2023 APWU Health Plan Federal Brochure

APWU Health Plan
www.apwuhp.com
Customer Service 800-222-2798
2023
A Fee-for-Service Plan (High Option) and a Consumer Driven Health
Plan with Preferred Provider Organizations
This plan's health coverage qualifies as minimum essential coverage

and meets the minimum value standard for the benefits it provides. See IMPORTANT
page 8 for details. This plan is accredited. See page 13. • Rates: Back Cover
• Changes for 2023: Page 15
Sponsored and administered by: American Postal Workers Union, • Summary of Benefits: Page 150
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 Membership dues: Associate members will be billed
Postal Service APWU bargaining unit employees must by the APWU for the $35 annual membership fee,
be, or must become, dues-paying members of the except where exempt by law. APWU will bill new
APWU, to be eligible to enroll in the Health Plan. All associate members for the annual dues when it receives
Federal and other Postal members and annuitants must notice of enrollment. APWU will also bill continuing
become associate member of APWU, see page 125 for associate members for the annual membership. APWU
details. 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).
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
• Types of coverage 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 ................................................................................................................................................................12
• 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
General features of our High Option.................................................................................................................................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 2023 .......................................................................................................................................................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 ..........................................................................................................................................................16
• 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
• Non-urgent care claims .................................................................................................................................................21
2023 APWU Health Plan 1 Table of Contents

• Urgent care claims ........................................................................................................................................................22
• Concurrent care claims .................................................................................................................................................22
• Emergency inpatient admission ....................................................................................................................................22
• Maternity care ...............................................................................................................................................................22
• 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 ......................................................................................................................................77
Non-FEHB Benefits Available to Plan Members......................................................................................................................125
Section 6. General Exclusions - Services, Drugs and Supplies We Do Not Cover ..................................................................126
Section 7. Filing a Claim For Covered Services ......................................................................................................................128
Section 8. The Disputed Claims Process..................................................................................................................................131
Section 9. Coordinating Benefits with Medicare and Other Coverage .....................................................................................134
When you have other health coverage ............................................................................................................................134
• TRICARE and CHAMPVA ........................................................................................................................................134
• Workers' Compensation ..............................................................................................................................................135
• Medicaid .....................................................................................................................................................................135
When other Government agencies are responsible for your care ...................................................................................135
When others are responsible for injuries.........................................................................................................................135
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) ........................................................137
Clinical trials ...................................................................................................................................................................137
When you have Medicare ...............................................................................................................................................138
• The Original Medicare Plan (Part A or Part B)...........................................................................................................138
• Tell us about your Medicare coverage ........................................................................................................................139
• Private contract with your physician ..........................................................................................................................139
• Medicare Advantage (Part C) .....................................................................................................................................139
• Medicare prescription drug coverage (Part D) ...........................................................................................................141
When you are age 65 or over and do not have Medicare ................................................................................................143
When you have the Original Medicare Plan (Part A, Part B, or both) ............................................................................144
Section 10. Definitions of Terms We Use in This Brochure ....................................................................................................145

Summary of Benefits for the High Option of the APWU Health Plan - 2023 ..........................................................................150
Summary of Benefits for the CDHP of the APWU Health Plan - 2023....................................................................................152
Index..........................................................................................................................................................................................154
2023 Rate Information for the APWU Health Plan ..................................................................................................................158

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, 2023, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2023, and changes are
summarized on 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.
2023 APWU Health Plan 4 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 APWU Health Plan complies with all applicable Federal civil rights laws, including Title VII of the Civil Rights Act of
1964.
You can also file a civil rights complaint with the Office of Personnel Management by mail at: Office of Personnel
Management Healthcare and Insurance Federal Employee Insurance Operations, Attention: Assistant Director FEIO, 1900 E
Street NW, Suite 3400 S, Washington, DC 20415-3610.

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?”

- “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.

FEHB Facts
Coverage information
• No pre-existing We will not refuse to cover the treatment of a condition you had before you enrolled in
condition limitation this Plan solely because you had the condition before you enrolled.
• Minimum essential Coverage under this plan qualifies as minimum essential coverage (MEC) and satisfies the
coverage (MEC) 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 value Our health coverage meets the minimum value standard of 60% established by the ACA.
standard 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.
• Where you can get See www.opm.gov/healthcare-insurance/healthcare for enrollment information as well as:
information about • Information on the FEHB Program and plans available to you
enrolling in the FEHB
Program • 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.
• Types of coverage Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and
available for you and one eligible family member. Self and Family coverage is for the enrollee and one or more
your family 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.
2023 APWU Health Plan 8 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 carrier to add a family member when there is already family Coverage.
Contact your employing or retirement office if you are changing from Self to Self Plus
One or Self and Family or to add a family member if you currently have a Self Only plan.
Your employing or retirement office will not notify you when a family member is no
longer eligible to receive benefits, nor will we. Please tell us immediately of changes in
family member status, including your marriage, divorce, annulment, or when your child
reaches 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 Member Family members covered under your Self and Family enrollment are your spouse
Coverage (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 26th
birthday.
Foster children
Coverage: Foster children are eligible for coverage until their 26th 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 26th birthday.
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 26th 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.
• Children's Equity Act 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.

• When benefits and The benefits in this brochure are effective January 1. If you joined this Plan during Open
premiums start 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 2023 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. 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 2023 but any unused PCA benefits from 2022 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 2022 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 you retire 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 lose benefits
• When FEHB coverage You will receive an additional 31 days of coverage, for no additional premium, when:
ends • 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 31st 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 60th day after the end of the 31 day temporary extension.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage
(TCC), or a conversion policy (a non-FEHB individual policy).

• Upon divorce If you are divorced from a Federal employee, or annuitant, you may not continue to get
benefits 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. 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.
• Temporary If you leave Federal service, Tribal employment, or if you lose coverage because you no
Continuation of longer qualify as a family member, you may be eligible for Temporary Continuation of
Coverage (TCC) 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.
• Converting to If you leave Federal or Tribal service, your employing office will notify you of your right
individual coverage 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.
• Health Insurance If you would like to purchase health insurance through the ACA's Health Insurance
Marketplace 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.
• APWU Health Plan The APWU Health Plan's Notice of Privacy Practices describes how medical information
Notice of Privacy about you may be used by the Health Plan, your rights concerning your health information
Practices 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.

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.
General features of our High Option
We have Preferred Provider Organizations (PPOs):

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 PPO networks for the
High Option and the Consumer Driven Option are different.
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 download a High Option PPO directory. If you
need assistance in identifying a participating provider or to verify their continued participation, call the Plan's PPO
administrator for your state: The Plan uses Cigna as its PPO network in all states and the U.S. Virgin Islands, Cigna
800-582-1314. For mental health/substance use disorder treatment providers (all states), call Cigna Behavioral Health,
800-582-1314.
When out of your state of residence, if you do not use a Cigna PPO provider or a Cigna PPO provider is not available,
standard non-PPO benefits apply. For assistance in identifying a provider in the network, call Cigna 800-582-1314.
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, www.welcometouhc.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 UHC 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.
2023 APWU Health Plan 13 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 60th percentile.
• For the Consumer Driven Option we use guides specifically prepared by Fair Health at the 80th 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.

