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APWU Health Plan FAQ

APWU Health Plan has been offering affordable, comprehensive coverage to postal workers, federal employees, and retirees since 1960. We’re here to help you choose a plan that’s right for you and make the most of your benefits.

If you can’t find an answer to your question, contact us to speak with a customer service representative:

1-800-222-2798 | 1-800-622-2511 (TTY)

Monday – Friday, 8:30 am – 6:30 pm ET

Displaying FAQs for Prescriptions

What is a preferred formulary?

A formulary is a list of medications APWU Health Plan has 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. The lists of exclusions are not all inclusive and there may be changes to the lists during the year.

In addition, the Plan’s formulary may change during the year.

The High Option prescription plan uses the National Preferred Formulary through Express Scripts. A formulary exception process is available if you feel the formulary alternatives are not appropriate. Prescribers may request a clinical exception by calling 1-800-753-2851.

The Consumer Driven Option prescription plan uses the Traditional Prescription Drug Formulary through OptumRx. A formulary exception process is available to physicians who feel the formulary alternatives are not appropriate. Physicians may request a clinical exception by calling 1-855-808-3003.

Does the Consumer Driven Option cover preventive care medications?

The Consumer Driven Option prescription plan covers preventive care medications with A and B recommendations from the U.S. Preventive Services Task Force. These may include some over-the-counter vitamins, nicotine replacement medications, and low-dose aspirin for certain patients.

View current recommendations

You pay:

Network retail: Nothing when prescribed by a healthcare professional and filled by a network pharmacy.

Network home delivery: Nothing when prescribed by a healthcare professional and filled by a network pharmacy.

Does the High Option cover preventive care medications?

The High Option prescription plan covers preventive care medications as follows:

• Medications to promote better health as recommended by ACA.

• Preventive medications with A and B recommendations from the U.S. Preventive Services Task Force. These may include some over-the-counter vitamins, nicotine replacement medications, and low-dose aspirin for certain patients.

View current recommendations

You pay:

Network retail: Nothing when prescribed by a healthcare professional and filled by a network pharmacy.

Non-network retail: 50% of cost for a 30-day supply.

Why use generic drugs?

A generic drug is a chemical equivalent of a corresponding brand-name 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.

High Option prescription benefits

With the High Option prescription plan, 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 an FDA-approved generic drug is available, and your prescriber has not received a preauthorization, you have to pay the difference in cost between the brand-name 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 1-800-753-2851.

High Option coverage limitations

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 1-800-841-2734.

What is Express Scripts Smart90?

Smart90 is a feature of your High Option prescription plan, managed by Express Scripts. With it, you have two ways to get up to a 90-day supply of your long-term medications (non-specialty drugs you take regularly for ongoing conditions):

1. Fill your prescriptions through home delivery from Express Scripts pharmacy.

2. Fill your prescriptions at a retail pharmacy the Smart90 network.

The High Option prescription plan includes access to nearly 64,000 pharmacies that belong to the Express Scripts network, along with home delivery options in all 50 states.

The advantages of getting up to a 90-day supply

By getting up to a 90-day supply of your long-term medication, you’ll make fewer trips to the pharmacy, and you’ll only need to make one payment every three months. Also, there’s usually a savings for getting one 90-day supply vs. three 30-day supplies at retail.

You will pay the same copayment for your 90-day supply whether you fill through home delivery from Express Scripts pharmacy or at a Smart90 network pharmacy.

To get started with Smart90, visit Express Scripts or call:

1-800-841-2734
1-800-759-1089 (TTY)
8 am – midnight ET, Monday – Friday
8 am – 6 pm ET, Saturday

If you’re a first-time visitor to the website, take a minute to register with your Health Plan member ID number.

What are prescription drug tiers?

Prescription drug lists (PDL) often have tiers, or groups of drugs categorized by cost. Generally, a drug in a lower tier will cost less than a drug in a higher tier. Your cost-share or copay is based on which tier your drug is in.

The High Option pharmacy plan has six drug tiers:

A 30-day supply of non-specialty retail prescription drugs and a 90-day supply of non-specialty mail-order prescription drugs have three tiers:

Tier 1: Includes generic drugs
Tier 2: Includes preferred brand-name drugs
Tier 3: Includes non-preferred brand-name drugs

A 30-day supply of specialty retail prescription drugs and a 90-day supply of specialty mail-order prescription drugs have three tiers:

Tier 4: Includes generic specialty drugs
Tier 5: Includes preferred brand-name specialty drugs
Tier 6: Includes non-preferred brand-name specialty

The Consumer Driven Option pharmacy plan has three drug tiers:

Tier 1: Mostly generic drugs, but some brand-name drugs may be included
Tier 2: A mix of brand-name and generic drugs
Tier 3: Mostly brand-name drugs and some generics

The Medicare PDP for Postal Service retirees and the Medicare PDP for federal retirees both have four drug tiers instead of the standard six tiers under Medicare Part D.

Plans can change the PDL at any time. Your plan must notify you of any changes to a list that affects the medications you take.

How do I file an online prescription drug claim?

Please submit a prescription drug claim form to request payment for covered services under your High Option plan.

If I enroll in Medicare Advantage, will I be penalized for not having drug coverage through APWU Health Plan previously?

If you had a Medicare Part D plan or coverage through PSHB or FEHB that included prescription drug coverage, you had what is known as “creditable coverage.” Creditable coverage means that your prescription drug coverage was at least as good as, or better than, what Medicare requires.

If you had creditable prescription drug coverage through another source, such as a spouse’s employer plan, you should have received a certificate of creditable coverage. This certificate is generally provided prior to tax season.

If you were eligible for Medicare Part D and you did not have any prescription drug coverage for more than 63 days, Medicare will determine if you need to pay a late enrollment penalty (LEP) for the length of time you were eligible but did not have Part D coverage. You may submit an appeal to have this LEP removed if you had creditable coverage. You will receive a letter from UnitedHealthcare if Medicare has reported a gap of more than 63 days with instructions on how to appeal this and provide proof of creditable coverage.

If I enroll in Medicare Advantage, do I need to get new OptumRx Home Delivery mail-order prescriptions?

You may need a new prescription. Your Home Delivery pharmacy is OptumRx, a UnitedHealth Group company. The Quick Start Guide that you receive following your enrollment in the plan will include OptumRx contact information.

Medicare Advantage pharmacies and prescriptions

APWU Health Plan FAQ

High Option prescription benefits

High Option coverage limitations

The advantages of getting up to a 90-day supply

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