 5(c) for cost-sharing associated with the

facility (i.e., hospital, surgical center, etc.).

Benefit Description You Pay

After the calendar year deductible...

Note: The calendar year deductible applies to almost all benefits in this Section. We say "(No deductible)" when it

does not apply.

Diagnostic and treatment services High Option

Professional services of physicians

• In physician’s office *

* Professional services of a physician via Telehealth/Telemedicine are

covered the same as in a physician's office.

PPO: $25 copayment (No deductible)

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Professional services of physicians

• During a hospital stay

• In a skilled nursing facility

• Second surgical opinion

• At home

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

• At Cancer Centers of Excellence PPO Cancer Center of Excellence (COE): 5%

of the Plan allowance

Diagnostic and treatment services - continued on next page

35 2024 APWU Health Plan High Option Section 5(a)

High Option

Benefit Description You Pay

After the calendar year deductible...

Diagnostic and treatment services (cont.) High Option

Note: To receive the higher level of benefits for cancer related

treatment, you are required to visit a designated Cancer Center of

Excellence facility.

PPO Cancer Center of Excellence (COE): 5%

of the Plan allowance

TeleHealth Services High Option

• Virtual visits are available through Teladoc

You can receive treatment from board-certified doctors for your non-

emergency conditions such as the flu, strep throat, eye infections,

bronchitis, and much more. Covered services include visits through the

web or your mobile device to obtain a consultation, diagnosis and

prescriptions (when appropriate). The service is available 24 hours a

day, 7 days a week.

Note: Telehealth services are available in most states, but some states do

not allow telehealth or prescriptions per state regulations.

Please visit www.teladoc.com, or call 800-835-2362 for information on

virtual visits

Note: There are no out-of-network benefits for Virtual visits.

Teladoc: $10 copayment (No deductible)

Lab, X-ray and other diagnostic tests High Option

Tests, such as:

• Blood tests

• Urinalysis

• Non-routine Pap test

• Pathology

• X-ray

• Non-routine mammogram, including 3D mammogram

• CT/CAT Scan/MRI/MRA/NC/PET (Outpatient requires

precertification – see Section 3, except for NC)

• Ultrasound

• Electrocardiogram and EEG

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Note: If your PPO provider uses a non-PPO lab

or radiologist, we will pay non-PPO benefits

for lab and X-ray charges billed by these non-

PPO providers.

If LabCorp or Quest Diagnostics performs your covered lab services,

you will have no out-of-pocket expense and you will not have to file a

claim. To find a location near you, in all states, call APWU Health Plan

at 800-222-2798 or visit our website at www.apwuhp.com.

Note: Not available in the U.S. Virgin Islands.

Nothing (No deductible)

Not covered:

•

Professional fees for automated lab tests

•

Genetic screening (see Definition, Section 10)

•

Qualitative (definitive) urine drug panel testing that is not medically

necessary

All charges

36 2024 APWU Health Plan High Option Section 5(a)

High Option

Benefit Description You Pay

After the calendar year deductible...

Preventive care, adult High Option

Routine physical every calendar year.

The following preventive services are covered at the time interval

recommended at each of the links below:

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/

Tdap, and human papillomavirus (HPV). For a complete list of

immunizations go to the Centers for Disease Control (CDC) website

at: www.cdc.gov/vaccines

• Screenings such as cancer, osteoporosis, depression, diabetes, high

blood pressure, total blood cholesterol, HIV, and colorectal cancer

screening. Preventive medications with a USPSTF recommendation

of A or B are covered without cost-share when prescribed by a

healthcare professional and filled by a network pharmacy. For a

complete list of screenings go to the U.S. Preventive Services Task

Force (USPSTF) website at: https://www.

uspreventiveservicestaskforce.org/uspstf/recommendation-topics/

uspstf-a-and-b-recommendations

• Individual counseling on prevention and reducing health risks

• Preventive care benefits for women such as Pap smears, gonorrhea

prophylactic medication to protect newborns, annual counseling for

sexually transmitted infections, contraceptive methods, and screening

for interpersonal and domestic violence. For a complete list of

preventive care benefits for women go to the Health and Human

Services (HHS) website at: https://www.healthcare.gov/preventive-

care-women/

• Routine Prostate Specific Antigen (PSA) test, one annually for men

age 40 and older

• Urinalysis

• Routine Electrocardiogram (EKG)

• Chest X-ray

• Hemoglobin A1C, age 18 and above

• At home Colorectal Cancer Screening Cologuard Kit provided

through Exact Sciences Laboratories, every three years starting at age

45, prescription needed from physician

• Medical Nutrition Therapy and Intensive Behavioral Therapy for the

prevention of obesity-related comorbidities as recommended under

the U.S. Preventive Services Task Force (USPSTF) A and B

recommendations

PPO: Nothing (No deductible)

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

• Routine mammogram - covered for women, including 3D

mammograms covered for women age 35 and older; as follows:

- From age 35 through 39, one during this five year period

- From age 40, one every calendar year

• To build your personalized list of preventive services go to https://

health.gov/myhealthfinder

PPO: Nothing (No deductible)

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

• Adult immunizations endorsed by the Centers for Disease Control and

Prevention (CDC): based on the Advisory Committee on

Immunization Practices (ACIP) schedule.

PPO: Nothing (No deductible)

Preventive care, adult - continued on next page

37 2024 APWU Health Plan High Option Section 5(a)

High Option

Benefit Description You Pay

After the calendar year deductible...

Preventive care, adult (cont.) High Option

Note: For immunizations at a network pharmacy, (see Section 5(f),

Prescription drug benefits).

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray

service done in conjunction with a routine examination and is not

included in the preventive recommended listing of services will be

subject to the applicable member copayments, coinsurance, and

deductible.

PPO: Nothing (No deductible)

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Preventive care, children High Option

• Well-child visits, examinations, and other preventive services as

described in the Bright Future Guidelines provided by the American

Academy of Pediatrics. For a complete list of the American Academy

of Pediatrics Bright Futures Guidelines go to: https://brightfutures.

aap.org

• Immunizations such as DTaP/Tdap, Polio, Measles, Mumps, and

Rubella (MMR), and Varicella. For a complete list of immunizations

go to the Centers for Disease Control (CDC) website at: www.cdc.

gov/vaccines/schedules/index.html

• You may also find a complete list of preventive care services

recommended under the U.S. Preventive Services Task force

(USPSTF) online at: https://www.uspreventiveservicestaskforce.org/

uspstf/recommendation-topics/uspstf-a-and-b-recommendations

PPO: Nothing (No deductible)

Non-PPO: Any difference between the Plan

allowance and the billed charge (No

deductible)

• Examinations, limited to:

- Examinations for amblyopia and strabismus - limited to one

screening examination (ages 3 through 5)

- Examinations done on the day of immunizations (ages 3 through

21)

- One Screening Examination of Premature Infants for Retinopathy

of Prematurity or infants with low birth weight or gestational age of

32 weeks or less

• To build your personalized list of preventive services go to https://

health.gov/myhealthfinder

Note: In-network facility and lab services directly related to covered, in-

network preventive care will also be covered at 100%.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray

service done in conjunction with a routine examination and is not

included in the preventive recommended listing of services will be

subject to the applicable member copayments, coinsurance, and

deductible.

PPO: Nothing (No deductible)

Non-PPO: Any difference between the Plan

allowance and the billed charge and any

amount above $250 per child (ages 0 through

3) each year and any amount above $150 per

child (ages 4 through 18) each year (No

deductible)

Not covered:

•

Adult immunizations not endorsed by the CDC

•

Physical exams required for obtaining or continuing employment or

insurance, attending schools or camp, athletic exams, or travel

•

Immunizations, boosters, and medications for travel or work-related

exposure

All charges

38 2024 APWU Health Plan High Option Section 5(a)

High Option

Benefit Description You Pay

After the calendar year deductible...

Maternity care High Option

Complete maternity (obstetrical) care, such as:

• Screening for gestational diabetes

• Prenatal and postpartum care

• Delivery

• Initial examination of a newborn child covered under a Self Plus One

or Self and Family enrollment

• Breastfeeding support, supplies and counseling for each birth

• Screening and counseling for prenatal and postpartum depression

Note: Maternity care expenses incurred by a Plan member serving as a

surrogate mother are covered by the Plan subject to reimbursement from

the other party to the surrogacy contract or agreement. The involved

Plan member must execute our Reimbursement Agreement completed

by APWU Health Plan against any payment they may receive under the

surrogacy contract or agreement. Expenses of the newborn child are not

covered under this or any other benefit in a surrogate mother situation.

Note - Here are some things to keep in mind:

• You do not need to precertify your vaginal or cesarean delivery; see

Section 3, page 23 for other circumstances, such as extended stays for

you or your baby.

• You may remain in the hospital up to 48 hours after a vaginal delivery

and 96 hours after a cesarean delivery.

• We cover routine nursery care of the newborn child during the

covered portion of the mother's maternity stay.

• We pay hospitalization and surgeon services for non-maternity care,

as well as covering an extended stay, if medically necessary, the same

as for illness and injury.

• Hospital services are covered under Section 5(c) and Surgical benefits

Section 5(b).

Note: When a newborn requires definitive treatment during or after the

mother's confinement, the newborn is considered a patient in their own

right. If the newborn is eligible for coverage, regular medical or surgical

benefits apply rather than maternity benefits.

PPO: Nothing (No deductible)

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Note: For inpatient hospital care related to

maternity, we pay for covered services in full

when you use preferred providers.

Note: In-network facility and lab services

directly related to covered, in-network

maternity care will also be covered at 100%.

Note: For Non-PPO inpatient hospital, a $300

per admission fee applies.

• We will cover other care of an infant who requires non-routine

treatment if we cover the infant under a Self Plus One or Self and

Family enrollment. Surgical benefits, not maternity benefits, apply to

circumcision of a covered newborn.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Not covered:

•

Amniocentesis if for diagnosing multiple births

•

Genetic screening (see Definitions, Section 10)

All charges

39 2024 APWU Health Plan High Option Section 5(a)

High Option

Benefit Description You Pay

After the calendar year deductible...

Family Planning High Option

Contraceptive counseling on an annual basis

Note: If you have concerns about the Health Plan’s compliance with the

ACA/HRSA requirements contact [email protected]. See OPM’s

web page about contraception.

PPO: Nothing (No deductible)

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

A range of voluntary family planning services, limited to:

• Tubal ligation and tubal implant procedures

• Surgically implanted contraceptives

• Injectable contraceptive drugs (such as Depo Provera)

• Intrauterine devices (IUDs)

• Diaphragms

Note: We cover oral contraceptives under Section 5(f),

Prescription drug

benefits

PPO: Nothing (No deductible)

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

• Voluntary vasectomy (see

Surgical

procedures

, Section 5(b)) PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Not covered:

•

Reversal of voluntary surgical sterilization

•

Genetic testing and counseling

All charges

Infertility services High Option

Diagnosis and treatment of infertility specific to, except as shown in

Not

covered,

see Section 10,

Definitions

• Artificial insemination (AI):

- Intravaginal insemination (IVI),

- Intracervical insemination (ICI)

- Intrauterine insemination (IUI)

• Infertility medications, including IVF related drugs. See Section 5(f),

Prescription drug benefits.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance

• Iatrogenic fertility preservation procedures (retrieval of and freezing

of eggs or sperm) caused by chemotherapy, pelvic radiotherapy, ovary

or testicle removal and other gonadotoxic therapies for the treatment

of disease and gender reassignment.

Note: Fertility preservation procedures require prior approval (see

Section 3,

Other services

Limited benefits: $12,000 lifetime maximum.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance

Infertility services - continued on next page

40 2024 APWU Health Plan High Option Section 5(a)

High Option

Benefit Description You Pay

After the calendar year deductible...

Infertility services (cont.) High Option

Not covered:

•

Infertility services after voluntary sterilization

•

Assisted reproductive technology (ART) procedures, such as:

In vitro fertilization (IVF) (excluding IVF drugs)

Embryo transfer and gamete intra-fallopian transfer (GIFT) and

zygote intra-fallopian transfer (ZIFT)

•

Services and supplies related to ART procedures

•

Cost of donor sperm

•

Cost of donor egg

All charges

Allergy care High Option

• Testing and treatment, including materials (such as allergy serum)

• Allergy injections

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Not covered:

•

Provocative food testing

•

Sublingual allergy desensitization

All charges

Treatment therapies High Option

• Chemotherapy and radiation therapy (preauthorization required by

UnitedHealthcare)

Note: High dose chemotherapy in association with autologous bone

marrow transplants is limited to those transplants listed in Section 5(b).

• Dialysis – hemodialysis and peritoneal dialysis

• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy

• Specialty drugs administered on an outpatient basis

Note: For Specialty drugs, you or your prescriber must contact Accredo

at 844-581-4862 to ask if a specialty medication you are receiving from

the physician's office or outpatient setting must be obtained through

Accredo Specialty Pharmacy. If the drugs are obtained through Accredo

Specialty Pharmacy, they will be paid at the in-network prescription

drug benefit, (see Section 5(f),

Prescription drug benefits

). If your

specialty medication is available through Accredo Specialty Pharmacy

and you do not obtain your medication through Accredo Specialty

Pharmacy, you will be responsible for the full cost of your medication.

• Respiratory and inhalation therapies

• Cardiac rehabilitation following qualifying event/condition

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

• Medical food formulas ordered by a healthcare provider that are

medically necessary to treat specific nutritional risks, including

Phenylketonuria (PKU) and other inborn errors of metabolism (IEM).

Limited benefits: We pay a maximum of $2,500 for each calendar year.

PPO: 15% of the Plan allowance and all

charges after we pay $2,500 in a calendar year

Non-PPO: 40% of the Plan allowance and all

charges after we pay $2,500 in a calendar year

Treatment therapies - continued on next page

41 2024 APWU Health Plan High Option Section 5(a)

High Option

Benefit Description You Pay

After the calendar year deductible...