Section 2. Changes for 2023
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 our High Option only
• Your share of the premium will increase for Self Only, Self Plus One and Self and Family. See page (see page 158).
• Out-of-network R&C has decreased to the 60th percentile (see page 14).
• Colorectal Cancer Screening Cologuard Kits are now covered starting at age 45 (see page 37).
• Iatrogenic fertility preservation procedure benefits were added with a $12,000 lifetime maximum (see page 40).
• Medical food formulas are now covered to treat Phenylketonuria (PKU) and other inborn errors of metabolism (see page
41).
• Copays for Virtual Visits through AmWell decreased to $10 (see pages 36 and 64).
• Repetitive Transcranial Magnetic Stimulation (TMS) now covered at a 15% coinsurance for PPO providers (see page 64).
• Intensive outpatient treatment no longer requires preauthorization (see page 65).
• Medicare Advantage enhanced benefits have increased to $85 for the Medicare Part B monthly reimbursement and $60
quarterly allowance for First Line Essentials, as well as a Renew Active gym membership and Healthy at Home Premium
(see page 139 and www.uhcvirtualretiree.com/apwuhp).
Changes to our Consumer Driven Health Plan only

• Your share of the premium will increase for Self Only, Self Plus One and Self and Family. See page (see page 158).
• Your share of the APWU Career premium will increase for Self Only, Self Plus One and Self and Family. See page (see
page 158).
• Colorectal Cancer Screening Cologuard Kits are now covered starting at age 45 (see page 81).
• Iatrogenic fertility preservation procedure benefits were added with a $12,000 lifetime maximum (see page 92).
• Medical food formulas are now covered to treat Phenylketonuria (PKU) and other inborn errors of metabolism (see page
93).
• Deductible and coinsurance no longer applies to bereavement benefits (see page 110).
• Prescription drugs have moved from a 3-tier traditional Prescription Drug List to a 3-tier advantage Prescription Drug List
(see page 117).
• Maven - a Maternity Support Program - has been added to our Health Education Resources (see page 124).
• Real Appeal program under Special Programs has been eliminated.

Section 3. How You Get Care
Identification cards 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.
Where you get covered You can get care from any “covered provider” or “covered facility.” How much we pay –
care and you pay – depends on the type of covered provider or facility you use. If you use our
preferred providers, you will pay less.
Balance Billing FEHB Carriers must have clauses in their in-network (participating) providers agreements.
Protection 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.
• Covered providers We provide benefits for the services of covered professional providers, as required by
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.
Covered professional 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.
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 and can be reached at
800-582-1314 for Cigna and 800-718-1299 for UnitedHealthcare for assistance.
• Covered facilities 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.
• Transitional care 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.
• If you are hospitalized We pay for covered services from the effective date of your enrollment. However, if you
when your enrollment are in the hospital when your enrollment in our High Option begins, call our Customer
begins 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 92nd day after you become a member of this Plan, whichever happens first.
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.

You need prior Plan The pre-service claim approval processes for inpatient hospital admissions (called
approval for certain precertification) and for other services, are detailed in this Section. A pre-service claim is
services 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).
• Inpatient hospital Precertification is the process by which – prior to your inpatient hospital admission – we
admission, inpatient evaluate the medical necessity of your proposed stay and the number of days required to
residential treatment treat your condition. Unless we are misled by the information given to us, we won’t
center admission or change our decision on medical necessity.
skilled nursing facility
admission 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.
Warning 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.
Exceptions 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.
• Other services Some services require prior approval.
Under the High Option, call Cigna/CareAllies at 800-582-1314 if you need any of the
services listed below:
• Applied Behavioral Analysis (ABA)
• 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, page 146)
• Home healthcare such as nursing visits, infusion therapy, growth hormone therapy
(GHT), rehabilitative and habilitative therapy (speech therapy) and pulmonary
rehabilitation programs
• Iatrogenic fertility preservation procedures
• 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, facet joint injections, sacroiliac joint injections.
• Organ transplantation - call before your first evaluation as a potential candidate
• Procedures which may be cosmetic in nature such as eyelid surgery (blepharoplasty),
varicose vein surgery (sclerotherapy), or Botox injections for medical diagnosis
• Recognized surgery for morbid obesity (bariatric surgery) or for organic impotence
• 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
• 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
• 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), page
72), and Optum Rx at 800-718-1299 for the Consumer Driven Option (see Section 5
(f), page 120).

• 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
(Cigna Behavioral Health for the High Option and UHC Behavioral Health Solutions
for the Consumer Driven Option). Under the High Option, call Cigna Behavioral
Health at 800-582-1314. Under the Consumer Driven Option, call UHC Behavioral
Health Solutions at 800-718-1299.
How to request • High Option: First you, your representative, your physician, or your hospital must
precertification for an call Cigna/CareAllies at 800-582-1314 at least 2 business days before admission or
admission or get prior services requiring prior authorization are rendered. For mental health and substance
authorization for Other use disorder inpatient treatment, your physician or your hospital must call Cigna/
services CareAllies at 800-582-1314 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.
What happens when you • If no one contacts us, we will decide whether the hospital stay was medically
do not follow the necessary.
precertification rules • If we determine that the stay was medically necessary, we will pay the inpatient
charges, less the $500 penalty.
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.
• Radiology/imaging High Option: Radiology precertification is required prior to scheduling specific imaging
procedures procedures. We evaluate the medical necessity of your proposed procedure to ensure that
precertification 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
• How to precertify a For these outpatient studies, you, your representative or doctor must call Cigna/CareAllies
radiology/imaging before scheduling the procedure. The toll free number is 800-582-1314.
procedure • 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
Warning 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.
Exceptions 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
• Non-urgent care For non-urgent care claims, we will tell the physician and/or hospital the number of
claims 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.
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.

• Urgent care claims 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).
Concurrent 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.
• Emergency inpatient If you have an emergency admission due to a condition that you reasonably believe puts
admission 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.
• Maternity care 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
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.
• If your hospital stay High Option: If your hospital stay – including for maternity care – needs to be extended,
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 Cigna/CareAllies at 800-582-1314.
If you remain in the hospital beyond the number of days we approved and did not get the
additional days precertified, then
benefits, but
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
benefits, but
pay inpatient benefits for out-of-network services only.
• If your treatment If you request an extension of an ongoing course of treatment at least 24 hours prior to the
needs to be extended 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 you disagree with our If you have a pre-service claim and you do not agree with our decision regarding
pre-service decision 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.
• To reconsider a non- Within 6 months of our initial decision, you may ask us in writing to reconsider our initial
urgent care claim 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.
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.
• To reconsider an In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial
urgent care claim 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 file an appeal with After we reconsider your pre-service claim, if you do not agree with our decision, you
OPM may ask OPM to review it by following Step 3 of the disputed claims process detailed in
Section 8 of this brochure.

Section 4. Your Costs for Covered Services
This is what you will pay out-of-pocket for covered care:
Cost-sharing 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.
Copayment 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.
Deductible 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.

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 and Family: $2,400
In-Network Net Deductible (You Pay)

Self Only: $1,000
Coinsurance 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.
If your provider routinely If your provider routinely waives (does not require you to pay) your copayments,
waives your cost 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).

Waivers 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.
Differences between our High Option: Our “Plan allowance” is the amount we use to calculate our payment for
allowance and the bill 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

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.
Your Catastrophic There is a limit to the amount you must pay out-of-pocket for combined medical and
protection out-of-pocket prescription drug coinsurance for the year for certain charges. When you have reached this
maximum for limit, you pay no coinsurance for covered services for the remainder of the calendar year.
deductibles, coinsurance
and copayments 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

• 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, pages 18-20)
• 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,
see page 42, and acupuncture, see page 46
• 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

• 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, pages 18-20)
• 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
Carryover 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.
If we overpay you 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.
When Government Facilities of the Department of Veterans Affairs, the Department of Defense, and the
facilities bill us 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.

