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High Option Inpatient Hospital
Benefits
For inpatient medical or maternity hospital
admissions, the Health Plan's precertification guidelines are as
follows:
- For elective (planned) medical admissions, precertification is
required at least 48 hours prior to admission.
- For emergency admissions, the stay must be certified within 48
hours of admission, even if the patient has been discharged at
that time.
- Failure to precertify a stay, or to precertify on a timely
basis, will result in a $500 penalty.
- To precertify a hospital stay, call the precertification
vendor for your area - click here.
| PPO benefit |
90% of negotiated rate for covered medical hospital stays in a PPO hospital. No deductible. |
| Non-PPO benefit |
70% of semiprivate and intensive/cardiac care unit charge, 70% of other hospital charges after a $300 per admission deductible. |
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High Option Outpatient Hospital
Benefits
Outpatient hospital and diagnostic services for
covered medical or maternity diagnoses are subject to an annual $275 PPO ($500 Non-PPO) per person
deductible. See the Health Plan's Federal Brochure (RI 71-004) for
services that are covered at the outpatient department of a
hospital.
| PPO benefit |
90% of covered charges of the negotiated rate. |
| Non-PPO benefit |
70% of Plan allowance for covered services. |
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High Option Home and Office
Physician Visits and Chiropractic Care
NOTE: For PPO the annual deductible is $275. For non-PPO, the annual deductible is
$500 per person, with a $1,000 family maximum.
| PPO Doctor |
No deductible and $18 copay for home and office visits to physicians, including visits
for chiropractic and accupuncture treatment. Other covered services applied to calendar year deductible, then paid at 90% of negotiated rate. |
| Non-PPO Doctor |
After satisfaction of the annual calendar year deductible, 70% of Plan allowance. |
| Chiropractic services - PPO |
No deductible and $18 copay for visits and/or manipulations. Limit of 12 visits/manipulations per person per year. |
| Chiropractic services - Non-PPO |
After satisfaction of the calendar year deductible, covered services are reimbursed at 70% of Plan allowance. Limit of 12 visits/manipulations per person per year. |
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High Option Outpatient Care
for Mental Health and Substance Abuse Benefits
The APWU Health Plan provides benefits for Mental
Health and Substance Abuse that are the same as those for medical
care. The Health Plan has contracted with ValueOptions, the nation's
largest mental health/substance abuse Preferred Provider
Organization (PPO). The Health Plan offers separate benefit levels
depending upon whether or not PPO providers are used.
| PPO benefit |
There is a $18 copay for each outpatient visit. Outpatient care must be preauthorized by ValueOptions (1-888/700-7965). |
| Non-PPO benefit |
After satisfaction of a $500 per person / $1,000 per family calendar year deductible, the Plan pays 70% of the Plan allowance. Outpatient care must be preauthorized by ValueOptions (1-888/700-7965). |
Related drug costs are covered under the Plan's "Prescription
Drug" benefits.
NOTE: All outpatient care for mental conditions
and/or substance abuse must be preauthorized by ValueOptions,
whether or not you are using a Preferred Provider. Call them
toll-free at 1-888/700-7965. You can also call this number to locate
a covered PPO provider near you.
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High Option Maternity
Benefits
Maternity care is covered under regular medical (inpatient
and outpatient)
and surgical
benefits.
| Infertility diagnosis and treatment |
Up to $2,500 per enrollment each calendar year. |
Please refer to the Health Plan's
Brochure for more information regarding this benefit. Return
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High Option Inpatient Care
for Mental Health and Substance Abuse Benefits
If the ValueOptions mental health network is used,
members receive in-patient benefits for Mental Health and Substance
Abuse that are identical to those for medical care. For inpatient
mental condition/substance abuse hospital admissions, the Health
Plan's precertification guidelines are as follows: For elective
(planned) admissions, precertification is required 48 hours prior to
admission. For emergency admissions, the stay must be certified
within 48 hours of admission, even if the patient has been
discharged at that time. Failure to precertify a stay, or to
precertify on a timely basis, will result in a $500 penalty. To
precertify a hospital stay, call ValueOptions, toll-free at
1-888/700-7965, whether or not you use a PPO facility. ValueOptions'
certification line is available 24 hours-a-day, 7 days a week.
The APWU Health Plan has contracted with
ValueOptions, the nation's largest mental health/substance abuse
Preferred Provider Organization (PPO). The Health Plan offers
separate benefit levels depending upon whether or not PPO providers
are used.
Mental Health and Substance Abuse Inpatient hospital benefits:
PPO benefit
(Mental Conditions) |
The Plan will pay for inpatient hospital treatment at 90%, if preauthorized.