Treatment therapies (cont.) High Option

• Gene Therapy: Curative gene therapy for rare genetic conditions

Note: Preauthorization of gene therapy is required, (see

Other services

Section 3)

PPO: 15% of the Plan allowance

Non-PPO: All charges

Not covered:

•

Medical foods for conditions other than permanent inborn errors of

metabolism.

All charges

Physical and occupational therapies High Option

Physical therapy and occupational therapy provided by a licensed

registered therapist or physician up to a combined 60 visits per calendar

year

Note: We also have the right to deny any type of therapy, service or

supply for the treatment of a condition which ceases to be therapeutic

treatment and is instead administered to maintain a level of functioning

or to prevent a medical problem from occurring or recurring.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Not covered:

•

Maintenance therapies

•

Exercise programs

All charges

Applied behavioral analysis (ABA) High Option

Outpatient Applied Behavioral Analysis (ABA) services, for the

treatment of Autism Spectrum Disorder. Services must be provided

under the supervision of a Board Certified Behavior Analyst who is

contracted with UnitedHealthcare Behavioral Health, or agrees to

participate with UnitedHealthcare Behavioral Health's care management

activities. Preauthorization required by UnitedHealthcare

Behavioral Health.

Note: UnitedHealthcare Behavioral Health's review of ABA services is

based on an intensive care management model that monitors treatment

plans, objectives, and progress milestones.

We have the right to deny services for treatment when outcomes do not

meet the defined treatment plan objectives and milestones.

PPO: 15% of the Plan allowance

Non-PPO: All charges

Speech therapy High Option

Speech therapy where medically necessary and provided by a licensed

therapist

Note: Speech therapy is combined with 60 visits per calendar year for

the services of physical therapy and/or occupational therapy (see above).

Note: We also have the right to deny any type of therapy, service or

supply for the treatment of a condition which ceases to be therapeutic

treatment and is instead administered to maintain a level of functioning

or to prevent a medical problem from occurring or recurring.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

42 2024 APWU Health Plan High Option Section 5(a)

High Option

Benefit Description You Pay

After the calendar year deductible...

Hearing services (testing, treatment, and supplies) High Option

• For treatment related to illness or injury, including evaluation and

diagnostic hearing tests performed by an M.D., D.O., or audiologist

• One examination and testing for hearing aids every 2 years

Note: For routine hearing screening performed during a child's

preventive care visit, (see Section 5(a),

Preventive care, children

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

• External hearing aids

• Implanted hearing-related devices, such as bone anchored hearing

aids (BAHA) and cochlear implants for bilateral hearing loss

Note: For benefits for the devices see Section

5(a),

Orthopedic and prosthetic devices

Not covered:

•

Hearing services that are not shown as covered

All charges

Vision services (testing, treatment, and supplies) High Option

• Internal (implant) ocular lenses and/or the first contact lenses required

to correct an impairment caused by accident or illness. Services are

limited to the testing, evaluation and fitting of the first contact lenses

required to correct an impairment caused by accident or illness

Note: See Section 5(a),

Preventive care

children

, for eye exams for

children.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Not covered:

•

Eyeglasses or contact lenses and examinations for them

•

Eye exercises and visual training

•

Radial keratotomy and other refractive surgery

•

Refraction

All charges

Foot care High Option

Routine foot care when you are under active treatment for a metabolic

or peripheral vascular disease, such as diabetes

PPO: $25 copayment for the office visit (No

deductible) plus 15% of the Plan allowance for

other services performed during the visit

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Not covered:

•

Cutting, trimming or removal of corns, calluses, or the free edge of

toenails, and similar routine treatment of conditions of the foot,

except as stated above

•

Treatment of weak, strained or flat feet or bunions or spurs; and of

any instability, imbalance or subluxation of the foot (unless the

treatment is by open cutting surgery)

All charges

43 2024 APWU Health Plan High Option Section 5(a)

High Option

Benefit Description You Pay

After the calendar year deductible...

Orthopedic and prosthetic devices High Option

• Artificial limbs and eyes

• Prosthetic sleeve or sock

• Externally worn breast prostheses and surgical bras, including

necessary replacements following a mastectomy

• Leg, arm, neck, joint and back braces

• Implanted hearing-related devices, such as bone anchored hearing

aids (BAHA) and cochlear implants for bilateral hearing loss

• Internal prosthetic devices, and surgically implanted breast implant

following mastectomy

Note: We recommend preauthorization of orthopedic and prosthetic

devices, (see

Other services

, Section 3).

Note: We require preauthorization of artificial limbs, (see

Other

services

, Section 3).

Note: For information on the professional charges for the surgery to

insert an implant, see Section 5(b),

Surgical procedures

. For information

on the hospital and/or ambulatory surgery center benefits see Section 5

(c),

Services provided by a hospital or other facility, and ambulance

services

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

External hearing aids

• Covered every 3 years limited to $1,500

Note: Excluding batteries, benefits for hearing aid dispensing fees,

accessories, supplies, and repair service are included in the benefit limit

described above.

See Section 5h,

Wellness and Other Special Features

, for information on

UnitedHealthcare Hearing.

PPO: All charges in excess of $1,500, up to the

PPO allowance (No deductible)

Non-PPO: All charges in excess of $1,500 (No

deductible)

Not covered:

•

Orthopedic and corrective shoes, arch supports, foot orthotics, heel

pads and heel cups

•

Lumbosacral supports

•

Corsets, trusses, elastic stockings, support hose, and other supportive

devices

All charges

Durable medical equipment (DME) High Option

Durable medical equipment (DME) is equipment and supplies that:

1. Are prescribed by your attending physician (i.e., the physician who is

treating your illness or injury)

2. Are medically necessary

3. Are primarily and customarily used only for a medical purpose

4. Are generally useful only to a person with an illness or injury

5. Are designed for prolonged use; and

6. Serve a specific therapeutic purpose in the treatment of an illness or

injury

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Durable medical equipment (DME) - continued on next page

44 2024 APWU Health Plan High Option Section 5(a)

High Option

Benefit Description You Pay

After the calendar year deductible...

Durable medical equipment (DME) (cont.) High Option

We cover rental or purchase, of durable medical equipment, at our

option, including repair and adjustment. Covered items include but are

not limited to:

• Oxygen

• Dialysis equipment

• Hospital beds

• Wheelchairs (standard and electric)

• Ostomy supplies (including supplies purchased at a pharmacy)

• Crutches

• Walkers

Note: Preauthorization of durable medical equipment is required, (see

Other services

, Section 3).

Note: We will pay only for the cost of the standard item. Coverage for

specialty equipment, such as all-terrain wheelchairs, is limited to the

cost of the standard equipment.

Note: We limit the Plan allowance for DME rental benefit to an amount

no greater than what we would have considered if the equipment had

been purchased.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Not covered :

•

Whirlpool equipment

•

Sun and heat lamps

•

Light boxes

•

Heating pads

•

Exercise devices

•

Stair glides

•

Elevators

•

Air Purifiers

•

Computer “story boards,” “light talkers,” or other communication aids

for communication-impaired individuals

All charges

Home health services High Option

Services for skilled nursing care up to 50 visits per calendar year, not to

exceed two hours per day; and

• a registered nurse (R.N.), licensed practical nurse (L.P.N.) or licensed

vocational nurse (L.V.N.) provides the services;

• the attending physician orders the care;

• the physician identifies the specific professional skills required by the

patient and the medical necessity for skilled services; and

• the physician indicates the length of time the services are needed

PPO: 15%; all charges in excess of two hours

Non-PPO: 40%; all charges in excess of two

hours

Home health services - continued on next page

45 2024 APWU Health Plan High Option Section 5(a)

High Option

Benefit Description You Pay

After the calendar year deductible...

Home health services (cont.) High Option

Not covered:

•

Nursing care requested by, or for the convenience of, the patient or the

patient’s family

•

Home care primarily for personal assistance that does not include a

medical component and is not diagnostic, therapeutic, rehabilitative,

or habilitative

•

Nursing services without preauthorization

•

Services of nurses' aides or home health aides

•

All charges in excess of two hours

All charges

Chiropractic High Option

• Chiropractic treatment limited to 24 visits and/or manipulations per

year

Note: X-ray covered under Section 5(a),

Lab, X-ray and other

diagnostic tests

PPO: $25 copayment (No deductible)

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount.

Not covered:

•

Massage therapy

•

Maintenance therapy

All charges

Alternative treatments High Option

• Acupuncture - by a doctor of medicine or osteopathy, or licensed or

certified acupuncture practitioner, benefits are limited to 26 visits per

person per calendar year

• Dry Needling – by a licensed or certified practitioner

PPO: $25 copayment (No deductible)

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Not covered:

•

Services of any provider not listed as covered (see Covered

providers, Section 3)

All charges

Educational classes and programs High Option

You may enroll in Quit For Life, a tobacco cessation program, by

visiting www.quitnow.net for:

• Telephonic and/or online counseling sessions

• Group therapy sessions

Note: Enrollment in the Quit For Life program must be initiated by the

member.

PPO: Nothing (No deductible)

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Select over-the-counter and prescription Tobacco Cessation medications

approved by the FDA to treat tobacco dependence. For a listing of

medications go to our website at:

https://www.apwuhp.com/members/high-option/pharmacy/

To qualify for these drugs, you need to be age 18 or older; get a

prescription for these products from your doctor, even if the products are

sold over-the-counter; fill the prescription at a network pharmacy.

PPO: Nothing (No deductible)

Non-PPO:

All charges

Educational classes and programs - continued on next page

46 2024 APWU Health Plan High Option Section 5(a)

High Option

Benefit Description You Pay

After the calendar year deductible...

Educational classes and programs (cont.) High Option

Multicomponent, family centered programs focused on childhood

obesity that are part of intensive behavioral interventions (behavior

change counseling for healthy diet and physical activity)

PPO: Nothing (No deductible)

Non-PPO: Nothing (No deductible)

Diabetes self-management training services, up to 10 hours initial

training the first year and 2 hours subsequent training annually.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

47 2024 APWU Health Plan High Option Section 5(a)

Section 5 (b). Surgical and Anesthesia Services

Provided by Physicians and Other Healthcare Professionals

High Option

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•The calendar year deductible is: PPO - $450 per person ($800 per Self Plus One enrollment, or $800

per Self and Family enrollment); Non-PPO - $1,000 per person ($2,000 per Self Plus One

enrollment, or $2,000 per Self and Family enrollment). The calendar year deductible applies to

almost all benefits in this Section. We added “(No deductible)” to show when the calendar year

deductible does not apply.

•The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use

a PPO provider. When no PPO provider is available, non-PPO benefits apply.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how

cost-sharing works. Also, read Section 9 for information about how we pay if you have other

coverage, or if you are age 65 or over.

•YOU MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please

refer to the precertification information shown in Section 3 to be sure which services require

precertification.

•If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is

primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our

FEHB members. This plan enhances your FEHB coverage by reducing/eliminating cost-sharing for

services and/or adding benefits at no additional cost. This would be an enhancement to your APWU

Health Plan's High Option benefits. It includes an $85 monthly Part B reimbursement. The

UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.

(See Section 9 for additional details.)

Benefit Description You Pay

After the calendar year deductible…

Note: The calendar year deductible applies to almost all benefits in this Section. We say “(No deductible)” when it

does not apply.

Surgical procedures High Option

A comprehensive range of services, such as:

• Operative procedures

• Treatment of fractures, including casting

• Normal pre- and post-operative care by the surgeon

• Correction of amblyopia and strabismus

• Endoscopy procedures

• Biopsy procedures

• Removal of tumors and cysts

• Correction of congenital anomalies (see

Reconstructive surgery

)

• Surgical treatment of severe obesity (bariatric surgery) (requires

preauthorization, see

Other services

, Section 3)

• Insertion of internal prosthetic devices (see Section 5(a),

Orthopedic

and prosthetic devices ,

for device coverage information)

• Voluntary vasectomy

• Treatment of burns

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Surgical procedures - continued on next page

48 2024 APWU Health Plan High Option Section 5(b)

High Option

Benefit Description You Pay

After the calendar year deductible…

Surgical procedures (cont.) High Option

• Assistant surgeons - We cover up to 20% of our allowance for the

surgeon’s charge

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

• Tubal ligation and tubal implant procedures

• Surgical implanted contraceptives

• Intrauterine devices (IUDs)

PPO: Nothing (No deductible)

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

When multiple or bilateral surgical procedures performed during the

same operative session add time or complexity to patient care, our

benefits are:

• For the primary procedure:

- PPO: 85% of the Plan allowance; or

- Non-PPO: 60% of the Plan allowance

• For the secondary procedure(s):

- PPO: 85% of one-half of the Plan allowance or

- Non-PPO: 60% of one-half of the Plan allowance

Note: When multiple or bilateral surgical procedures add complexity to

an operative session, the Plan allowance for the second or less expensive

procedure is one-half of what the Plan allowance would have been if that

procedure had been performed independently.

• When a surgery requires two primary surgeons (co-surgeons), the Plan

allowance for each surgeon will not exceed 62.5% of our allowance.

This allowance will be further reduced by half for secondary

procedures.

• Multiple or bilateral surgical procedures performed through the same

incision are "incidental" to the primary surgery. That is, the procedure

would not add time or complexity to patient care. We do not pay

extra for incidental procedures.