Important Notice About The No Surprises Act (NSA) is a federal law that provides you with protections against
Surprise Billing - Know "surprise billing" and "balance billing" under certain circumstances. A surprise bill is an
Your Rights unexpected bill you receive from a nonparticipating healthcare provider, facility, or air
ambulance service for healthcare. Surprise bills can happen when you receive emergency
care - when you have little or no say in the facility or provider from whom you receive
care. They can also happen when you receive non-emergency services at participating
facilities, but you receive some care from nonparticipating providers.
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
unexpected 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.
The Federal Flexible Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare
Spending Account expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs
Program - FSAFEDS 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.

Section 5. High Option Health Plan Benefits
See page 15 for how our benefits changed this year. Page 150 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
2023 APWU Health Plan 32 High Option Section 5

Professional services .........................................................................................................................................................64
TeleHealth services ...........................................................................................................................................................64
Diagnostics ........................................................................................................................................................................65
Inpatient hospital or other covered facility .......................................................................................................................65
Outpatient hospital or other covered facility.....................................................................................................................65
Section 5 (f). Prescription Drug Benefits ...................................................................................................................................66
Covered medications and supplies ....................................................................................................................................68
Preventive care medications..............................................................................................................................................71
Section 5 (g). Dental Benefits ....................................................................................................................................................74
Accidental injury benefit ...................................................................................................................................................74
Dental benefits service ......................................................................................................................................................74
Section 5 (h). Wellness and Other Special Features...................................................................................................................75
Flexible benefits option .....................................................................................................................................................75
24-hour nurse line .............................................................................................................................................................75
Services for deaf and hearing impaired.............................................................................................................................75
Disease Management Program..........................................................................................................................................75
Review and Reward Program ...........................................................................................................................................75
Weight Management Program...........................................................................................................................................75
Healthy Pregnancies, Healthy Babies® Program .............................................................................................................75
Special Programs...............................................................................................................................................................76
Online tools and resources ................................................................................................................................................76
Health Risk Assessment (HRA) ........................................................................................................................................76
Consumer choice information ...........................................................................................................................................76
Summary of Benefits for the High Option of the APWU Health Plan - 2023 ..........................................................................150
2023 APWU Health Plan 33 High Option Section 5

High Option
High Option Overview

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 Well Woman 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.
Special features
Obtaining help from a medical professional is quick, confidential, and free with the Plan’s voluntary Nurse Advisory Line,
available 24/7 anywhere in the country. Our voluntary Disease and Weight Management programs offer some $0 copays and
coinsurance for members with these conditions. Online access to claims information and customer service is available
through www.myAPWUHP.com. 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 consumer health information and non-FEHB savings on health and wellness products, and a CignaPlus
Savings dental discount card when a Health Risk Assessment is completed.
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 on page 139.
2023 APWU Health Plan 34 High Option Section 5 Overview

High Option
Section 5 (a). Medical Services and Supplies Provided by Physicians and Other
Healthcare Professionals
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 PPO: $25 copayment (No deductible)
• In physician’s office Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount
Professional services of physicians PPO: 15% of the Plan allowance
• During a hospital stay Non-PPO: 40% of the Plan allowance and any
• In a skilled nursing facility difference between our allowance and the
• Second surgical opinion billed amount
• At home
• At Cancer Centers of Excellence PPO Cancer Center of Excellence (COE): 5%

of the Plan allowance
Diagnostic and treatment services - continued on next page
2023 APWU Health Plan 35 High Option Section 5(a)

High Option

Diagnostic and treatment services (cont.) High Option
Note: To receive the higher level of benefits for cancer related PPO Cancer Center of Excellence (COE): 5%
treatment, you are required to visit a designated Cancer Center of of the Plan allowance
Excellence facility.
TeleHealth Services High Option
• Virtual visits are available through AmWell AmWell: $10 copayment (No deductible)
You can receive treatment from board-certified doctors for your non- PPO: $25 copayment (No deductible)
emergency conditions such as the flu, strep throat, eye infections, Non-PPO: N/A
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 see www.AmWell.com, or call 855-818-DOCS for information

on virtual visits
Note: There are no out-of-network benefits for Virtual visits.

Lab, X-ray and other diagnostic tests High Option
Tests, such as: PPO: 15% of the Plan allowance
• Blood tests Non-PPO: 40% of the Plan allowance and any
• Urinalysis difference between our allowance and the
• Non-routine Pap test billed amount
• Pathology Note: If your PPO provider uses a non-PPO lab

• X-ray or radiologist, we will pay non-PPO benefits
for lab and X-ray charges billed by these non-
• Non-routine mammogram, including 3D mammogram PPO providers.
• CT/CAT Scan/MRI/MRA/NC/PET (Outpatient requires
precertification – see Section 3, except for NC)
• Ultrasound
• Electrocardiogram and EEG
If LabCorp or Quest Diagnostics performs your covered lab services, Nothing (No deductible)
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 Cigna at
800-582-1314; or visit our website at www.apwuhp.com.
Note: Not available in the U.S. Virgin Islands.

Not covered: All charges
• Professional fees for automated lab tests
• Genetic screening (see Definition, Section 10)
• Qualitative (definitive) urine drug panel testing that is not medically
necessary

High Option

Preventive care, adult High Option
Routine physical every calendar year. PPO: Nothing (No deductible)
The following preventive services are covered at the time interval Non-PPO: 40% of the Plan allowance and any
recommended at each of the links below: difference between our allowance and the
• Immunizations such as Pneumococcal, influenza, shingles, tetanus/ billed amount
DTaP, 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. For a complete list of screenings go to the U.S. Preventive
Services Task Force (USPSTF) website at: www.
uspreventiveservicestaskforce.org
• 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
• Routine mammogram - covered for women, including 3D PPO: Nothing (No deductible)
mammograms covered for women age 35 and older; as follows:
Non-PPO: 40% of the Plan allowance and any
- From age 35 through 39, one during this five year period difference between our allowance and the
- From age 40, one every calendar year billed amount
• To build your personalized list of preventive services go to https://
health.gov/myhealthfinder
• Adult immunizations endorsed by the Centers for Disease Control and PPO: Nothing (No deductible)
Prevention (CDC): based on the Advisory Committee on
Immunization Practices (ACIP) schedule. Non-PPO: 40% of the Plan allowance and any
Note: For immunizations at a network pharmacy, (see Section 5(f), billed amount
Prescription drug benefits).
Preventive care, adult - continued on next page

High Option

Preventive care, adult (cont.) High Option
Note: Any procedure, injection, diagnostic service, laboratory, or X-ray PPO: Nothing (No deductible)
service done in conjunction with a routine examination and is not
included in the preventive recommended listing of services will be Non-PPO: 40% of the Plan allowance and any
subject to the applicable member copayments, coinsurance, and difference between our allowance and the
deductible. billed amount
Preventive care, children High Option

• Well-child visits, examinations, and other preventive services as PPO: Nothing (No deductible)
described in the Bright Future Guidelines provided by the American
Academy of Pediatrics. For a complete list of the American Academy Non-PPO: Any difference between the Plan
of Pediatrics Bright Futures Guidelines go to: https://brightfutures. allowance and the billed charge (No
aap.org deductible)
• Immunizations such as DTaP, 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: www.uspreventiveservicestaskforce.org
• Examinations, limited to: PPO: Nothing (No deductible)

- Examinations for amblyopia and strabismus - limited to one Non-PPO: Any difference between the Plan
screening examination (ages 3 through 5) allowance and the billed charge and any
- Examinations done on the day of immunizations (ages 3 through amount above $250 per child (ages 0 through
21) 3) each year and any amount above $150 per
- One Screening Examination of Premature Infants for Retinopathy child (ages 4 through 18) each year (No
of Prematurity or infants with low birth weight or gestational age of deductible)
32 weeks or less
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

included in the preventive recommended listing of services will be
subject to the applicable member copayments, coinsurance, and
deductible.
• 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