After $275 annual deductible, the Plan will pay for inpatient professional fees at 90%, if preauthorized. |
Non-PPO benefit
(Mental Conditions) |
$300 per admission and the Plan pays 70% of the Plan allowance if preauthorized. |
PPO Benefit
(Substance Abuse) |
The Plan will pay for inpatient hospital treatment at 90%, if preauthorized.
|
Non-PPO Benefit
(Substance Abuse) |
$300 per admission and the Plan pays 70% of the Plan allowance. Must be preauthorized. |
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High Option Accidental
Injury Benefits
| PPO benefit |
100% of provider's negotiated rate (no deductible), within 24 hours of onset. Applies to outpatient services. |
| Non-PPO benefit |
100% of Plan allowance (no deductible), within 24 hours of onset. Applies to outpatient services. |
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High Option Surgery
Benefits
Benefits for covered inpatient or outpatient
surgery are subject to the annual $275 PPO ($500 non-PPO) per person deductible. Inpatient and outpatient surgical benefits:
| PPO Benefit |
90% of a negotiated fee. |
| Non-PPO Benefit |
70% of Plan allowance. |
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High Option Dental Care
Benefits
Refer to the Plan's Brochure for listing of covered oral surgery procedures. Dental benefits:
| Office visits* |
The Plan pays 70% of the Plan allowance. No deductible. |
| Restorative care (fillings) |
The Plan pays 70% of the Plan allowance. No deductible. |
| Simple extractions |
The Plan pays 70% of the Plan allowance. No deductible. |
There is no deductible for dental.
* Includes exam, cleanings, x-rays, and flouride treatment.
You can purchase a supplemental dental coverage
through the APWU Voluntary Benefits Plan. APWU Health Plan members
will receive a 7.5% discount on their V.B.P. Dental Insurance
program. For more information, click on this link: www.voluntarybenefitsplan.com.
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High Option Prescription Drug Benefits
The APWU Health Plan offers the cost-savings and
convenience of a Mail Order Pharmacy service for its members who
use long-term or maintenance prescriptions, with prescriptions
delivered right to your door.
Over sixty thousand pharmacies are part of the
Plan's Retail Pharmacy program network, including pharmacy giants
such as Walgreens, Rite Aid, K-Mart, COSTCO and CVS.
| |
You Pay In-Network |
You Pay Out of Network |
| Mail Order |
$15 copay per generic drug
25% coinsurance per brand name drug
(or a minimum of $12); maximum of $600 |
All charges |
| Retail Pharmacy |
$8 copay per generic drug
25% coinsurance per brand name drug
(or a minimum of $8); maximum of $200 |
50% |
Personalized Medicine (voluntary program) - Available at no additional cost, pharmacogenomic testing to optomize prescription drug therapies for patients taking Warafin (anticoagulant) and Tamoxifen (for breast cancer).
Contact the Plan for an order kit and instructions
on how to use the Mail Order Prescription program, or call the
Plan's Mail Order vendor at 1-800/841-2734.
Members may check the status of an order, order a refill or locate
a participating retail pharmacy by clicking here.
Prospective members and visitors may check the High Option retail
pharmacy network and benefit information by clicking here.
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High Option Special Features
Wellness Benefit
The Health Plan is the only plan in the Federal Employees Health Benefits (FEHB) Program that rewards you for staying well. We reimburse you up to $250 per Self Only enrollment and $350 per Self and Family enrollment per calendar year for routine services that are not normally covered, such as eyeglasses, orthodontics, and hearing aids.
The Health Plan notifies eligible members in November and includes a Wellness Claim Form. You use the Wellness service before the end of the year. Submit a receipt or itemized bill with the Wellness Claim Form after January 1 of the following year, and the Wellness claims are paid after March 1.
Nurse Advisory Line
We offer a 24-hour nurse advisory service for your use. This program is strictly voluntary and confidential. You may call
toll-free at 800/582-1314 and reach registered nurses to discuss an existing medical concern or to receive information about numerous health care issues.
Disease Management Program
A voluntary program that helps members better manage their care when they have certain chronic conditions: diabetes and cardiac conditions.
Review and Reward 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.
Services for the Deaf and Hearing Impaired
We offer a toll-free TDD line for customer service. The number is 800/622-2511. TDD equipment is required.
Diabetes Management Program
If you are an APWU Health Plan primary member enrolled in the Care Allies Diabetes Disease Management program and participate as required by the program, you may be eligible for the following incentives for in-network services only:
- $0 co-pay for in-network medical office visits for diabetes management (this does not include visits to a Podiatrist or Ophthalmologist)
- $0 coinsurance for in-network lab test related to diabetes management
- $0 co-pay for Generic drugs at mail for the treatment of diabetes
- $0 co-pay for Insulin at mail
- $0 co-pay for test strips at mail
If you are an APWU Health Plan member who has other primary insurance (i.e., Medicare primary), you do not have to enroll in the Diabetes Management program. If we determine based on medical and pharmacy claims that you are eligible and compliant with diabetes management (i.e., diabetic office visits and lab tests every three months and medication refills), you may be eligible for the following incentives:
- $0 co-pay for Generic drugs at mail for the treatment of diabetes
- $0 co-pay for Insulin at mail
- $0 co-pay for test strips at mail
- $0 coinsurance for in-network lab tests related to diabetes management
Hypertension (High Blood Pressure) Management Program
If you are an APWU Health Plan primary member enrolled in the Hypertension Education and Coaching program and participate as required by the program, you may be eligible for the following incentives for in-network services only:
- $0 co-pay for in-network office visits for the treatment of hypertension
- $0 coinsurance for in-network lab tests related to the treatment of hypertension
- $0 co-pay for Generic drugs at mail for the treatment of hypertension
If you are an APWU Health Plan member who has other primary insurance (i.e., Medicare primary), you do not have to enroll in the Hypertension Education and Coaching Program. You will be eligible for the following incentives:
- $0 co-pay for Generic drugs at mail for the treatment of hypertension
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