PPO: 15% of the Plan allowance for the

primary procedure and 15% of one-half of the

Plan allowance for the secondary procedure(s)

Non-PPO: 40% of the Plan allowance for the

primary procedure and 40% of one-half of the

Plan allowance for the secondary procedure(s);

and any difference between our allowance and

the billed amount

Not covered:

•

Cosmetic surgery and other related expenses if not preauthorized

•

Reversal of voluntary sterilization

•

Services of a standby surgeon, except during angioplasty or other high

risk procedures when we determine standbys are medically necessary

•

Radial keratotomy and other refractive surgery

•

Routine treatment of conditions of the foot (see Foot care,

Section 5

(a))

All charges

49 2024 APWU Health Plan High Option Section 5(b)

High Option

Benefit Description You Pay

After the calendar year deductible…

Reconstructive surgery High Option

• Surgery to correct a functional defect

• Surgery to correct a condition caused by injury or illness if:

- The condition produced a major effect on the member’s appearance

and

- The condition can reasonably be expected to be corrected by such

surgery

• Surgery to correct a condition that existed at or from birth and is a

significant deviation from the common form or norm. Examples of

congenital anomalies are: protruding ear deformities; cleft lip; cleft

palate; birth marks (including port wine stains); and webbed fingers

and toes.

• All stages of breast reconstruction surgery following a mastectomy,

such as:

- Surgery to produce a symmetrical appearance of breasts

- Treatment of any physical complications, such as lymphedema

- Breast prostheses; and surgical bras and replacements, (see Section

5(a),

Prosthetic devices

, for coverage)

Note: We pay for internal breast prostheses as hospital benefits.

Note: If you need a mastectomy, you may choose to have the procedure

performed on an inpatient basis and remain in the hospital up to 48

hours after the procedure.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

• Surgical treatment for gender affirmation

• Gender affirming surgery benefits are only available for the diagnosis

of gender dysphoria

Requirements:

• Prior approval is required.

• Must be at least 18 years of age at time prior approval is requested

and treatment plan is submitted.

• Must have diagnosis of gender dysphoria by a qualified healthcare

professional.

• Persistent, well-documented gender dysphoria.

• Member’s gender dysphoria is not a symptom of another mental

disorder or chromosomal abnormality.

• Continuous hormone therapy as appropriate.

• Two clinical assessments from qualified healthcare professionals are

required for genital and gonadal surgeries, all other surgeries require

one assessment.

• If medical or mental health concerns are present, they are being

optimally managed and are reasonably well-controlled.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Not covered:

•

Cosmetic services that are not medically necessary

•

Travel and lodging

All charges

50 2024 APWU Health Plan High Option Section 5(b)

High Option

Benefit Description You Pay

After the calendar year deductible…

Oral and maxillofacial surgery High Option

Oral surgical procedures, limited to:

• Reduction of fractures of the jaw or facial bones

• Surgical correction of cleft lip, cleft palate or severe functional

malocclusion

• Removal of stones from salivary ducts

• Excision of leukoplakia or malignancies

• Excision of cysts and incision of abscesses when done as independent

procedures

• Other surgical procedures that do not involve the teeth or their

supporting structures

• Extraction of impacted (unerupted) teeth

• Alveoplasty, partial ostectomy and radical resection of mandible with

bone graft unrelated to tooth structure

• Excision of bony cysts of the jaw unrelated to tooth structure

• Excision of tori, tumors, and premalignant lesions, and biopsy of hard

and soft oral tissues

• Reduction of dislocations and excision, manipulation, arthrocentesis,

aspiration or injection of temporomandibular joints

• Removal of foreign body, skin, subcutaneous alveolar tissue, reaction-

producing foreign bodies in the musculoskeletal system and salivary

stones

• Incision/excision of salivary glands and ducts

• Repair of traumatic wounds

• Sinusotomy, including repair of oroantral and oromaxillary fistula

and/or root recovery

• Surgical treatment of trigeminal neuralgia

• Frenectomy or frenotomy, skin graft or vestibuloplasty-stomatoplasty

unrelated to periodontal disease

• Incision and drainage of cellulitis unrelated to tooth structure

Note: Call UnitedHealthcare at 866-569-2064 to determine if a

procedure is covered.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Not covered:

•

Oral implants and transplants

•

Procedures that involve the teeth or their supporting structures (such

as the periodontal membrane, gingiva and alveolar bone)

•

Dental bridges, replacement of natural teeth, dental/orthodontic/

temporomandibular joint dysfunction appliances and any related

expenses

•

Treatment of periodontal disease and gingival tissues, and abscesses

•

Charges related to orthodontic treatment

All charges

51 2024 APWU Health Plan High Option Section 5(b)

High Option

Benefit Description You Pay

After the calendar year deductible…

Organ/tissue transplants High Option

These solid organ transplants are subject to medical necessity and

experimental/investigational review by the Plan. Refer to

Other services

in Section 3, for prior authorization procedures.

Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near

total pancreatectomy) only for patients with chronic pancreatitis

• Cornea

• Heart

• Heart/lung

• Intestinal transplants

- Isolated small intestine

- Small intestine with the liver

- Small intestine with multiple organs, such as the liver, stomach, and

pancreas

• Kidney

• Kidney-pancreas

• Liver

• Lung single/bilateral/lobar

• Pancreas

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount and any amount over $50,000 for

kidney transplants or $100,000 for other listed

transplants

These tandem blood or marrow stem cell transplants for covered

transplants are subject to medical necessity review by the Plan. Refer

Other services

in Section 3, for prior authorization procedures.

• Autologous tandem transplants for

- AL Amyloidosis

- Multiple myeloma (de novo and treated)

- Recurrent germ cell tumors (including testicular cancer)

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount and any amount over $50,000 for

kidney transplants or $100,000 for other listed

transplants

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below:

• Allogeneic transplants for

- Acute lymphocytic or non-lymphocytic (i.e., myelogenous)

leukemia

- Acute myeloid leukemia

- Advanced Hodgkin's lymphoma with recurrence (relapsed)

- Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)

- Advanced Myeloproliferative Disorders (MPDs)

- Advanced neuroblastoma

- Amyloidosis

- Beta Thalassemia Major

- Chronic inflammatory demyelination polyneuropathy (CIDP)

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount and any amount over $50,000 for

kidney transplants or $100,000 for other listed

transplants

Organ/tissue transplants - continued on next page

52 2024 APWU Health Plan High Option Section 5(b)

High Option

Benefit Description You Pay

After the calendar year deductible…

Organ/tissue transplants (cont.) High Option

- Chronic lymphocytic leukemia/small lymphocytic lymphoma

(CLL/SLL)

- Early stage (indolent or non-advanced) small cell lymphocytic

lymphoma

- Hemoglobinopathy

- Infantile malignant osteopetrosis

- Kostmann's syndrome

- Leukocyte adhesion deficiencies

- Marrow failure and related disorders (i.e., Fanconi's Paroxysmal

Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)

- Mucolipidosis (e.g., Gaucher's disease, metachromatic

leukodystrophy, adrenoleukodystrophy)

- Mucopolysaccharidosis (e.g., Hunter's syndrome, Hurler's

syndrome, Sanfillippo's syndrome, Maroteaux-Lamy syndrome

variants)

- Multiple Myeloma

- Myelodysplasia/Myelodysplastic Syndromes

- Myeloproliferative disorders

- Paroxysmal Nocturnal Hemoglobinuria

- Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-

Aldrich syndrome)

- Severe combined immunodeficiency

- Severe or very severe aplastic anemia

- Sickle cell anemia (pediatric only)

- X-linked lymphoproliferative syndrome

• Autologous transplants for

- Acute lymphocytic or non-lymphocytic (i.e., myelogenous)

leukemia

- Advanced childhood kidney cancers

- Advanced Hodgkin's lymphoma with recurrence (relapsed)

- Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)

- Amyloidosis

- Aggressive non-Hodgkin's lymphomas

- Breast cancer

- Childhood rhabdomyosarcoma

- Ependymoblastoma

- Epithelial ovarian cancer

- Ewing's sarcoma

- Mantle cell (non-Hodgkin's lymphoma)

- Medulloblastoma

- Multiple myeloma

- Neuroblastoma

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount and any amount over $50,000 for

kidney transplants or $100,000 for other listed

transplants

Organ/tissue transplants - continued on next page

53 2024 APWU Health Plan High Option Section 5(b)

High Option

Benefit Description You Pay

After the calendar year deductible…

Organ/tissue transplants (cont.) High Option

- Pineoblastoma

- Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell

tumors

- Waldenstrom's macroglobulinemia

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount and any amount over $50,000 for

kidney transplants or $100,000 for other listed

transplants

Mini-transplants (non-myeloablative, reduced intensity conditioning or

RIC) are subject to medical necessity review by the Plan.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount and any amount over $50,000 for

kidney transplants or $100,000 for other listed

transplants

These blood or marrow stem cell transplants are covered only in a

National Cancer Institute or National Institutes of Health

approved clinical trial or a Plan-designated center of excellence.

If you are a participant in a clinical trial, the Plan will provide benefits

for related routine care that is medically necessary (such as doctor visits,

lab tests, X-rays and scans, and hospitalization related to treating the

patient's condition) if it is not provided by the clinical trial. Section 9

has additional information on costs related to clinical trials. We

encourage you to contact the Plan to discuss specific services if you

participate in a clinical trial.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount and any amount over $50,000 for

kidney transplants or $100,000 for other listed

transplants

Transplant Network

The Plan uses specific Plan-designated organ/tissue transplant facilities.

Before your initial evaluation as a potential candidate for a transplant

procedure, you or your doctor must contact the precertification vendor

(see

Other services

, Section 3); UnitedHealthcare at 866-569-2064; and

ask to speak to a Transplant Case Manager. You will be provided with

information about transplant preferred providers. If you choose a Plan-

designated transplant facility, you may receive prior approval for travel

and lodging costs.

Limited Benefits – If you don’t use a Plan-designated transplant facility,

benefits for pretransplant evaluation, organ procurement, inpatient

hospital, surgical and medical expenses for covered transplants, whether

incurred by the recipient or donor, are limited to a maximum of $50,000

for kidney transplants or $100,000 for each other listed transplant,

including multiple organ transplants.

Note: We cover related medical and hospital expenses of the donor

when we cover the recipient.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount and any amount over $50,000 for

kidney transplants or $100,000 for other listed

transplants

Organ/tissue transplants - continued on next page

54 2024 APWU Health Plan High Option Section 5(b)

High Option

Benefit Description You Pay

After the calendar year deductible…

Organ/tissue transplants (cont.) High Option

Not covered:

•

Donor screening tests and donor search expenses, except as shown

above

•

Transplants not listed as covered

All charges

Anesthesia High Option

Professional services for administration of anesthesia

Note: If surgical services are rendered at a PPO hospital or a PPO

freestanding ambulatory facility, we will pay the services of non-PPO

anesthesiologists at the PPO rate, based on Plan allowance.

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

55 2024 APWU Health Plan High Option Section 5(b)

Section 5 (c). Services Provided by a Hospital or Other Facility, and Ambulance

Services

High Option

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•In this Section, unlike Sections 5(a) and 5(b), the calendar year deductible applies to only a few

benefits. We added “(calendar year deductible applies)”. The calendar year deductible is: PPO -

$450 per person ($800 per Self Plus One enrollment, or $800 per Self and Family enrollment); Non-

PPO - $1,000 per person ($2,000 per Self Plus One enrollment, or $2,000 per Self and Family

enrollment).

•The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use

a PPO provider. When no PPO provider is available, non-PPO benefits apply.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how

cost-sharing works. Also, read Section 9 for information about how we pay if you have other

coverage, or if you are age 65 or over.

•The services listed below are for the charges billed by the facility (i.e. hospital or surgical center) or

ambulance service for your surgery or care. Any costs associated with the professional charge (i.e.

physicians, etc.) are in Sections 5(a) or (b).

•YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO

WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification

information shown in Section 3 to be sure which services require precertification.

•You must get prior approval for gender reassignment surgery. See Section 3 for prior approval and

Section 5(b) for the surgical benefit.

•When you receive hospital observation services, we apply outpatient benefits to covered services up

to 48 hours. Inpatient benefits will apply only when your physician formally admits you to the

hospital as inpatient. Once you are formally admitted, your entire stay (including observation

services) will be processed and paid as inpatient benefits.

•If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is

primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our

FEHB members. This plan enhances your FEHB coverage by reducing/eliminating cost-sharing for

services and/or adding benefits at no additional cost. This would be an enhancement to your APWU

Health Plan's High Option benefits. It includes an $85 monthly Part B reimbursement. The

UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.

(See Section 9 for additional details.)

Benefit Description You Pay

Note: The calendar year deductible applies ONLY when we say below: “(calendar year deductible applies).”

Inpatient hospital High Option

Room and board, such as:

• Ward, semiprivate, or intensive care accommodations

• General nursing care

• Meals and special diets

Note: We only cover a private room when you must be isolated to

prevent contagion. Otherwise, we will pay the hospital’s average charge

for semiprivate accommodations. If the hospital only has private rooms,

we will cover the private room rate.

PPO: 15% of the covered charges

Non-PPO: $300 per admission and 40% of the

covered charges and any difference between

our allowance and the billed amount

Note: For inpatient hospital care related to

maternity, we pay for covered services in full

when you use preferred providers, (see Section

5(a)

, Maternity care

Inpatient hospital - continued on next page

56 2024 APWU Health Plan High Option Section 5(c)

High Option

Benefit Description You Pay

Inpatient hospital (cont.) High Option

Note: When the non-PPO hospital bills a flat rate, we prorate the charges

to determine how to pay them, as follows: 30% room and board and

70% other charges.

PPO: 15% of the covered charges

Non-PPO: $300 per admission and 40% of the

covered charges and any difference between

our allowance and the billed amount

Note: For inpatient hospital care related to

maternity, we pay for covered services in full

when you use preferred providers, (see Section

5(a)

, Maternity care

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms

• Prescribed drugs and medications

• Diagnostic laboratory tests and X-rays

• Blood or blood plasma, if not donated or replaced

• Dressings, splints, casts, and sterile tray services

• Medical supplies and equipment, including oxygen

• Anesthetics, including nurse anesthetist services

Note: We cover appliances, medical equipment and medical supplies

provided for take-home use under Section 5(a). We cover prescription

drugs and medicines dispensed for take-home use under Section 5(f).