High Option

Maternity care High Option
Complete maternity (obstetrical) care, such as: PPO: Nothing (No deductible)
• Screening for gestational diabetes Non-PPO: 40% of the Plan allowance and any
• Prenatal care difference between our allowance and the
• Delivery billed amount
• Postnatal care
• Initial examination of a newborn child covered under a Self Plus One Note: For inpatient hospital care related to
or Self and Family enrollment maternity, we pay for covered services in full
• Breastfeeding support, supplies and counseling for each birth when you use preferred providers.
Note: Maternity care expenses incurred by a Plan member serving as a Note: In-network facility and lab services
surrogate mother are covered by the Plan subject to reimbursement from directly related to covered, in-network
the other party to the surrogacy contract or agreement. The involved maternity care will also be covered at 100%.
Plan member must execute our Reimbursement Agreement completed Note: For Non-PPO inpatient hospital, a $300
by APWU Health Plan against any payment they may receive under the per admission fee applies.
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
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.
Note: To obtain the in-network, breastfeeding equipment and supplies,

please call 877-466-0164 after 28 weeks of pregnancy. A physician's
order is required.
• We will cover other care of an infant who requires non-routine PPO: 15% of the Plan allowance
treatment if we cover the infant under a Self Plus One or Self and
Family enrollment. Surgical benefits, not maternity benefits, apply to Non-PPO: 40% of the Plan allowance and any
circumcision of a covered newborn. difference between our allowance and the
billed amount
• Amniocentesis if for diagnosing multiple births
• Genetic screening (see Definitions, Section 10, page 146)

High Option

Family Planning High Option
Contraceptive counseling on an annual basis PPO: Nothing (No deductible)
Note: If you have concerns about the Health Plan’s compliance with the Non-PPO: 40% of the Plan allowance and any
ACA/HRSA requirements contact [email protected]. See OPM’s difference between our allowance and the
web page about contraception. billed amount
A range of voluntary family planning services, limited to: PPO: Nothing (No deductible)
• Tubal ligation and tubal implant procedures Non-PPO: 40% of the Plan allowance and any
• Surgically implanted contraceptives difference between our allowance and the
• Injectable contraceptive drugs (such as Depo Provera) billed amount
• Intrauterine devices (IUDs)

• Diaphragms
Note: We cover oral contraceptives under Section 5(f), Prescription drug

benefits
• Voluntary vasectomy (see Surgical procedures, Section 5(b)) PPO: 15% of the Plan allowance

billed amount
• Reversal of voluntary surgical sterilization
• Genetic testing and counseling
Infertility services High Option

• Diagnosis and treatment of infertility, except as shown in Not covered PPO: 15% of the Plan allowance and all
charges after we pay $2,500 in a calendar year
Limited benefits: We pay a maximum of $2,500 for medical and $2,500
for prescription drugs each calendar year per person to diagnose and Non-PPO: 40% of the Plan allowance and all
treat infertility. See Section 5(f), Prescription drug benefits charges after we pay $2,500 in a calendar year
• Iatrogenic fertility preservation procedures (retrieval of and freezing PPO: 15% of the Plan allowance
of eggs or sperm) caused by chemotherapy, pelvic radiotherapy, ovary
or testicle removal and other gonadotoxic therapies for the treatment Non-PPO: 40% of the Plan allowance
of disease and gender reassignment.
Note: Fertility preservation procedures require prior approval (see

Section 3, Other services).
Limited benefits: $12,000 lifetime maximum.

• Infertility services after voluntary sterilization
• Assisted reproductive technology (ART) procedures, such as:
- Artificial insemination (all procedures) (AI)
- In vitro fertilization (IVF)
- Embryo transfer and gamete intra-fallopian transfer (GIFT) and
zygote intra-fallopian transfer (ZIFT)
- Intravaginal insemination (IVI)
- Intracervical insemination (ICI)
Infertility services - continued on next page

High Option

Infertility services (cont.) High Option
- Intrauterine insemination (IUI) All charges
• Services and supplies related to ART procedures
• Cost of donor sperm
• Cost of donor egg
Allergy care High Option

• Testing and treatment, including materials (such as allergy serum) PPO: 15% of the Plan allowance
• Allergy injections Non-PPO: 40% of the Plan allowance and any
billed amount
• Provocative food testing
• Sublingual allergy desensitization
Treatment therapies High Option

• Chemotherapy and radiation therapy PPO: 15% of the Plan allowance
Note: High dose chemotherapy in association with autologous bone Non-PPO: 40% of the Plan allowance and any
marrow transplants is limited to those transplants listed on pages 52-54. difference between our allowance and the
billed amount
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy -
preauthorization is required, (see Other services, Section 3, page 18)
• 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, page 69). 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
• Medical food formulas ordered by a healthcare provider that are PPO: 15% of the Plan allowance and all
medically necessary to treat specific nutritional risks, including charges after we pay $2,500 in a calendar year
Phenylketonuria (PKU) and other inborn errors of metabolism (IEM).
Non-PPO: 40% of the Plan allowance and all
Limited benefits: We pay a maximum of $2,500 for each calendar year. charges after we pay $2,500 in a calendar year
• Gene Therapy: Curative gene therapy for rare genetic conditions PPO: 15% of the Plan allowance
Note: Preauthorization of gene therapy is required, (see Other services, NON PPO: All charges
Section 3, page 18)
Treatment therapies - continued on next page

High Option

Treatment therapies (cont.) High Option
• Medical foods for conditions other than permanent inborn errors of
metabolism.
Physical and occupational therapies High Option

Physical therapy and occupational therapy provided by a licensed PPO: 15% of the Plan allowance
registered therapist or physician up to a combined 60 visits per calendar
year Non-PPO: 40% of the Plan allowance and any
Note: We also have the right to deny any type of therapy, service or billed amount
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.
• Maintenance therapies
• Exercise programs
Applied behavioral analysis (ABA) High Option

Outpatient Applied Behavioral Analysis (ABA) services, for the PPO: 15% of the Plan allowance
treatment of Autism Spectrum Disorder. Services must be provided
under the supervision of a Board Certified Behavior Analyst who is Non-PPO: All charges
contracted with Cigna Behavioral Health, or agrees to participate with
Cigna Behavioral Health's care management activities.
Preauthorization required by Cigna Behavioral Health.
Note: Cigna Behavioral Health Options' 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.
Speech therapy High Option
Speech therapy where medically necessary and provided by a licensed PPO: 15% of the Plan allowance
therapist
Note: Preauthorization of speech therapy is required, (see Other difference between our allowance and the
services, Section 3, page 18). billed amount
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

High Option

Hearing services (testing, treatment, and supplies) High Option
• For treatment related to illness or injury, including evaluation and PPO: 15% of the Plan allowance
diagnostic hearing tests performed by an M.D., D.O., or audiologist
• One examination and testing for hearing aids every 2 years difference between our allowance and the
billed amount
Note: For routine hearing screening performed during a child's
preventive care visit, (see Section 5(a), Preventive care, children, page
38).
• External hearing aids Note: For benefits for the devices see Section
• Implanted hearing-related devices, such as bone anchored hearing 5(a), Orthopedic and prosthetic devices, see
aids (BAHA) and cochlear implants for bilateral hearing loss page 44.

• Hearing services that are not shown as covered
Vision services (testing, treatment, and supplies) High Option

• Internal (implant) ocular lenses and/or the first contact lenses required PPO: 15% of the Plan allowance
to correct an impairment caused by accident or illness. The services of
an optometrist are limited to the testing, evaluation and fitting of the Non-PPO: 40% of the Plan allowance and any
first contact lenses required to correct an impairment caused by difference between our allowance and the
accident or illness billed amount
Note: See Section 5(a), Preventive care, children, page 38 for eye
exams for children.
• Eyeglasses or contact lenses and examinations for them
• Eye exercises and visual training
• Radial keratotomy and other refractive surgery
• Refraction
Foot care High Option

Routine foot care when you are under active treatment for a metabolic PPO: $25 copayment for the office visit (No
or peripheral vascular disease, such as diabetes deductible) plus 15% of the Plan allowance for
other services performed during the visit

billed amount
• 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)

High Option

Orthopedic and prosthetic devices High Option
• Artificial limbs and eyes PPO: 15% of the Plan allowance
• Prosthetic sleeve or sock Non-PPO: 40% of the Plan allowance and any
• Externally worn breast prostheses and surgical bras, including difference between our allowance and the
necessary replacements following a mastectomy billed amount
• 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, page 18).
Note: We require preauthorization of artificial limbs, (see Other

services, Section 3, page 18).
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.
External hearing aids PPO: All charges in excess of $1,500, up to the
• Covered every 3 years limited to $1,500 PPO allowance (No deductible)
Non-PPO: All charges in excess of $1,500 (No

Note: Excluding batteries, benefits for hearing aid dispensing fees, deductible)
accessories, supplies, and repair service are included in the benefit limit
described above.
• 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
Durable medical equipment (DME) High Option

Durable medical equipment (DME) is equipment and supplies that: PPO: 15% of the Plan allowance
1. Are prescribed by your attending physician (i.e., the physician who is Non-PPO: 40% of the Plan allowance and any
treating your illness or injury) difference between our allowance and the
2. Are medically necessary billed amount
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
Durable medical equipment (DME) - continued on next page

High Option

Durable medical equipment (DME) (cont.) High Option
We cover rental or purchase, of durable medical equipment, at our PPO: 15% of the Plan allowance
option, including repair and adjustment. Covered items include but are
not limited to: Non-PPO: 40% of the Plan allowance and any
• Oxygen billed amount
• 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, page 18).
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.
• 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
Home health services High Option

Services for skilled nursing care up to 25 visits per calendar year, not to PPO: 15%; all charges in excess of two hours
exceed two hours per day, when preauthorized; and
Non-PPO: 40%; all charges in excess of two
• a registered nurse (R.N.), licensed practical nurse (L.P.N.) or licensed hours
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
Note: Skilled nursing care must be preauthorized (see Other services,

Section 3, page 18).
Home health services - continued on next page

High Option

Home health services (cont.) High Option
• 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
Chiropractic High Option

Chiropractic treatment limited to 24 visits and/or manipulations per year PPO: $25 copayment (No deductible)
Note: X-ray covered under Lab, X-ray and other diagnostic tests, page Non-PPO: 40% of the Plan allowance and any
36. difference between our allowance and the
billed amount.
• Massage therapy
• Maintenance therapy
Alternative treatments High Option

Acupuncture – by a doctor of medicine or osteopathy or licensed PPO: $25 copayment (No deductible)
acupuncturist, benefits are limited to 26 visits per person per calendar
year Non-PPO: 40% of the Plan allowance and any
billed amount
• Services of any provider not listed as covered (see Covered
providers, Section 3, page 16)
Educational classes and programs High Option

You may enroll in a Tobacco Cessation program as follows: PPO: Nothing (No deductible)
• Telephonic counseling sessions with Cigna/CareAllies or; Non-PPO: 40% of the Plan allowance and any
• Group therapy sessions or; difference between our allowance and the
• Educational sessions with a physician billed amount
Note: Enrollment in the Cigna/CareAllies program must be initiated by

the member. For more information contact Cigna/CareAllies at
800-582-1314.
Select over-the-counter and prescription Tobacco Cessation medications PPO: Nothing (No deductible)
approved by the FDA to treat tobacco dependence. For a listing of
medications go to our website at: Non-PPO: All charges
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.
Educational classes and programs - continued on next page

High Option

Educational classes and programs (cont.) High Option
Childhood obesity screening programs and treatment interventions PPO: Nothing (No deductible)

billed amount
Diabetes self-management training services, up to 10 hours initial PPO: 15% of the Plan allowance
training the first year and 2 hours subsequent training annually.
billed amount

High Option
Section 5 (b). Surgical and Anesthesia Services

Provided by Physicians and Other Healthcare Professionals
• 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
• 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.
• 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.
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: PPO: 15% of the Plan allowance
• Operative procedures Non-PPO: 40% of the Plan allowance and any
• Treatment of fractures, including casting difference between our allowance and the
• Normal pre- and post-operative care by the surgeon billed amount
• Correction of amblyopia and strabismus

• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of morbid obesity (bariatric surgery) requires
preauthorization (see Other services, Section 3, page 18)
• Insertion of internal prosthetic devices (see Section 5(a), Orthopedic
and prosthetic devices, page 44, for device coverage information)
• Voluntary vasectomy
• Treatment of burns
Surgical procedures - continued on next page
2023 APWU Health Plan 48 High Option Section 5(b)

High Option

Surgical procedures (cont.) High Option
• Assistant surgeons - We cover up to 20% of our allowance for the PPO: 15% of the Plan allowance
surgeon’s charge
billed amount
• Tubal ligation and tubal implant procedures PPO: Nothing (No deductible)
• Surgical implanted contraceptives Non-PPO: 40% of the Plan allowance and any
• Intrauterine devices (IUDs) difference between our allowance and the
billed amount
When multiple or bilateral surgical procedures performed during the PPO: 15% of the Plan allowance for the
same operative session add time or complexity to patient care, our primary procedure and 15% of one-half of the
benefits are: Plan allowance for the secondary procedure(s)
• For the primary procedure: Non-PPO: 40% of the Plan allowance for the
- PPO: 85% of the Plan allowance; or primary procedure and 40% of one-half of the
- Non-PPO: 60% of the Plan allowance Plan allowance for the secondary procedure(s);
and any difference between our allowance and
• For the secondary procedure(s): the billed amount
- 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.

• 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
• Routine treatment of conditions of the foot (see Foot care, Section 5
(a), page 43)

High Option

Reconstructive surgery High Option
• Surgery to correct a functional defect PPO: 15% of the Plan allowance
• Surgery to correct a condition caused by injury or illness if: Non-PPO: 40% of the Plan allowance and any
- The condition produced a major effect on the member’s appearance difference between our allowance and the
and billed amount
- 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, page 44, 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.
• Surgical treatment of gender affirmation such as surgical change of PPO: 15% of the Plan allowance
sex characteristics. For female to male surgery: mastectomy,
hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, Non-PPO: 40% of the Plan allowance and any
phalloplasty, urethroplasty, scrotoplasty, and placement of testicular difference between our allowance and the
and erectile prosthesis. For male to female surgery: penectomy, billed amount
orchiectomy, vaginoplasty, clitoroplasty, labiaplasty
- Benefits are limited to once per covered procedure, per lifetime
- Benefits are not available for repeat or revision procedure when
benefits were provided for initial procedure
• Gender affirming surgery benefits are only available for the diagnosis
of gender
Requirements:
1. Prior approval is required.
2. Must be at least 18 years of age at time prior approval is requested
and treatment plan is submitted.
3. Must have diagnosis of gender dysphoria by a qualified healthcare
professional.
4. New gender identity has been present for at least 24 continuous
months.
5. Member has a strong desire to be rid of primary and/or secondary sex
characteristics because of a marked incongruence with the member’s
identified gender.
Reconstructive surgery - continued on next page