Note: We base payment on whether the facility or a healthcare

professional bills for the services or supplies. For example, when the

hospital bills for its nurse anesthetists’ services, we pay Hospital benefits

and when the anesthesiologist bills, we pay Surgery benefits.

PPO: 15% of the covered charges

Non-PPO: $300 per admission and 40% of the

covered charges and any difference between

our allowance and the billed amount.

Note: For inpatient hospital care related to

maternity, we pay for covered services in full

when you use preferred providers, (see Section

5(a)

, Maternity care

Not covered:

•

Any part of a hospital admission that is not medically necessary (see

Section 10, Definitions), such as when you do not need acute hospital

inpatient (overnight) care, but could receive care in some other setting

without adversely affecting your condition or the quality of your

medical care. Note: In this event, we pay benefits for services and

supplies other than room and board and in-hospital physician care at

the level they would have been covered if provided in an alternative

setting

•

Custodial care; (see Section 10, Definitions)

•

Non-covered facilities, such as, day and evening care centers, and

schools

•

Personal comfort items such as radio, television, air conditioners,

beauty and barber services, guest meals and beds

•

Services of a private duty nurse that would normally be provided by

hospital nursing staff

All charges

57 2024 APWU Health Plan High Option Section 5(c)

High Option

Benefit Description You Pay

Cancer Centers of Excellence High Option

The Plan provides access to designated Cancer Centers of Excellence.

For information, you must contact UnitedHealthcare at 866-569-2064

prior to obtaining covered services. To receive the higher level of

benefits for a cancer related treatment, you are required to visit a

designated facility.

When you contact UnitedHealthcare, you will be provided with

information about the Cancer Centers of Excellence.

PPO Cancer Centers of Excellence (COE): 5%

of the Plan allowance

Outpatient hospital or ambulatory surgical center High Option

• Operating, recovery, and other treatment rooms

• Prescribed drugs and medications

• Diagnostic laboratory tests, X-rays, and pathology services

• Administration of blood, blood plasma, and other biologicals

• Blood and blood plasma, if not donated or replaced

• Pre-surgical testing

• Dressings, casts, and sterile tray services

• Medical supplies, including oxygen

• Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental

procedures when necessitated by an underlying medical condition. We

do not cover the dental procedures.

Note: We cover outpatient services and supplies of a hospital or free-

standing ambulatory facility the day of a surgical procedure (including

change of cast), hemophilia treatment, hyperalimentation, rabies shots,

cast or suture removal, oral surgery, foot treatment, chemotherapy for

treatment of cancer, and radiation therapy.

PPO: 15% of the Plan allowance (calendar year

deductible applies)

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount (calendar year deductible

applies)

Extended care benefits/Skilled nursing care facility

benefits

High Option

When APWU Health Plan is Primary

Semiprivate room, board, services and supplies provided in a skilled

nursing care facility (SNF) for up to 30 days per person per calendar

year when you are admitted directly from a covered inpatient hospital

stay.

Note: Prior approval for these services is required. Call

UnitedHealthcare at 866-569-2064, (see

Other services

, Section 3).

When Medicare A or Other Insurance is Primary

Semiprivate room, board, services and supplies provided in a skilled

nursing care facility (SNF) for up to 30 days per person per calendar

year when you are admitted directly from a covered inpatient hospital

stay.

Note: If Medicare pays the first 20 days in full, Plan benefits will begin

on the 21

day (when Medicare Part A coinsurance begins) and will end

on the 30

day.

PPO: 15% of the covered charges

Non-PPO: $300 per admission and 40% of the

covered charges and any difference between

our allowance and the billed amount

Note: If enrolled in Medicare A, we waive the

deductible and coinsurance.

Extended care benefits/Skilled nursing care facility benefits - continued on next page

58 2024 APWU Health Plan High Option Section 5(c)

High Option

Benefit Description You Pay

Extended care benefits/Skilled nursing care facility

benefits (cont.)

High Option

Not covered:

•

Custodial care (see Section 10, Definitions)

•

All charges after 30 days per person per calendar year

All charges

Hospice care High Option

Hospice is a coordinated program of home and inpatient supportive care

for the terminally ill patient and the patient’s family provided by a

medically supervised specialized team under the direction of a duly

licensed or certified Hospice Care Program.

• We pay up to $15,000 lifetime maximum for combined outpatient and

inpatient services, which includes advance care planning

• We pay a $200 annual bereavement benefit per family unit

Any amount over the maximums shown

End of life care High Option

End of life care

• See

Hospice care

benefit, which includes advance care planning, (see

above).

Any amount over the maximums shown

Ambulance High Option

• Local professional ambulance service when medically appropriate

immediately before, during or after an inpatient admission

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Not covered:

•

Ambulance service used for routine transport

All charges

59 2024 APWU Health Plan High Option Section 5(c)

Section 5 (d). Emergency Services/Accidents

High Option

Important things to keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•The calendar year deductible is: PPO - $450 per person ($800 per Self Plus One enrollment, or $800

per Self and Family enrollment); Non-PPO - $1,000 per person ($2,000 per Self Plus One

enrollment, or $2,000 per Self and Family enrollment). The calendar year deductible applies to

almost all benefits in this Section. We added “(No deductible)” to show when the calendar year

deductible does not apply.

•The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use

a PPO provider. When no PPO provider is available, non-PPO benefits apply.

•When you use a PPO hospital for emergency services, the emergency room physician who provides

the services to you in the emergency room may not be a preferred provider. If they are not, they will

be paid by this Plan as a PPO provider at the PPO rate, based on the Plan allowance.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how

cost-sharing works. Also, read Section 9 for information about how we pay if you have other

coverage, or if you are age 65 or over.

•When multiple or bilateral surgical procedures add complexity to an operative session, the Plan

allowance for the second or less expensive procedure is one-half of what the Plan allowance would

have been if that procedure had been performed independently.

- When a surgery requires two primary surgeons (co-surgeons), the Plan allowance for each

surgeon will not exceed 62.5% of our allowance. This allowance will be further reduced by half

for secondary procedures.

- Multiple or bilateral surgical procedures performed through the same incision are "incidental" to

the primary surgery. That is, the procedure would not add time or complexity to patient care. We

do not pay extra for incidental procedures.

•If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is

primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our

FEHB members. This plan enhances your FEHB coverage by reducing/eliminating cost-sharing for

services and/or adding benefits at no additional cost. This would be an enhancement to your APWU

Health Plan's High Option benefits. It includes an $85 monthly Part B reimbursement. The

UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.

(See Section 9 for additional details.)

What is an accidental injury?

An accidental injury is a bodily injury sustained solely through violent, external, and accidental means, such as broken bones,

animal bites, and poisonings.

What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or

could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies

because, if not treated promptly, they might become more serious; examples include deep cuts, broken bones and mental

health related care. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes,

poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are

medical emergencies – what they all have in common is the need for quick action. If you are unsure of the severity of a

condition in terms of this benefit, the Plan recommends that you first call UnitedHealthcare's 24-hour NurseLine

at 866-569-2064, or your physician.

60 2024 APWU Health Plan High Option Section 5(d)

High Option

Benefit Description You Pay

After the calendar year deductible…

Note: The calendar year deductible applies to almost all benefits in this Section. We say "(No deductible)" when it

does not apply.

Accidental injury High Option

If you receive care for your accidental injury within 72 hours, we cover:

• Physician services and supplies

• Related outpatient hospital services

• Air ambulance to nearest facility where necessary treatment is

available is covered if no emergency ground transportation is

available or suitable and the patient's condition warrants immediate

evacuation. Air ambulance will not be covered if transport is beyond

the nearest available suitable facility, but is requested by patient or

physician for continuity of care or other reasons

Note: See Section 5(c) for hospital benefits if you are admitted.

Services received after 72 hours are considered the same as any other

illness and regular Plan benefits will apply.

PPO: Nothing (No deductible)

Non-PPO: Nothing (No deductible)

If you receive care for your accidental injury within 72 hours, we cover:

• Professional Ambulance Services

PPO: Nothing

Non-PPO: Only the difference between our

allowance and the billed amount (No

deductible)

Medical emergency High Option

Outpatient facility charges including medical or surgical services and

supplies in an Urgent Care Center

Note: High technology radiology/imaging services including CT/CAT

Scan, MRI, MRA, Nuclear Cardiology and PET are subject to

coinsurance and deductible (outpatient requires precertification except

for Nuclear Cardiology), (see Section 5(a)).

PPO: $30 copayment (No deductible)

Non-PPO: 40% of the Plan allowance

Note: For Non-PPO benefits, members may be

billed the difference between the Plan

allowance and the billed amount.

Outpatient medical or surgical services and supplies, other than an

Urgent Care Center

PPO: 15% of the Plan allowance

Non-PPO: 15% of the Plan allowance

Ambulance High Option

Professional ambulance services within 24 hours of a medical

emergency

Note: See Section 5(c) for non-emergency service.

PPO: 15% of the Plan allowance

(No deductible)

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount (No deductible)

Air ambulance High Option

Air ambulance to nearest facility where necessary treatment is available

is covered if no emergency ground transportation is available or suitable

and the patient's condition warrants immediate evacuation.

PPO: 15% of the Plan allowance (No

deductible)

Non-PPO: 15% of the Plan allowance (No

deductible)

Air ambulance - continued on next page

61 2024 APWU Health Plan High Option Section 5(d)

High Option

Benefit Description You Pay

After the calendar year deductible…

Air ambulance (cont.) High Option

Not covered:

•

Non-emergent Air ambulance

•

Emergent transport beyond the nearest suitable facility

•

Air ambulance requested by patient or physician which are beyond the

nearest facility for continuity of care or other reasons

All charges

62 2024 APWU Health Plan High Option Section 5(d)

Section 5 (e). Mental Health and Substance Use Disorder Benefits

High Option

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•The calendar year deductible is: PPO - $450 per person ($800 per Self Plus One enrollment, or $800

per Self and Family enrollment); Non-PPO - $1,000 per person ($2,000 per Self Plus One

enrollment, or $2,000 per Self and Family enrollment). The calendar year deductible applies to

almost all benefits in this Section. We added “(No deductible)” to show when the calendar year

deductible does not apply.

•The calendar year deductible or, for facility care, the inpatient deductible applies to almost all

benefits in this Section. We added "(No deductible)" to show when a deductible does not apply.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how

cost-sharing works. Also, read Section 9 for information about how we pay if you have other

coverage, or if you are age 65 or over.

•YOU MUST GET PREAUTHORIZATION FOR HOSPITAL STAYS; FAILURE TO DO SO

WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification

information shown in Section 3 to be sure which services require precertification.

•To obtain preauthorization of an admission for mental conditions or substance use disorder

treatment, call UnitedHealthcare at 866-569-2064.

•We will provide medical review criteria or reasons for treatment plan denials to enrollees, members

or providers upon request or otherwise required.

•OPM will base its review of disputes about treatment plans on the treatment plan's clinical

appropriateness. OPM will generally not order us to pay or provide one clinically appropriate

treatment plan in favor of another.

•We do not make available provider directories for mental health or substance use disorder treatment

providers. To find a mental health or substance use disorder treatment provider, call APWU Health

Plan at 800-222-2798 or visit our website at www.apwuhp.com.

•Schools or other educational institutions are not covered.

•If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is

primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our

FEHB members. This plan enhances your FEHB coverage by reducing/eliminating cost-sharing for

services and/or adding benefits at no additional cost. This would be an enhancement to your APWU

Health Plan's High Option benefits. It includes an $85 monthly Part B reimbursement. The

UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.

(See Section 9 for additional details.)

63 2024 APWU Health Plan High Option Section 5(e)

High Option

Benefit Description You Pay

After the calendar year deductible…

Note: The calendar year deductible applies to almost all benefits in this Section. We say “(No deductible)” when it

does not apply.

Professional services High Option

We cover professional services by licensed professional mental

health and substance use disorder treatment practitioners when

acting within the scope of their license, such as psychiatrists,

psychologists, clinical social workers, licensed professional

counselors, or marriage and family therapists.

Your cost-sharing responsibilities are no greater than

for other illnesses or conditions.

In a physician's office *

• Treatment and counseling (including individual or group

therapy visits)

• Diagnosis and treatment to address gender dysphoria (in-

network only), (see Section 5(b) and 5(c) for exclusions)

• Diagnosis and treatment of substance use disorders (outpatient)

• Diagnosis and treatment of psychiatric conditions, mental

illness, or mental disorders. Services include:

- Diagnostic evaluation

- Crisis intervention and stabilization for acute episodes

- Medication evaluation and management (pharmacotherapy)

• Professional charges for intensive outpatient treatment in a

provider's office or other professional setting (preauthorization

required by UnitedHealthcare)

* Professional services of a physician via Telehealth/Telemedicine

are covered the same as in a physician's office.

PPO: $25 copayment (No deductible)

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the billed

charges

Professional and other services for the diagnosis and treatment of

psychiatric conditions, mental illness or mental disorders:

• Psychological and neuropsychological testing necessary to

determine the appropriate psychiatric treatment

• Diagnosis and treatment of substance use disorders, including

detoxification, treatment and counseling (inpatient)

• Repetitive Transcranial Magnetic Stimulation, TMS, for the

treatment of depressive disorders which have not been

responsive to other interventions such as psychotherapy and

antidepressant medications (preauthorization required by

UnitedHealthcare)

• Electroconvulsive therapy

Note: Applied Behavioral Analysis (ABA) therapy benefit is listed

in Section 5(a),

Medical Services and Supplies Provided by

Physicians and Other Healthcare Professionals

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the billed

charges

64 2024 APWU Health Plan High Option Section 5(e)

High Option

Benefit Description You Pay

After the calendar year deductible…

TeleHealth services High Option

Virtual visits through Teladoc for non-emergency visits.