High Option

Reconstructive surgery (cont.) High Option
6. Member’s gender dysphoria is not a symptom of another mental PPO: 15% of the Plan allowance
disorder or chromosomal abnormality.
7. Gender dysphoria causes clinical distress or impairment in social, difference between our allowance and the
occupational, or other important areas of functioning. billed amount
8. 12 months of continuous hormone therapy appropriate to the
member's gender identity.
9. Two referral letters from qualified mental health professionals, one of
them being a psychiatrist or clinical psychologist (PhD). One must be
from the psychotherapist who has treated the member for at least 12
continuous months. Letters must document: diagnosis of persistent
and chronic gender dysphoria; any existing co-morbid conditions are
stable; member is prepared to undergo surgery and understands all
practical aspects of the planned surgery.
10.If medical or mental health concerns are present, they are being
optimally managed and are reasonably well-controlled.

• Cosmetic surgery – any surgical procedure (or any portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury if
repair is initiated within two years of the accident
Oral and maxillofacial surgery High Option

Oral surgical procedures, limited to: PPO: 15% of the Plan allowance
• Reduction of fractures of the jaw or facial bones Non-PPO: 40% of the Plan allowance and any
• Surgical correction of cleft lip, cleft palate or severe functional difference between our allowance and the
malocclusion billed amount
• 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
Oral and maxillofacial surgery - continued on next page

High Option

Oral and maxillofacial surgery (cont.) High Option
• Sinusotomy, including repair of oroantral and oromaxillary fistula PPO: 15% of the Plan allowance
and/or root recovery
• Surgical treatment of trigeminal neuralgia difference between our allowance and the
• Frenectomy or frenotomy, skin graft or vestibuloplasty-stomatoplasty billed amount
unrelated to periodontal disease
• Incision and drainage of cellulitis unrelated to tooth structure
Note: Call us at 800-222-2798 to determine if a procedure is 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
Organ/tissue transplants High Option

These solid organ transplants are subject to medical necessity and PPO: 15% of the Plan allowance
experimental/investigational review by the Plan. Refer to Other services
in Section 3, page 18, for prior authorization procedures. Non-PPO: 40% of the Plan allowance and any
Solid organ transplants are limited to: billed amount and any amount over $50,000 for
• Autologous pancreas islet cell transplant (as an adjunct to total or near kidney transplants or $100,000 for other listed
total pancreatectomy) only for patients with chronic pancreatitis transplants
• 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
Organ/tissue transplants - continued on next page

High Option

Organ/tissue transplants (cont.) High Option
These tandem blood or marrow stem cell transplants for covered PPO: 15% of the Plan allowance
transplants are subject to medical necessity review by the Plan. Refer
to Other services in Section 3, page 18, for prior authorization Non-PPO: 40% of the Plan allowance and any
procedures. difference between our allowance and the
billed amount and any amount over $50,000 for
• Autologous tandem transplants for kidney transplants or $100,000 for other listed
- AL Amyloidosis transplants
- Multiple myeloma (de novo and treated)
- Recurrent germ cell tumors (including testicular cancer)
Blood or marrow stem cell transplants PPO: 15% of the Plan allowance
The Plan extends coverage for the diagnoses as indicated below: Non-PPO: 40% of the Plan allowance and any
• Allogeneic transplants for difference between our allowance and the
- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) kidney transplants or $100,000 for other listed
leukemia transplants
- 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)
- 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)

High Option

- Severe combined immunodeficiency PPO: 15% of the Plan allowance
- Severe or very severe aplastic anemia Non-PPO: 40% of the Plan allowance and any
- Sickle cell anemia (pediatric only) difference between our allowance and the
- X-linked lymphoproliferative syndrome billed amount and any amount over $50,000 for
kidney transplants or $100,000 for other listed
• Autologous transplants for transplants
- Acute lymphocytic or non-lymphocytic (i.e., myelogenous)
leukemia
- Advanced childhood kidney cancers
- 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
- Pineoblastoma
- Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell
tumors
- Waldenstrom's macroglobulinemia
Mini-transplants (non-myeloablative, reduced intensity conditioning or PPO: 15% of the Plan allowance
RIC) are subject to medical necessity review by the Plan.
kidney transplants or $100,000 for other listed
transplants
These blood or marrow stem cell transplants are covered only in a PPO: 15% of the Plan allowance
National Cancer Institute or National Institutes of Health
approved clinical trial or a Plan-designated center of excellence. Non-PPO: 40% of the Plan allowance and any
If you are a participant in a clinical trial, the Plan will provide benefits billed amount and any amount over $50,000 for
for related routine care that is medically necessary (such as doctor visits, kidney transplants or $100,000 for other listed
lab tests, X-rays and scans, and hospitalization related to treating the transplants
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.

High Option

Transplant Network PPO: 15% of the Plan allowance
The Plan uses specific Plan-designated organ/tissue transplant facilities. Non-PPO: 40% of the Plan allowance and any
Before your initial evaluation as a potential candidate for a transplant difference between our allowance and the
procedure, you or your doctor must contact the precertification vendor billed amount and any amount over $50,000 for
(see Other services, Section 3); Cigna at 1-800-668-9682; and ask to kidney transplants or $100,000 for other listed
speak to a Transplant Case Manager. You will be provided with transplants
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.
• Donor screening tests and donor search expenses, except as shown
above
• Transplants not listed as covered
Anesthesia High Option

Professional services for administration of anesthesia PPO: 15% of the Plan allowance
Note: If surgical services are rendered at a PPO hospital or a PPO Non-PPO: 40% of the Plan allowance and any
freestanding ambulatory facility, we will pay the services of non-PPO difference between our allowance and the
anesthesiologists at the PPO rate, based on Plan allowance. billed amount

High Option
Section 5 (c). Services Provided by a Hospital or Other Facility, and Ambulance

Services
• 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 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 page 18 for prior approval and
page 50 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.
Note: The calendar year deductible applies ONLY when we say below: “(calendar year deductible applies).”
Inpatient hospital High Option
Room and board, such as: PPO: 15% of the covered charges
• Ward, semiprivate, or intensive care accommodations Non-PPO: $300 per admission and 40% of the
• General nursing care covered charges and any difference between
• Meals and special diets our allowance and the billed amount
Note: For inpatient hospital care related to

Note: We only cover a private room when you must be isolated to maternity, we pay for covered services in full
prevent contagion. Otherwise, we will pay the hospital’s average charge when you use preferred providers, (see Section
for semiprivate accommodations. If the hospital only has private rooms, 5(a), Maternity care, page 39.)
we will cover the private room rate.
Inpatient hospital - continued on next page
2023 APWU Health Plan 56 High Option Section 5(c)

High Option

Inpatient hospital (cont.) High Option
Note: When the non-PPO hospital bills a flat rate, we prorate the charges PPO: 15% of the covered charges
to determine how to pay them, as follows: 30% room and board and
70% other charges. Non-PPO: $300 per admission and 40% of the
covered charges and any difference between
our allowance and the billed amount

maternity, we pay for covered services in full
when you use preferred providers, (see Section
5(a), Maternity care, page 39.)
Other hospital services and supplies, such as: PPO: 15% of the covered charges
• Operating, recovery, maternity, and other treatment rooms Non-PPO: $300 per admission and 40% of the
• Prescribed drugs and medications covered charges and any difference between
• Diagnostic laboratory tests and X-rays our allowance and the billed amount.
• Blood or blood plasma, if not donated or replaced Note: For inpatient hospital care related to
• Dressings, splints, casts, and sterile tray services maternity, we pay for covered services in full
• Medical supplies and equipment, including oxygen 5(a), Maternity care, page 39.)
• 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.
• Any part of a hospital admission that is not medically necessary (see
Section 10, Definitions, page 147), 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, page 145)
• 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

High Option

Cancer Centers of Excellence High Option
The Plan provides access to designated Cancer Centers of Excellence. PPO Cancer Centers of Excellence (COE): 5%
For information, you must contact Cigna/CareAllies at 800-582-1314 of the Plan allowance
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 Cigna/CareAllies, you will be provided with

information about the Cancer Centers of Excellence.
Outpatient hospital or ambulatory surgical center High Option
• Operating, recovery, and other treatment rooms PPO: 15% of the Plan allowance (calendar year
• Prescribed drugs and medications deductible applies)
• Diagnostic laboratory tests, X-rays, and pathology services Non-PPO: 40% of the Plan allowance and any
• Administration of blood, blood plasma, and other biologicals difference between our allowance and the
billed amount (calendar year deductible
• Blood and blood plasma, if not donated or replaced applies)
• 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.
Extended care benefits/Skilled nursing care facility High Option
benefits
When APWU Health Plan is Primary PPO: 15% of the covered charges
Semiprivate room, board, services and supplies provided in a skilled Non-PPO: $300 per admission and 40% of the
nursing care facility (SNF) for up to 30 days per person per calendar covered charges and any difference between
year when you are admitted directly from a covered inpatient hospital our allowance and the billed amount
stay.
Note: If enrolled in Medicare A, we waive the
Note: Prior approval for these services is required. Call CareAllies at deductible and coinsurance.
800-582-1314, (see Other services, Section 3, page 18).
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 21st day (when Medicare Part A coinsurance begins) and will end
on the 30th day.
Extended care benefits/Skilled nursing care facility benefits - continued on next page

High Option

Extended care benefits/Skilled nursing care facility High Option
benefits (cont.)
• Custodial care (see Section 10, Definitions, page 145)
• All charges after 30 days per person per calendar year
Hospice care High Option

Hospice is a coordinated program of home and inpatient supportive care Any amount over the maximums shown
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
End of life care High Option

End of life care Any amount over the maximums shown
• See Hospice care benefit, which includes advance care planning, (see
above).
Ambulance High Option

• Local professional ambulance service when medically appropriate PPO: 15% of the Plan allowance
immediately before, during or after an inpatient admission
billed amount
• Ambulance service used for routine transport

High Option
Section 5 (d). Emergency Services/Accidents

Important things to keep in mind about these benefits:
• 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.
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 its 24-hour nurse advisory service 800-582-1314,
option 7, or your physician.
2023 APWU Health Plan 60 High Option Section 5(d)

High Option

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: PPO: Nothing (No deductible)
• Physician services and supplies Non-PPO: Nothing (No deductible)
• 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), pages 56-57, 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.
If you receive care for your accidental injury within 72 hours, we cover: PPO: Nothing
• Professional Ambulance Services 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 PPO: $30 copayment (No deductible)
supplies in an Urgent Care Center
Non-PPO: 40% of the Plan allowance
Note: High technology radiology/imaging services including CT/CAT
Scan, MRI, MRA, Nuclear Cardiology and PET are subject to Note: For Non-PPO benefits, members may be
coinsurance and deductible (outpatient requires precertification except billed the difference between the Plan
for Nuclear Cardiology), (see Section 5(a), page 36). allowance and the billed amount.
Outpatient medical or surgical services and supplies, other than an PPO: 15% of the Plan allowance
Urgent Care Center
Non-PPO: 15% of the Plan allowance
Ambulance High Option
Professional ambulance services within 24 hours of a medical PPO: 15% of the Plan allowance
emergency (No deductible)
Note: See Section 5(c), page 59 for non-emergency service. Non-PPO: 40% of the Plan allowance and any
billed amount (No deductible)
Air ambulance High Option
Air ambulance to nearest facility where necessary treatment is available PPO: 15% of the Plan allowance (No
is covered if no emergency ground transportation is available or suitable deductible)
and the patient's condition warrants immediate evacuation. Air
ambulance will not be covered if transport is beyond the nearest Non-PPO: 15% of the Plan allowance (No
available suitable facility, but is requested by patient or physician for deductible)
continuity of care or other reasons
Air ambulance - continued on next page

High Option

Air ambulance (cont.) High Option
• Air ambulance if transport is beyond the nearest available suitable
facility, but is requested by patient or physician for continuity of care
or other reasons

High Option
Section 5 (e). Mental Health and Substance Use Disorder Benefits

• 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.
• YOU MUST GET PREAUTHORIZATION FOR HOSPITAL STAYS; FAILURE TO DO SO
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 Cigna/CareAllies at 800-582-1314.
• 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. Cigna Behavioral Health will provide you with a choice of network providers at
800-582-1314 or visit our website at www.apwuhp.com.
• Schools or other educational institutions are not covered.
2023 APWU Health Plan 63 High Option Section 5(e)

High Option

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 Your cost-sharing responsibilities are no greater than
health and substance use disorder treatment practitioners when for other illnesses or conditions.
acting within the scope of their license, such as psychiatrists,
psychologists, clinical social workers, licensed professional
counselors, or marriage and family therapists.
In a physician's office PPO: $25 copayment (No deductible)
• Treatment and counseling (including individual or group Non-PPO: 40% of the Plan allowance and any
therapy visits) difference between our allowance and the billed
• Diagnosis and treatment to address gender dysphoria (in- charges
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
Professional and other services for the diagnosis and treatment of PPO: 15% of the Plan allowance
psychiatric conditions, mental illness or mental disorders:
• Psychological and neuropsychological testing necessary to difference between our allowance and the billed
determine the appropriate psychiatric treatment charges
• 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 Cigna/
CareAllies)
• 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, page 42.
TeleHealth services High Option
Virtual visits through AmWell for non-emergency visits AmWell: $10 copayment (No deductible)
Covered services include consultation, diagnosis and prescriptions PPO: $25 copayment (No deductible)
(when appropriate) through the web or your mobile device.
Non-PPO: N/A
Note: Telehealth services are available in most states, but some
states do not allow telehealth or prescriptions per state regulations.
Please see www.AmWell.com, or call 855-818-DOCS to start your

virtual visit.
TeleHealth services - continued on next page

High Option

TeleHealth services (cont.) High Option
Note: There are no out-of-network benefits for Virtual visits. AmWell: $10 copayment (No deductible)
PPO: $25 copayment (No deductible)
Non-PPO: N/A
Diagnostics High Option
• Outpatient diagnostic tests provided and billed by a licensed PPO: 15% of the Plan allowance
mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, difference between our allowance and the billed
hospital or other covered facility charges
Inpatient hospital or other covered facility High Option
Inpatient services provided and billed by a hospital, Residential PPO: 15% of the Plan allowance (No deductible)
Treatment Center (RTC), or other covered facility
(preauthorization required by Cigna/CareAllies) Non-PPO: After $300 per admission, 40% of our
allowance and any difference between our allowance
• Room and board, such as semiprivate or intensive and the billed charges (No deductible)
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

• 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.
Outpatient hospital or other covered facility High Option

Outpatient services provided and billed by a hospital or other PPO: 15% of the Plan allowance
covered facility
• Services such as partial hospitalization or full-day difference between our allowance and the billed
hospitalization (preauthorization required by Cigna/CareAllies) charges
• Facility-based intensive outpatient treatment

• 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

High Option
Section 5 (f). Prescription Drug Benefits

• We cover prescribed drugs and medications, as described in the chart below.
• 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.
cost-sharing works. Also read Section 9, for information about how we pay if you have other
• 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 page 72, for more information about this program.
See Section 9 for additional details.
There are important features you should be aware of. These include:
• Who can write your prescription. A licensed prescriber or dentist, and in states allowing it, licensed/certified providers
with prescriptive authority prescribing within their scope of practice.
• 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.
2023 APWU Health Plan 66 High Option Section 5(f)

High Option
• We use a 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.