Covered services include consultation, diagnosis and prescriptions

(when appropriate) through the web or your mobile device.

Note: Telehealth services are available in most states, but some

states do not allow telehealth or prescriptions per state regulations.

Please visit www.teladoc.com, or call 800-835-2362 to start your

virtual visit.

Note: There are no out-of-network benefits for Virtual visits.

Teladoc: $10 copayment (No deductible)

Diagnostics High Option

• Outpatient diagnostic tests provided and billed by a licensed

mental health and substance use disorder treatment practitioner

• Outpatient diagnostic tests provided and billed by a laboratory,

hospital or other covered facility

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the billed

charges

Inpatient hospital or other covered facility High Option

Inpatient services provided and billed by a hospital, Residential

Treatment Center (RTC), or other covered facility

(preauthorization required by UnitedHealthcare)

• Room and board, such as semiprivate or intensive

accommodations, general nursing care, meals and special diets,

and other hospital services

• Inpatient diagnostic tests provided and billed by a hospital,

Residential Treatment Center (RTC), or other covered facility

PPO: 15% of the Plan allowance (No deductible)

Non-PPO: After $300 per admission, 40% of our

allowance and any difference between our allowance

and the billed charges (No deductible)

Not covered:

•

For Residential Treatment Centers, benefits are not available for

non-covered services, including: respite care; outdoor

residential programs; services provided outside of the

provider’s scope of practice; recreational therapy; educational

therapy; educational classes; bio-feedback; Outward Bound

programs; equine therapy provided during the approved stay;

personal comfort items, such as guest meals and beds,

telephone, television, beauty and barber services, which may be

part of the treatment program’s milieu and/or physical

environment, are not covered as separately billed items;

custodial or long term care; and domiciliary care provided

because care in the home is not available or is unsuitable.

All charges

Outpatient hospital or other covered facility High Option

Outpatient services provided and billed by a hospital or other

covered facility

• Services such as partial hospitalization or full-day

hospitalization (preauthorization required by UnitedHealthcare)

• Facility-based intensive outpatient treatment (preauthorization

required by UnitedHealthcare)

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the billed

charges

Outpatient hospital or other covered facility - continued on next page

65 2024 APWU Health Plan High Option Section 5(e)

High Option

Benefit Description You Pay

After the calendar year deductible…

Outpatient hospital or other covered facility (cont.) High Option

Not covered:

•

Services that require preauthorization that are not part of a

preauthorized approved treatment plan

•

Services that are not medically necessary

•

Services performed at schools or other education institutions

All charges

66 2024 APWU Health Plan High Option Section 5(e)

Section 5 (f). Prescription Drug Benefits

High Option

Important things to keep in mind about these benefits:

•We cover prescribed drugs and medications, as described in the chart below.

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•Your prescribers must obtain prior approval/authorizations for certain prescription drugs and

supplies before coverage applies. Prior approval/authorizations must be renewed periodically.

•Federal law prevents the pharmacy from accepting unused medications.

•The calendar year deductible does not apply to prescription drug benefits.

•The non-network benefits are the standard benefits of this Plan. Network benefits apply only when

you use a network provider. When no network provider is available, non-network benefits apply.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how

cost-sharing works. Also read Section 9, for information about how we pay if you have other

coverage, or if you are age 65 or over.

•See Section 9 for the PDP EGWP opt-out process.

•Prior authorization is required for certain drugs and must be renewed periodically. This review uses

Plan rules based on FDA-approved prescribing and safety information, clinical guidelines and uses

that are considered reasonable, safe and effective. See the coverage authorization information

shown in Section 3,

Other services

and Section 5(f),

Prescription Drug Utilization Management

, for

more information about this program.

•If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is

primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our

FEHB members. This plan enhances your FEHB coverage by reducing/eliminating cost-sharing for

services and/or adding benefits at no additional cost. This would be an enhancement to your APWU

Health Plan's High Option benefits. It includes an $85 monthly Part B reimbursement. The

UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.

See Section 9 for additional details.

There are important features you should be aware of. These include:

•Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/certified providers

with prescriptive authority prescribing within their scope of practice must prescribe your medication.

•Where can you obtain them. You can fill the prescription at an Express Scripts network pharmacy, a non-network

pharmacy, or by mail. We pay our highest level of benefits for mail order and you should use the mail order program to

obtain your maintenance medications.

•You may only obtain a 30-day supply and one refill of maintenance prescriptions at a network pharmacy participating with

Express Scripts. After two courtesy 30-day fills at regular network retail, you will pay the non-network pharmacy benefit

level.

•You may purchase maintenance prescription medications (non-specialty drugs that you take regularly for ongoing

conditions, for a 90-day supply) from a participating Smart90

Retail Network pharmacy or Express Scripts mail order.

•To find a Smart90

Retail Network pharmacy that participates in filling 90-day supplies, log in or register at www.

express-scripts.com/rx, select "Manage Prescriptions," and look for a link directing you to the Participating Smart90

Retail Network pharmacies, or call 866-890-1419. The pharmacy can tell you how to transfer your non-specialty

maintenance medication prescription or start a new one. If you continue to use a non-participating Smart90

pharmacy,

you will pay the non-network pharmacy benefit level.

•Your copayment for your 90-day supply will be the same whether you fill your prescription through Express Scripts Mail

order or at a participating Smart90

Retail Network pharmacy.

67 2024 APWU Health Plan High Option Section 5(f)

High Option

•We have a managed formulary. Our formulary is the National Preferred Formulary through Express Scripts. A formulary

is a list of medications we have selected based on their clinical effectiveness and lower cost. By asking your doctor to

prescribe formulary medications, you can help reduce your costs while maintaining high-quality care. There are safe,

proven medication alternatives in each therapy class that are covered on the formulary. Some drugs will be excluded from

the formulary and coverage, see www.apwuhp.com/high_option_pharmacy_program.php for a list of excluded

medications. This list is not all inclusive and there may be changes to the list during the year. A formulary exception

process is available to prescribers if they feel the formulary alternatives are not appropriate. Prescribers may request a

clinical exception by calling 800-753-2851. During the year, the Plan's formulary may change.

•Member cost-share for prescription drugs is determined by the tier to which a drug has been assigned. To determine the

tier assignments for formulary drugs, our Pharmacy Benefit Managers (PBM) work with their Pharmacy and Therapeutic

Committee, a group of physicians and pharmacists who are not employees or agents of, nor have financial interest in the

Plan. The Committee’s recommendations, together with our PBM's evaluation of the relative cost of the drugs, determine

the placement of formulary drugs on a specific tier. Using lower cost preferred drugs will provide you with a high quality,

cost-effective prescription drug benefit. You can view a list on our website at www.apwuhp.com/

high_option_pharmacy_program.php.

•Our payment levels are generally categorized as:

- Tier 1 Includes generic drugs

- Tier 2 Includes preferred brand name drugs

- Tier 3 Includes non-preferred brand name drugs

- Tier 4 Includes generic specialty drugs

- Tier 5 Includes preferred brand name specialty drugs

- Tier 6 Includes non-preferred brand name specialty

Brand/Generic Drugs

•Why use generic drugs? A generic drug is a chemical equivalent of a corresponding name brand drug. The US Food and

Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality

and strength as brand name drugs. Generic drugs are generally less expensive than brand drugs, therefore, you may reduce

your out-of-pocket-expenses by choosing to use a generic drug.

•A generic equivalent will be dispensed if it is available, unless your prescriber specifically requires a brand name drug. If

you receive a brand name drug when a FDA approved generic drug is available, and your prescriber has not received a

preauthorization, you have to pay the difference in cost between the name brand drug and the generic, in addition to your

coinsurance. However, if your doctor obtains preauthorization because it is medically necessary that a brand name drug be

dispensed, you will not be required to pay this cost difference. Your doctor may seek preauthorization by calling

800-753-2851.

•The Plan may have certain coverage limitations to ensure clinical appropriateness. For example, prescription drugs used

for cosmetic purposes may not be covered, a medication might be limited to a certain amount (such as the number of pills

or total dosage) within a specific time period, or require authorization to confirm clinical use based on FDA labeling. In

these cases, you or your prescriber can begin the coverage review process by calling Express Scripts Customer Service at

800-841-2734.

These are the dispensing limitations:

•The Express Scripts Retail Network – you may obtain up to a 30-day supply plus one 30-day refill for each prescription

purchased from an Express Scripts network pharmacy. After one 30-day refill, you must obtain a new prescription and

either purchase your non-specialty maintenance prescription medications (drugs you take regularly for ongoing conditions)

at either a participating Smart90 Retail Network pharmacy or the Express Scripts mail order. If you do not, we will pay the

non-network pharmacy benefit level. To receive maximum savings you must present your card at the time of each

purchase, and your enrollment information must be current and correct. In most cases, you simply present the card together

with the prescription to the pharmacist. Refills cannot be obtained until 75% of the drug has been used.

68 2024 APWU Health Plan High Option Section 5(f)

High Option

•Exceptions for special circumstances – the Plan will authorize up to a 90-day supply at a network pharmacy for covered

persons called to active military service. Also, the Plan will authorize an extra 30-day supply, either at network retail or

Home Delivery, for civilian Government employees who are relocated for assignment in the event of a national

emergency. Authorization may be obtained from Express Scripts at 800-841-2734 or from the Plan at 800-222-2798.

•Non-network pharmacy – if you do not use your identification card, if you elect to use a non-network pharmacy, or if an

Express Scripts network pharmacy is not available, you will need to file a claim and we will pay at the non-network retail

pharmacy benefit level.

•Mail order – through this program, you may receive up to a 90-day supply of maintenance medications for drugs which

require a prescription, diabetic supplies and Insulin, syringes and needles for covered injectable medications, and oral

contraceptives. Some medications may not be available in a 90-day supply from Express Scripts by Mail even though the

prescription is for 90 days.

•Refills for maintenance medications are not considered new prescriptions except when the doctor changes the strength or

180 days has elapsed since the previous purchase. Refill orders submitted too early after the last one was filled are held

until the right amount of time has passed. As part of the administration of the prescription drug program, we reserve the

right to maximize your quality of care as it relates to the utilization of pharmacies.

•You may fill your prescription at any pharmacy participating in the Express Scripts system. For the names of participating

pharmacies, call 800-841-2734, or go to www.express-scripts.com.

Certain controlled substances and several other prescribed medications may be subject to other dispensing limitations, such

as quantities dispensed, and to the judgment of the pharmacist.

Benefit Description You Pay

Note: The calendar year deductible does not apply to this section.

Covered medications and supplies High Option

Each new enrollee will receive a description of our prescription drug

program, a combined prescription drug/Plan identification card, a mail

order form/patient profile and a pre-addressed reply envelope.

You may purchase the following medications and supplies prescribed

from either a pharmacy or by mail:

• Drugs and medications, for use at home that are obtainable only upon

a doctor’s prescription and listed in official formularies

• Drugs and medications (including those administered during a non-

covered admission or in a non-covered facility) that by Federal law of

the United States require a prescription for their purchase, except

those listed as not covered

• Insulin, Insulin Pump supplies and test strips for known diabetics

• Disposable needles and syringes for the administration of covered

medications

• Approved drugs for organic impotence such as Viagra and Levitra are

subject to prior authorization, (see Section 3,

Other services

and

Section 5(f),

Prescription Drug Utilization Management

)

• Drugs that could be used for cosmetic purposes such as Retin A or

Botox (requires prior authorization, see Section 3,

Other services

and

Section 5(f),

Prescription Drug Utilization Management

)

• FDA approved drugs for weight management (requires prior

authorization, see

Prescription Drug Utilization Management

)

• Drugs to treat gender dysphoria

• Network Retail: $10 Tier 1. 25% Tier 2 up to

a maximum of $200 coinsurance per

prescription for a 30-day supply. 45% Tier 3

up to a maximum of $300 coinsurance per

prescription for a 30-day supply

• Non-network Retail: 50% of cost for a 30-

day supply

• Network Mail Order: $20 Tier 1. 25% Tier 2

up to a maximum of $300 coinsurance per

prescription for a 90-day supply. 45% Tier 3

up to a maximum of $500 coinsurance per

prescription for a 90-day supply

Covered medications and supplies - continued on next page

69 2024 APWU Health Plan High Option Section 5(f)

High Option

Benefit Description You Pay

Covered medications and supplies (cont.) High Option

Diabetes medications and supplies

• Certain Insulins and non-Insulin Diabetes drugs to treat diabetes

For a list of Insulins and non-Insulin Diabetes drugs with fixed copays,

go to https://apwuhp.com/members/high-option/pharmacy/

Note: Standard Plan coinsurance applies to all other covered diabetic

medications and supplies.

Note: Standard dispensing limitations apply (see Section 5(f),

Brand/

Generic Drugs

• Network Retail: $25 copay for a 30-day

supply

• Network Mail Order: $75 copay for a 90-day

supply

Diabetic medications and supplies

• Oral Generic (Tier 1) medications for the specific purpose of lowering

blood sugar

• Formulary (Tier 2) blood glucose test strips and lancets

• Network Mail Order: $0

Specialty Prescription Drugs

• Specialty drugs must be obtained through Accredo Specialty

Pharmacy. This benefit pertains to specialty drugs administered either

at home or in an outpatient setting.

Note: See

Prescription Drug Utilization Management

for definition.

Note: If your specialty medication is available through Accredo

Specialty Pharmacy and you do not obtain your medication through

Accredo Specialty Pharmacy, you will be responsible for the full cost of

your medication.

• Network Retail: 25% Tier 4 with up to a

maximum of $300 per prescription for a 30-

day supply. 25% Tier 5 up to a maximum of

$600 coinsurance per prescription for a 30-

day supply. 45% Tier 6 up to a maximum of

$1,000 coinsurance per prescription for a 30-

day supply

• Non-network Retail: 50% of cost for a 30-

day supply

• Network Mail Order: 25% Tier 4 with up to

a maximum of $150 per prescription for a

90-day supply. 25% Tier 5 up to a maximum

of $300 coinsurance per prescription for a

90-day supply. 45% Tier 6 up to a maximum

of $500 coinsurance per prescription for a

90-day supply

Contraceptive drugs and devices as listed on the ACA/HRSA site.

Contraceptive coverage is available at no cost to FEHB members. The

contraceptive benefit includes at least one option in all methods of

contraception (as well as the screening, education, counseling, and

follow-up care). Any contraceptive that is not already available without

cost sharing on the formulary can be accessed through the contraceptive

exceptions process described below.

• In-network prescription drugs from Express Script's Patient Protection

and Affordable Care Act (PPACA) Preventive Contraceptive Drug

List for contraception. Find list at www.apwuhp.com.

• A formulary exception process is available to prescribers if they feel

the formulary alternatives are not appropriate. Prescribers should

request a clinical exception by calling 800-753-2851. Once your

physician receives prior authorization, the contraceptive drug not on

the PPACA list will be dispensed and you will pay $0.

• Network Retail: $0

• Network Mail order: $0

Covered medications and supplies - continued on next page

70 2024 APWU Health Plan High Option Section 5(f)

High Option

Benefit Description You Pay

Covered medications and supplies (cont.) High Option

• Reimbursement for over-the-counter contraceptives can be submitted

by filling out a prescription drug claim form (prescription required)

which can be found on our website www.apwuhp.com and mailed to

the address on the form.

Note: If you have concerns about the Health Plan’s compliance with the

ACA/HRSA requirements contact [email protected]. See OPM’s

web page about contraception.

• Network Retail: $0

• Network Mail order: $0

In-network devices approved by the FDA for contraception Nothing

Naloxone 0.4 mg/ml vial and Naloxone 2 mg/ml syringe; and Narcan

nasal spray for the prevention of opioid overdose related deaths

Note: Copay maximum does not apply to out-of-network retail drugs or

to brand name drugs when there is a generic available.

Note: If you choose a brand name drug when a generic is available and

the physician has not received prior authorization, you are responsible

for the difference in cost between the brand name drug and the generic,

in addition to your coinsurance.

Note: The Plan requires a coverage review (prior authorization) of

certain prescription drugs based on FDA-approved prescribing and

safety information, clinical guidelines, and uses that are considered

reasonable, safe and effective. See

Prescription Drug Utilization

Management

for more information. To find out if your prescription

requires prior authorization or more about your prescription drug plan,

visit Express Scripts online at www.express-scripts.com or call Express

Scripts member services at 800-841-2734.

Note: Over-the-counter or prescription drugs approved by the FDA to

treat tobacco dependence are covered under the Tobacco Cessation

programs benefit, see

Educational classes and programs

Network Retail: Nothing

Non-network Retail: 50% of cost for a 30-day

supply

Network Mail Order: Nothing

Not covered:

•

Drugs and supplies for cosmetic purposes

•

Drugs to enhance athletic performance

•

Vitamins, nutrients and food supplements not listed as a covered

benefit even if a doctor prescribes or administers them

•

Medical supplies such as dressings and antiseptics

•

Nonprescription medications/over-the-counter drugs

except as stated

below:

Over-the counter emergency contraceptive drugs, the "morning

after pill", are covered at no cost if prescribed by a doctor and

purchased at a network pharmacy

Over-the-counter FDA-approved contraception methods are

covered at no cost if prescribed by a doctor and purchased at a

network pharmacy

•

Prescription drugs approved by the U.S. Food and Drug

Administration when an over-the-counter equivalent is available.

All charges

71 2024 APWU Health Plan High Option Section 5(f)

High Option

Benefit Description You Pay

Preventive care medications High Option

• Medications to promote better health as recommended by ACA.

• Preventive Medications with a USPSTF recommendation of A or B

are covered without cost-share when prescribed by a healthcare

professional and filled by a network pharmacy. These may include

some over-the-counter vitamins, nicotine replacement medications,

and low dose aspirin for certain patients. For current

recommendations go to

www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-

recommendations.

Network Retail: Nothing

Non-network Retail: 50% of cost for a 30-day

supply

72 2024 APWU Health Plan High Option Section 5(f)

High Option

Prescription Drug Utilization Management

•The information below describes a feature of your prescription drug plan known as utilization management. Utilization

management programs help to ensure you are taking safe and effective medications at a reasonable cost.

•Some medications require a prior authorization and are not covered unless you receive approval through a coverage review

(prior authorization). Examples of drug categories that require a coverage review include but are not limited to, growth

hormones, Botox, Interferons, rheumatoid arthritis agents, Retin A, drugs for organic impotence/sexual disorders, FDA

approved drugs for weight management, gender dysphoria and gender transition, blood disorders treatment, pain treatment,

cardiovascular disease, respiratory disease treatment, skin conditions, ophthalmic conditions, neuromuscular, mental/

neurological, renal disease, anti infectives, gastrointestinal and endocrine. This review uses Plan rules based on FDA-

approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and

effective. There are other medications that may be covered with limits (for example, only for a certain amount or for

certain uses) unless you receive approval through a review. During this review, Express Scripts asks your doctor for more

information than what is on the prescription before the medication may be covered under your plan. If coverage is

approved, you simply pay your normal copayment for the medication. If coverage is not approved, you will be responsible

for the full cost of the medication.

•In our ongoing effort to provide a robust yet cost-effective prescription drug benefit, APWU Health Plan participates in

programs to encourage the prescribing and use of generics and lower-cost alternative brands when appropriate. In most

cases, you save money when the preferred generic or formulary brand is dispensed. Step therapy helps to ensure that your

prescriber considers cost-effective alternatives before prescribing more expensive medications. If you have received one or

more of the less costly alternatives in the past, you will be able to get your medicine at the pharmacy without any delay.

Currently the Plan offers step therapy programs on specialty cholesterol, hypnotic, osteoporosis, migraine, glaucoma,

hypoglycemic, Non Steroidal Anti-Inflammatory (NSAID's), COX-2 Inhibitors, nasal steroids, Proton Pump Inhibitors

(PPI's), oral Tetracyclines, topical acne, topical Corticosteroids, topical Immunomodulator medications, allergies,

respiratory conditions, stimulants, bone conditions, genitourinary conditions, diabetes, endocrine disorders, blood

disorders, cardiovascular disease, inflammatory conditions, depression, metabolic disorders, pain, gastrointestinal

disorders, mental/neurological, electrolyte imbalance, BPH, hypertension, and vitamin deficiency. In situations where your

prescribed drug is targeted and there is no history of a first line agent, a new prescription for a first line agent will need to

be obtained or a coverage review will be necessary for coverage of your medication. If the coverage review is approved,

the member is responsible for the normal coinsurance found in Section (f),

Covered medications and supplies

. If the

coverage review is denied, the member is responsible for the full cost of the drug. If the member does not first obtain the

coverage review (prior authorization) approval, they will pay the full cost of the drug. Coverage reviews can be initiated

by the member, pharmacist, or doctor by calling Express Scripts at 800-841-2734.

•The APWU Health Plan prescription benefit plan will no longer cover prescriptions for certain compound medications.

The U.S. Food and Drug Administration (FDA) defines a compound medication as one that requires a licensed pharmacist

to combine, mix or alter the ingredients of a medication when filling a prescription. The FDA does not verify the quality,

safety and/or effectiveness of compound medications, therefore the Plan will no longer cover certain compounded

prescriptions unless FDA approved. To avoid paying the full cost of these medications, you should ask your doctor for a

new prescription for a manufactured FDA-approved drug before your next fill.

•The Plan will participate in other approved managed care programs to ensure patient safety and appropriate therapy in

accordance with the Plan rules based on FDA guidelines referenced above.

•To find out more about your prescription drug plan, please visit Express Scripts online at www.express-scripts.com or call

Express Scripts Member Services at 800-841-2734.

•“Specialty Drugs” are injectable, infused, oral or inhaled drugs defined as having one or more of several key

characteristics: (1) requires frequent dosing adjustments and intensive clinical monitoring to decrease potential for drug

toxicity and increase probability for beneficial treatment outcomes; (2) need for intensive patient training and compliance

assistance to facilitate therapeutic goals; (3) limited or exclusive product availability and distribution; (4) specialized

product handling and/or administration requirements.

Some examples of the disease categories currently in Express Scripts specialty pharmacy programs include cancer,

cystic fibrosis, Gaucher disease, growth hormone deficiency, hemophilia, immune deficiency, hepatitis C, infertility,

multiple sclerosis, rheumatoid arthritis and RSV prophylaxis.

73 2024 APWU Health Plan High Option Section 5(f)

High Option

In addition, a follow-on-biologic or generic product will be considered a Specialty Drug if the innovator drug is a

Specialty Drug.

Many of the Specialty Drugs covered by the Plan fall under the Prescription Drug Utilization Management program

mentioned. Many of the Specialty medications must be obtained through Accredo. You can send your prescription

through your normal mail service process or have your physician fax your prescription to Accredo.

You or your prescriber must contact Accredo at 844-581-4862 to determine if a specialty medication that you are

receiving from the physician's office or outpatient setting must be obtained through Accredo Specialty

Pharmacy. Contact Accredo to speak to a representative to inquire how your medication can be obtained through

Accredo and possibly administered at home using Accredo nursing services. If your specialty medication is available

through Accredo Specialty Pharmacy and you do not obtain your medication through Accredo Specialty Pharmacy,

you will be responsible for the full cost of the medication.

•For Medicare Part B insurance coverage. If Medicare Part B is primary, ask about your options for submitting claims

for Medicare-covered medications and supplies, whether you use a Medicare-approved supplier or Express Scripts by

Mail. Prescriptions typically covered by Medicare Part B include diabetes supplies (test strips and meters), specific

medications used to aid tissue acceptance (such as with organ transplants), certain oral medications used to treat cancer,

and ostomy supplies.

•When you do have to file a claim. Use a Prescription Drug Claim Form to claim benefits for prescription drugs

and supplies purchased from a non-network pharmacy. You may obtain forms by calling 800-222-2798 or from our

website at www.apwuhp.com. Your claim must include receipts that show the prescription number, the National Drug

Code (NDC) number, name of the drug, prescriber's name, date of purchase and charge for the drug. Mail the claim form

and receipt(s) to:

APWU Health Plan

P.O. Box 1358

Glen Burnie, MD 21060-1358

74 2024 APWU Health Plan High Option Section 5(f)

Section 5 (g). Dental Benefits

High Option

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental

Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan

is secondary to your FEHB Plan. See Section 9,

Coordinating Benefits with Medicare and Other

Coverage

•The calendar year deductible is: PPO - $450 per person ($800 per Self Plus One enrollment, or $800

per Self and Family enrollment); Non-PPO - $1,000 per person ($2,000 per Self Plus One

enrollment, or $2,000 per Self and Family enrollment). The calendar year deductible applies to

almost all benefits in this Section. We added “(No deductible)” to show when the calendar year

deductible does not apply.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how

cost-sharing works. Also read Section 9, for information abut how we pay if you have other

coverage, or if you are age 65 or over.

Note: We cover hospitalization and anesthesia for dental procedures only when a non-dental physical

impairment exists which makes hospitalization necessary to safeguard the health of the patient. We do

not cover the dental procedure, (see Section 5(c),

Inpatient hospital benefits)

Accidental injury benefit You Pay

Accidental injury benefit High Option

We cover restorative services and supplies necessary to repair (but not

replace) sound natural teeth. The need for these services must result

from an accidental injury (a blow or fall) and must be performed within

two years of the accident (see also Section 5(d),

Accidental injury

Within 72 hours of accident:

PPO: Nothing (No deductible)

Non-PPO: Only the difference between our

allowance and the billed amount (No

deductible)

More than 72 hours after accident:

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any

difference between our allowance and the

billed amount

Dental benefits service High Option

• Office visits (routine limited to 2 visits per year)

• Restorative care (fillings)

• X-rays of all types (limited to 2 per year)

• Prophylaxis (cleanings), (limited to 2 per year)

• Simple extractions

Note: Office visits include examinations and fluoride treatment.

Note: Restorative care does not include crowns or in-lay/on-lay

restoration.

Note: General anesthetics not covered unless due to an underlying

medical condition.

30% of the Plan allowance and any difference

between our allowance and the billed amount

(No deductible)

Note: No in-network dental providers; choose

any provider.

75 2024 APWU Health Plan High Option Section 5(g)

Section 5 (h). Wellness and Other Special Features

High Option

Special feature Description

Under the flexible benefits option, we determine the most effective way to provide

services.

• We may identify medically appropriate alternatives to regular contract benefits as a

less costly alternative. If we identify a less costly alternative, we will ask you to sign

an alternative benefits agreement that will include all of the following terms in

addition to other terms as necessary. Until you sign and return the agreement, regular

contract benefits will continue.

• Alternative benefits will be made available for a limited time period and are subject to

our ongoing review. You must cooperate with the review process.

• By approving an alternative benefit, we do not guarantee you will get it in the future.

• The decision to offer an alternative benefit is solely ours, and except as expressly

provided in the agreement, we may withdraw it at any time and resume regular

contract benefits.

• If you sign the agreement, we will provide the agreed-upon alternative benefits for the

stated time period (unless circumstances change). You may request an extension of the

time period, but regular contract benefits will resume if we do not approve your

request.

• Our decision to offer or withdraw alternative benefits is not subject to OPM review

under the disputed claims process. However, if at the time we make a decision

regarding alternative benefits, we also decide that regular contract benefits are not

payable, then you may dispute our regular contract benefits under the OPM disputed

claims process (see Section 8,

The Disputed Claims Process

Flexible benefits option

We offer a 24-hour nurse advisory service for your use. This program is strictly voluntary

and confidential. You may call toll-free at 866-569-2064 and reach registered nurses to

discuss an existing medical concern or to receive information about numerous healthcare

issues.

24-hour NurseLine

We offer a toll-free TDD line for customer service. The number is 800-622-2511. TDD

equipment is required.

Services for deaf and

hearing impaired

A voluntary program that provides a variety of services to help you manage a chronic

condition with outpatient treatment and avoid unnecessary emergency care or inpatient

admissions. As an example, members with cardiac conditions can participate in this

program. We use medical and/or pharmacy claims data as well as interactions with you

and your physician(s). If you have a chronic condition and would like additional

information, call UnitedHealthcare at 866-569-2064.

Disease Management

Program

If you send us a corrected hospital billing, we will credit 20% of any hospital charge over

$20 for covered services and supplies that were not actually provided to a covered person.

The maximum amount payable under this program is $100 per person per calendar year.

Review and Reward

Program

$0 copay for in-network office visits to a registered Dietician/Nutritionist

Weight Management

76 2024 APWU Health Plan High Option Section 5(h)

High Option

Special feature Description

Online programs and services provide extra support and savings, visit www.apwuhp.com

or call 866-569-2064 for more information.

• Pregnancy Support Program - Enroll in this program and you take the first step

toward giving your baby a healthy start in life.

• Maven - Mothers-to-be receive online support through every stage of pregnancy and

delivery.

• Cancer Support Program - Enroll in the program and receive enhanced benefits at

Cancer Centers of Excellence.

• Kidney Resources Program - For those diagnosed with end-stage renal disease or

those who are currently receiving dialysis treatment, this program will help you.

• One Pass Gym Discount – visit www.WeRally.com to sign up for One Pass, a gym

membership discount program offering access to national gym memberships, online

fitness classes and Grocery Delivery service.

• UnitedHealthcare Hearing- Call 855-523-9355 or visit www.UHCHearing.com for

hearing aids, care options and dedicated support.

• Alternative medicine - find discounts for acupuncture, chiropractor, and massage.

Special Programs

Online tools are available at www.myAPWUHP.com:

• www.myAPWUHP.com - online information for member services and claims to view

claims and find year-to-date information with claim details

Online tools and

resources

A Health Risk Assessment (HRA) is available at www.apwuhp.com and via the Member

Portal at www.myAPWUHP.com. The HRA is an online program that analyzes your

health related responses and gives you a personalized plan to achieve specific health

goals. Your HRA profile provides information to put you on a path to good physical and

mental health.

Health Risk Assessment

(HRA)

Access by Internet (www.apwuhp.com) is provided to support your important health and

wellness decisions, including:

• Online Preferrred Organization (PPO) Directory - nationwide PPO network to find

doctors, hospitals and other outpatient providers anywhere in the country

• Hospital Quality Ratings Guide - Compare hospitals for quality in your area or

anywhere in the country

• Treatment Cost Estimator - receive cost estimates for the most common medical

conditions, tests and procedures

• Prescription drug information, pricing, and network retail pharmacies

Consumer choice

information

77 2024 APWU Health Plan High Option Section 5(h)

Consumer Driven Health Plan Benefits

CDHP

See Section 2 for how our benefits changed this year and page 156 for a benefits summary.

Consumer Driven Health Plan Overview ....................................................................................................................................80

Section 5. In-Network Preventive Care ......................................................................................................................................81

Preventive care, adult ........................................................................................................................................................81

Preventive care, children ...................................................................................................................................................82

Section 5. Personal Care Account (PCA) ....................................................................................................................................84

Personal Care Account (PCA) ...........................................................................................................................................85

Section 5. Traditional Health Coverage Overview .....................................................................................................................87

Deductible before Traditional Health Coverage begins ....................................................................................................87

Section 5 (a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals .............................90

Diagnostic and treatment services .....................................................................................................................................90

TeleHealth services ...........................................................................................................................................................91

Lab, X-ray and other diagnostic tests ................................................................................................................................91

Maternity care ...................................................................................................................................................................91

Family Planning ................................................................................................................................................................92

Infertility services .............................................................................................................................................................93

Allergy care .......................................................................................................................................................................93

Treatment therapies ...........................................................................................................................................................94

Physical and occupational therapies .................................................................................................................................94

Applied behavioral analysis (ABA) ..................................................................................................................................95

Speech therapy ..................................................................................................................................................................95

Hearing services (testing, treatment, and supplies) ...........................................................................................................95

Vision services (testing, treatment, and supplies) .............................................................................................................95

Foot care ............................................................................................................................................................................96

Orthopedic and prosthetic devices ....................................................................................................................................96

Durable medical equipment (DME) ..................................................................................................................................97

Home health services ........................................................................................................................................................98

Chiropractic .......................................................................................................................................................................98

Alternative treatments .......................................................................................................................................................98

Educational classes and programs .....................................................................................................................................99

Section 5 (b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals .......................100

Surgical procedures .........................................................................................................................................................100

Reconstructive surgery ....................................................................................................................................................101

Oral and maxillofacial surgery ........................................................................................................................................103

Organ/tissue transplants ..................................................................................................................................................104

Anesthesia .......................................................................................................................................................................107

Section 5 (c). Services Provided by a Hospital or Other Facility, and Ambulance Services ....................................................108

Inpatient hospital .............................................................................................................................................................108

Cancer Centers of Excellence .........................................................................................................................................109

Outpatient hospital or ambulatory surgical center ..........................................................................................................110

Extended care benefits/Skilled nursing care facility benefits .........................................................................................110

Hospice care ....................................................................................................................................................................111

End of life care ................................................................................................................................................................111

Ambulance ......................................................................................................................................................................111

Section 5 (d). Emergency Services/Accidents ..........................................................................................................................112

Accidental injury .............................................................................................................................................................113

78 2024 APWU Health Plan CDHP Section 5

CDHP

Medical emergency .........................................................................................................................................................113

Ambulance ......................................................................................................................................................................113

Air ambulance .................................................................................................................................................................113

Section 5 (e). Mental Health and Substance Use Disorder Benefits .........................................................................................114

Professional services .......................................................................................................................................................114

TeleHealth Services .........................................................................................................................................................115

Diagnostics ......................................................................................................................................................................115

Inpatient hospital or other covered facility .....................................................................................................................116

Outpatient hospital or other covered facility ...................................................................................................................116

Section 5 (f). Prescription Drug Benefits ..................................................................................................................................117

Covered medications and supplies ..................................................................................................................................118

Preventive care medications ............................................................................................................................................120

Section 5 (g). Dental Benefits ...................................................................................................................................................123

Section 5 (h). Wellness and Other Special Features ..................................................................................................................124

Section 5 (i). Health Education Resources and Account Management Tools ...........................................................................125

Online tools and resources ..............................................................................................................................................125

Consumer choice information .........................................................................................................................................125

Special Programs .............................................................................................................................................................125

Wellness Incentive ..........................................................................................................................................................126

Health Risk Assessment ..................................................................................................................................................126

Summary of Benefits for the CDHP of the APWU Health Plan - 2024 ....................................................................................156

79 2024 APWU Health Plan CDHP Section 5

Consumer Driven Health Plan Overview

CDHP

The Plan offers a Consumer Driven Health Plan (CDHP). The CDHP benefit package is described in this section. Make sure

that you review the benefits that are available under the benefit product in which you are enrolled.

CDHP Section 5, which describes the CDHP benefits, is divided into subsections. Please read

Important things you should

keep in mind about these benefits

at the beginning of each subsection. Also read the general exclusions in Section 6, they

apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about

CDHP benefits, contact us at 800-718-1299 or on our website at www.welcometouhc.com/apwu.

This CDHP focuses on you, the healthcare consumer, and gives you greater control in how you use your healthcare benefits.

With this Plan, eligible in-network preventive care is covered in full, and you can use the Personal Care Account for any

covered care. If you use up your Personal Care Account, the Traditional Health Coverage begins after you satisfy

your Deductible. If you don’t use up your Personal Care Account for the year, you can roll it over to the next year, up to the

maximum account balance amount, as long as you continue to be enrolled in this CDHP.

The CDHP includes:

In-network Preventive Care

This component covers 100% for preventive care for adults and children if you use a network provider. The covered services

include office visits/exams, immunizations and screenings and are fully described in Section 5,

In-network preventive care

They are based on recommendations by the American Medical Association. We emphasize women's wellness through a

Preventive Care benefit that includes a broad range of preventive services, preventive tests and screenings, counseling

services, and contraceptives, including prescription drug contraceptives.

Personal Care Account (PCA)

The Plan also provides a Personal Care Account (PCA) for each enrollment. Each year, the Plan provides $1,200 for a Self

Only enrollment or $2,400 for a Self Plus One or Self and Family enrollment. The PCA covers 100% for your covered

medical expenses, which include dental and vision care. If you have an unused PCA balance at the end of the year, you can

rollover that balance so you can use it in the future. The Personal Care Account is described in Section 5,

Personal Care

Account

(PCA)

Note that the in-network Preventive Care benefits paid under Section 5 do NOT count against your Personal Care Account

(PCA).

Traditional Health Coverage

After you have used up your Personal Care Account (PCA) and paid your Net Deductible, the Plan starts paying benefits

under the Traditional Health Coverage described in Section 5,

Traditional Health Coverage

. The Plan generally pays 85% of

the cost for in-network care and 50% of the Plan allowance for out-of-network care.

Covered services include:

•Medical services and supplies, Section 5(a)

•Surgical and anesthesia services, Section 5(b)

•Hospital services, other facilities and ambulance, Section 5(c)

•Emergency services/Accidents, Section 5(d)

•Mental health and substance use disorder treatment benefits, Section 5(e)

•Prescription drug benefits, Section 5(f)

Health Education Resources and Account Management Tools

Section 5(i) describes the health tools and resources available to you under the Consumer Driven Option to help you improve

the quality of your healthcare and manage your expenses. You can receive a $25 wellness incentive when you complete an

annual physical with a clinical professional each year.

80 2024 APWU Health Plan CDHP Section 5 Overview

Section 5. In-Network Preventive Care

CDHP

Important things you should keep in mind about these in-network preventive care benefits:

•Under the Consumer Driven Option, the Plan pays 100% for the Preventive Care services listed in

this Section as long as you use a network PPO provider.

•For preventive care not listed in this Section or for preventive care from a non-network provider,

please see CDHP Section 5,

Personal Care Account

(PCA)

•For all other covered expenses, please see CDHP Section 5,

Personal Care Account

(PCA)

and

Traditional Health Coverage

•Note that the in-network Preventive Care paid under this Section does NOT count against or use up

your Personal Care Account (PCA).

•Please remember that all benefits are subject to the definitions, limitations and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how

cost-sharing works. Also read Section 9 for information about how we pay if you have other

coverage, or if you are age 65 or over.

•Receive $25 when you complete an annual physical with a clinical professional each year, see

Section 5(i) for details.

Benefit Description You Pay

Note: There is no calendar year deductible for in-network preventive care under the Consumer Driven Option.

Preventive care, adult Consumer Driven Option

Routine physical every calendar year.

The following preventive services are covered at the time interval

recommended at each of the links below:

• Receive $25 when you complete an annual physical with a clinical

professional each year (see Section 5(i) for details)

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/

Tdap, and human papillomavirus (HPV). For a complete list of

immunizations go to the Centers for Disease Control (CDC) website

at: www.cdc.gov/vaccines/index.html

• Screenings such as cancer, osteoporosis, depression, diabetes, high

blood pressure, total blood cholesterol, HIV, and colorectal cancer

screening. Preventive medications with a USPSTF recommendation

of A or B are covered without cost-share when prescribed by a

healthcare professional and filled by a network pharmacy. For a

complete list of screenings go to the U.S. Preventive Services Task

Force (USPSTF) website at: www.uspreventiveservicestaskforce.org/

uspstf/recommendation-topics/uspstf-a-and-b-recommendations

• Individual counseling on prevention and reducing health risks

• Preventive care benefits for women such as Pap smears, gonorrhea

prophylactic medication to protect newborns, annual counseling for

sexually transmitted infections, contraceptive methods, and screening

for interpersonal and domestic violence. For a complete list

of preventive care benefits for women go to the Health and Human

Services (HHS) website at: https://www.healthcare.gov/preventive-

care-women/

• Routine Prostate Specific Antigen (PSA) test, one annually for men

age 40 and older

In-network: Nothing

Out-of-network: Any difference between our

allowance and the billed amount. Uses PCA

while funds available.

Preventive care, adult - continued on next page

81 2024 APWU Health Plan CDHP Section 5 In-network preventive care

CDHP

Benefit Description You Pay

Preventive care, adult (cont.) Consumer Driven Option

• Urinalysis

• Routine Electrocardiogram (EKG)

• Chest X-ray

• Hemoglobin A1C, age 18 and above

• At home Colorectal Cancer Screening Cologuard Kit provided

through Exact Sciences Laboratories, every three years starting at age

45, prescription needed from physician

• Medical Nutrition Therapy and Intensive Behavioral Therapy for the

prevention of obesity-related comorbidities as recommended under

the U.S. Preventive Services Task Force (USPSTF) A and B

recommendations

In-network: Nothing

Out-of-network: Any difference between our

allowance and the billed amount. Uses PCA

while funds available.

Routine mammogram - covered for women, including 3D mammograms

covered for women age 35 and older; as follows:

• From age 35 through 39, one during this five year period

• From age 40 through 64, one every calendar year

• At age 65 and older, one every two consecutive calendar years

• To build your personalized list of preventive services go to https://

health.gov/myhealthfinder

In-network: Nothing

Out-of-network: Any difference between our

allowance and the billed amount. Uses PCA

while funds available.

Immunizations, such as:

Adult immunizations endorsed by the Centers for Disease Control and

Prevention (CDC): based on the Advisory Committee on Immunization

Practices (ACIP) schedule.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray

service done in conjunction with a routine examination and is not

included in the preventive recommended listing of services will be

subject to the applicable member copayments, coinsurance, and

deductible.

In-network: Nothing

Out-of-network: Any difference between our

allowance and the billed amount. Uses PCA

while funds available.

Preventive care, children Consumer Driven Option

• Well-child visits, examinations, and other preventive services as

described in the Bright Future Guidelines provided by the American

Academy of Pediatrics. For a complete list of the American Academy

of Pediatrics Bright Futures Guidelines go to: https://brightfutures.

aap.org

• Immunizations such as DTaP/Tdap, Polio, Measles, Mumps, and

Rubella (MMR), and Varicella. For a complete list of immunizations

go to the Centers for Disease Control (CDC) website at: https://www.

cdc.gov/vaccines/schedules/index.html

• You may also find a complete list of preventive care services

recommended under the U.S. Preventive Services Task force

(USPSTF) online at: https://www.uspreventiveservicestaskforce.org/

uspstf/recommendation-topics/uspstf-a-and-b-recommendations

• To build your personalized list of preventive services go to https://

health.gov/myhealthfinder

In-network: Nothing

Out-of-network: Any difference between our

allowance and the billed amount. Uses PCA

while funds available.

Preventive care, children - continued on next page

82 2024 APWU Health Plan CDHP Section 5 In-network preventive care

CDHP

Benefit Description You Pay

Preventive care, children (cont.) Consumer Driven Option

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray

service done in conjunction with a routine examination and is not

included in the preventive recommended listing of services will be

subject to the applicable member coinsurance, and deductible.

Note: For directly related associated facilities services and lab work for

preventive care, we pay for covered services in full when you use

preferred providers.

In-network: Nothing

Out-of-network: Any difference between our

allowance and the billed amount. Uses PCA

while funds available.

• Examinations limited to:

- Examinations for amblyopia and strabismus - limited to one

screening examination (ages 3 through 5)

- Examinations done on the day of immunizations (ages 3 through

21)

- One Screening Examination of Premature Infants for Retinopathy

of Prematurity or infants with low birth weight or gestational age of

32 weeks or less

In-network: Nothing

Out-of-network: Any difference between our

allowance and the billed amount. Uses PCA

while funds available.

Not covered:

•

Adult immunizations not endorsed by the CDC

•

Physical exams required for obtaining or continuing employment or

insurance, attending schools or camp, athletic exams, or travel

•

Immunizations, boosters, and medications for travel or work-related

exposure

All charges

83 2024 APWU Health Plan CDHP Section 5 In-network preventive care

Section 5. Personal Care Account (PCA)

CDHP

Important things you should keep in mind about your Personal Care Account:

•All eligible healthcare expenses (except in-network preventive care) are paid first from

your Personal Care Account (PCA). Traditional Health Coverage (under CDHP Section 5) will only

start once your Personal Care Account is exhausted.

•Note that in-network preventive care covered under CDHP Section 5, does NOT count against your

PCA.

•The Personal Care Account provides full coverage for both in-network and out-of-network

providers. However your Personal Care Account will generally go much further when you use

network providers because network providers agree to discount their fees.

•You have flexibility about how to spend your PCA, and the Plan provides you with the resources to

manage your PCA. You can track your PCA on your personal private website, by telephone

at 1-800-718-1299 (toll-free), or with quarterly statements mailed directly to you at home.

•If you join this Plan during Open Season, you receive the full PCA ($1,200 per Self Only, $2,400

per Self Plus One or $2,400 per Self and Family enrollment) as of your effective date of coverage. If

you join at any other time during the year, your PCA for your first year will be prorated at a rate of

$100 per month for Self Only or $200 per month for Self Plus One or Self and Family for each full

month of coverage remaining in that calendar year.

•Unused PCA benefits are forfeited when leaving this Plan.

•If PCA benefits are available in your account at the time a claim is processed, out-of-pocket

expenses will be paid from your PCA regardless of the date the expense was incurred.

•If the member has funds available in the PCA account, claims will always be paid out of the PCA

first. If the member would like to use their FSA to pay a bill prior to using the PCA, please instruct

the provider not to submit the claim to UnitedHealthcare. The member should get a copy of the bill

from the provider and submit to the FSA carrier for reimbursement. This means that in some cases,

the member may have to pay the cost of the services up front.

•Please remember that all benefits are subject to the definitions, limitations and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how

cost-sharing works. Also read Section 9 for information about how we pay if you have

other coverage, or if you are age 65 or over.

•YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO

WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification

information shown in Section 3 to confirm which services require precertification.

•Members can turn off the PCA for medical claims only via www.myuhc.com. Medical claims must

then be submitted manually to UnitedHealthcare. Pharmacy claims will continue to pay from the

PCA.

84 2024 APWU Health Plan CDHP Section 5 Personal Care Account (PCA)

CDHP

Benefit Description You pay

There is no calendar year deductible for in-network preventive care under the Consumer Driven Option.

Personal Care Account (PCA) Consumer Driven Option

A Personal Care Account (PCA) is provided by the Plan for each

enrollment. Each year the Plan adds to your account:

• $1,200 per year for a Self Only enrollment or

• $2,400 per year for a Self Plus One or Self and Family enrollment

The Personal Care Account covers eligible expenses at 100%. For

example, if you are ill and go to a network doctor, the doctor will submit

your claim and the provider's contracted rate for the visit will be

deducted automatically from your PCA; you pay nothing.

Balance in PCA for Self Only $1,200

Less provider contracted rate for visit -$60

Remaining Balance in PCA $1,140

There are two types of eligible expenses covered by your PCA.

• Basic PCA Expenses are the same medical, surgical, hospital,

emergency, mental health and substance use disorder treatment, and

prescription drug services and supplies covered under the Traditional

Health Coverage (see CDHP Section 5 for details)

• Extra PCA Expenses include:

- Dental and/or vision services are reimbursable out of your PCA.

Only the PCA amount paid for the dental/vision services is applied

to the plan year deductible/out-of-pocket. We will reimburse up to

a combined maximum of $400 per Self Only enrollment or $800

per Self Plus One or Self and Family enrollment each calendar year,

including:

- Vision exam performed by an optometrist or ophthalmologist

- Eyeglasses and contact lenses

- Dental treatment (including examinations, cleanings, fillings,

restorative treatment, endodontics, and periodontics)

- In-network preventive care services not included under CDHP

Section 5,

In-network Preventive Care benefits

Out-of-network preventive care

limited to services shown as

covered under CDHP Section 5

- Amounts in excess of the Plan allowance for services received out-

of-network and covered under Basic PCA Expenses

Note: Both Basic and Extra PCA Expenses are covered at 100% as long

as you have not used up your Personal Care Account.

To make the most of your Personal Care Account, you should:

• Use the network providers wherever possible;

• Use Tier 1 prescriptions wherever possible; and

• Only use your PCA for Extra PCA Expenses if you expect to have an

unused balance in your PCA at the end of the calendar year

In-network and Out-of-network: Nothing up to

$1,200 for a Self Only enrollment or $2,400 for

a Self Plus One or Self and Family enrollment

Personal Care Account (PCA) - continued on next page

85 2024 APWU Health Plan CDHP Section 5 Personal Care Account (PCA)

CDHP

Benefit Description You pay

Personal Care Account (PCA) (cont.) Consumer Driven Option

Not covered:

•

Orthodontia

•

Dental treatment for cosmetic purposes including teeth whitening

•

Out-of-network preventive care services not included under CDHP

Section 5

•

Services or supplies shown as not covered under Traditional Health

Coverage (see CDHP Section 5) and not included under Extra PCA

Expenses above

All charges

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 may not exceed $5,000 per Self Only enrollment,

$10,000 per Self Plus One enrollment and $10,000 per Self and Family enrollment.

86 2024 APWU Health Plan CDHP Section 5 Personal Care Account (PCA)

Section 5. Traditional Health Coverage Overview

CDHP

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•In-network Preventive Care is covered at 100% under CDHP Section 5 and does not count against

your Personal Care Account.

•Your Personal Care Account must be used first for eligible healthcare expenses.

•If your Personal Care Account has been exhausted, you must pay your Net Deductible before your

Traditional Health Coverage may begin. Your Deductible applies to all benefits in this section.

•The Consumer Driven Option provides coverage for both in-network and out-of-network providers.

The out-of-network benefits are the standard benefits under the Traditional Health Coverage. In-

network benefits apply only when you use a provider from the large, national network. When a

network provider is not available, out-of-network benefits apply.

•If you join at any time during the year other than Open Season, your Deductible for your first year

will be prorated at a rate of: in-network $83.33 per month for Self Only, $166.67 per month for Self

Plus One or Self and Family; or out-of-network $125.00 per month for Self Only or $250.00 per

month for Self Plus One or Self and Family for each full month of coverage remaining in that

calendar year.

•Be sure to read Section 4,

Your Costs for Covered Services

, for valuable information about how

cost-sharing works. Also, read Section 9 for information about how we pay if you have other

coverage, or if you are age 65 or over.

•YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO

WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification

information shown in Section 3 to confirm which services require precertification.

Benefit Description You Pay

Deductible before Traditional Health Coverage begins Consumer Driven Option

If your Personal Care Account has been exhausted, you are responsible

to pay your Deductible before your Traditional Health Coverage begins.

Traditional Health Coverage benefits begin for in-network after covered

eligible expenses (deductible) total $2,200 for Self Only, $4,400 for Self

Plus One or $4,400 for Self and Family (the combination of eligible

expenses paid out of your PCA and your Net Deductible) each calendar

year. For out-of-network, covered benefits begin after covered eligible

expenses total $2,700 for Self Only, $5,400 for Self Plus One and $5,400

for Self and Family.

Note: You must use any available PCA benefits, including any amounts

rolled over from previous years, before Traditional Health Coverage

begins.

In year one, therefore, the Net Deductible is $1,000 for Self Only,

$2,000 for Self Plus One and $2,000 for Self and Family enrollment.

In-network: $1,000 per Self Only enrollment,

$2,000 for Self Plus One enrollment or $2,000

per Self and Family enrollment

Out-of-network: $1,500 per Self Only

enrollment, $3,000 for Self Plus One and

$3,000 for Self and Family enrollment

Deductible before Traditional Health Coverage begins - continued on next page

87 2024 APWU Health Plan CDHP Section 5 Traditional Health Coverage

CDHP

Benefit Description You Pay

Deductible before Traditional Health Coverage begins

(cont.)

Consumer Driven Option

Type of Plan

In-Network Deductible

Self Only: $2,200 Deductible ($1,200 PCA + $1,000 Net Deductible)

Self Plus One: $4,400 Deductible ($2,400 PCA + $2,000 Net

Deductible)

Self and Family: $4,400 Deductible ($2,400 PCA + $2,000 Net

Deductible

Out-of-Network Deductible

Self Only: $2,700 Deductible ($1,200 PCA + $1,500 Net Deductible)

Self Plus One: $5,400 Deductible ($2,400 PCA + $3,000 Net

Deductible)

Self and Family: $5,400 Deductible ($2,400 PCA + $3,000 Net

Deductible)

Basic PCA Expenses paid by PCA

Self Only: $1,200

Self Plus One: $2,400

Self and Family: $2,400

Deductible paid by you

Self Only: In-network $1,000; Out-of-network $1,500

Self Plus One: In-network $2,000; Out-of-network $3,000

Self and Family: In-network $2,000; Out-of-network $3,000

Traditional Health Coverage starts after

Self Only: In-network $2,200; Out-of-network $2,700

Self Plus One: In-network $4,400; Out-of-network $5,400

Self and Family: In-network $4,400; Out-of-network $5,400

Any PCA dollars that you rollover at the end of the year will reduce your

Deductible next year. In future years, the amount of your Deductible

may be lower if you rollover PCA dollars at the end of the year. For

example, if you rollover $300 at the end of the year:

PCA for year 2 Rollover from year 1

Self Only: $1,200 + $300 $1,500

Self Plus One: $2,400+ $300 $2,700

Self Self and Family: $2,400+ $300 $2,700

Net Deductible paid by you

Self Only: In-network + $700 Out-of-network + $1,200

Self Plus One: In-network + $700 Out-of-network + $2,700

In-network + $700 Out-of-network + $2,700

Traditional Health Coverage starts when eligible expenses total

Self Only: In-network $2,200 Out-of-network $2,700

Self Plus One: In-network $4,400 Out-of-network $5,400

Self and Family: In-network $4,400 Out-of-network $5,400

In-network: $1,000 per Self Only enrollment,

$2,000 for Self Plus One enrollment or $2,000

per Self and Family enrollment

Out-of-network: $1,500 per Self Only

enrollment, $3,000 for Self Plus One and

$3,000 for Self and Family enrollment

Deductible before Traditional Health Coverage begins - continued on next page

88 2024 APWU Health Plan CDHP Section 5 Traditional Health Coverage

CDHP

Benefit Description You Pay

Deductible before Traditional Health Coverage begins

(cont.)

Consumer Driven Option

If you decide to use your PCA for Extra PCA Expenses for other than

covered dental and/or vision services, you may increase your

Deductible. For example, if you have out-of-network preventive care

for $150 and later an accident that leads to a hospital stay, you will have

to pay your Deductible plus "make up" the $150 dollars you spent on

Extra PCA Expenses.

In-network: $1,000 per Self Only enrollment,

$2,000 for Self Plus One enrollment or $2,000

per Self and Family enrollment

Out-of-network: $1,500 per Self Only

enrollment, $3,000 for Self Plus One and

$3,000 for Self and Family enrollment

89 2024 APWU Health Plan CDHP Section 5 Traditional Health Coverage