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.
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 • Network Retail: $10 Tier 1. 25% Tier 2 up to
program, a combined prescription drug/Plan identification card, a mail a maximum of $200 coinsurance per
order form/patient profile and a pre-addressed reply envelope. prescription for a 30-day supply. 45% Tier 3
up to a maximum of $300 coinsurance per
You may purchase the following medications and supplies prescribed prescription for a 30-day supply
from either a pharmacy or by mail:
• Non-network Retail: 50% of cost for a 30-
• Drugs and medications, for use at home that are obtainable only upon day supply
a doctor’s prescription and listed in official formularies
• Network Mail Order: $20 Tier 1. 25% Tier 2
• Drugs and medications (including those administered during a non- up to a maximum of $300 coinsurance per
covered admission or in a non-covered facility) that by Federal law of prescription for a 90-day supply. 45% Tier 3
the United States require a prescription for their purchase, except up to a maximum of $500 coinsurance per
those listed as not covered prescription for a 90-day supply
• 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, page 18,
and Section 5(f), page 72)
• Drugs that could be used for cosmetic purposes such as: Retin A or
Botox (requires prior authorization), (see Section 3, Other services,
page 18, and Section 5(f), page 72)
• FDA approved drugs for weight management (prior authorization is
required), page 72
• Drugs to treat gender dysphoria
Covered medications and supplies - continued on next page

High Option

Covered medications and supplies (cont.) High Option
Diabetes medications and supplies • Network Retail: $25 copay for a 30-day
• Certain Insulins and non-Insulin Diabetes drugs to treat diabetes supply
• Network Mail Order: $75 copay for a 90-day
For a list of Insulins and non-Insulin Diabetes drugs with fixed copays, supply
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), page 67).
Diabetic medications and supplies • Network Mail Order: $0
• Oral Generic (Tier 1) medications for the specific purpose of lowering
blood sugar
• Formulary (Tier 2) blood glucose test strips and lancets
Specialty Prescription Drugs • Network Retail: 25% Tier 4 with up to a

• Specialty drugs must be obtained through Accredo Specialty maximum of $300 per prescription for a 30-
Pharmacy. This benefit pertains to specialty drugs administered either day supply. 25% Tier 5 up to a maximum of
at home or in an outpatient setting. $600 coinsurance per prescription for a 30-
day supply. 45% Tier 6 up to a maximum of
Note: See pages 72-73 for definition. $1,000 coinsurance per prescription for a 30-
day supply
Note: If your specialty medication is available through Accredo • Non-network Retail: 50% of cost for a 30-
Specialty Pharmacy and you do not obtain your medication through day supply
Accredo Specialty Pharmacy, you will be responsible for the full cost of
your medication. • 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. • Network Retail: $0
Contraceptive coverage is available at no cost to FEHB members. The • Network Mail order: $0
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.
• 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.

High Option

Covered medications and supplies (cont.) High Option
Note: If you have concerns about the Health Plan’s compliance with the • Network Retail: $0
ACA/HRSA requirements contact [email protected]. See OPM’s • Network Mail order: $0
web page about contraception.
In-network devices approved by the FDA for contraception Nothing
Naloxone 0.4 mg/ml vial and Naloxone 2 mg/ml syringe; and Narcan Network Retail: Nothing
nasal spray for the prevention of opioid overdose related deaths
Non-network Retail: 50% of cost for a 30-day
Note: Copay maximum does not apply to out-of-network retail drugs or supply
to brand name drugs when there is a generic available.
Network Mail Order: Nothing
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 page 72 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, page 46.
• 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.

High Option

Preventive care medications High Option
• Medications to promote better health as recommended by ACA. Network Retail: Nothing
• Preventive Medications with a USPSTF recommendation of A or B Non-network Retail: 50% of cost for a 30-day
are covered without cost-share when prescribed by a healthcare supply
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.

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 on pages 68-70. 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.

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

High Option
Section 5 (g). Dental Benefits

• 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.
cost-sharing works. Also read Section 9, for information abut how we pay if you have other
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 Within 72 hours of accident:
replace) sound natural teeth. The need for these services must result
from an accidental injury (a blow or fall) and must be performed within PPO: Nothing (No deductible)
two years of the accident (see also Section 5(d), Accidental injury, page Non-PPO: Only the difference between our
61). allowance and the billed amount (No
deductible)
More than 72 hours after accident:
PPO: 15% of the Plan allowance

billed amount
Dental benefits service High Option
• Office visits (routine limited to 2 visits per year) 30% of the Plan allowance and any difference
• Restorative care (fillings) between our allowance and the billed amount
(No deductible)
• X-rays of all types (limited to 2 per year)
• Prophylaxis (cleanings), (limited to 2 per year) Note: No in-network dental providers; choose
any provider.
• 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.
2023 APWU Health Plan 74 High Option Section 5(g)

High Option
Section 5 (h). Wellness and Other Special Features

Special feature Description
Flexible benefits option 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, pages 131-133).
24-hour nurse 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 healthcare
issues.
Services for deaf and We offer a toll-free TDD line for customer service. The number is 800-622-2511. TDD
hearing impaired equipment is required.
Disease Management A voluntary program that provides a variety of services to help you manage a chronic
Program 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 Cigna/CareAllies at 800-582-1314.
Review and Reward If you send us a corrected hospital billing, we will credit 20% of any hospital charge over
Program $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.
Weight Management $0 copay for in-network office visit to a registered Dietician/Nutritionist

Program
Healthy Pregnancies, Enroll in this program and you take the first step toward giving your baby a healthy start
Healthy in life. Enroll by calling CareAllies at 1-800-582-1314, prompt 8.
Babies® Program
2023 APWU Health Plan 75 High Option Section 5(h)

High Option
Special Programs • Lifestyle Programs - Wellness Coaches help you develop a personalized plan for
tobacco cessation and weight management. For information, call Cigna/CareAllies at
800-582-1314, select Weight Management/Tobacco Cessation option.
• Healthy Rewards - MyCigna provides non-FEHB savings on gym memberships,
tobacco cessation, weight reduction programs, and more. Visit www.apwuhp.com or
call 800-558-9443.
- Tobacco cessation - find discounts on smoking cessation products
- Fitness - get fit and save on gym memberships
- Vision and hearing care - receive vision and hearing exams and discounts on
hearing aids, discounts on glasses and frames, and discounts on Lasik vision
corrections
- Alternative medicine - find discounts for acupuncture, chiropractor, and massage
- Dental care - save on dental care with discounts on anti-cavity products and
toothbrushes
Online tools and Online tools are available at www.myAPWUHP.com:

resources • www.myAPWUHP.com - online information for member services and claims to view
claims and find year-to-date information with claim details
• HealthVault - an online tool to organize important medical information in one secure
and central location to share with family and doctors
• Health Risk Assessment - answer questions about your health and receive a
personalized health program through MyCigna
Health Risk Assessment A Health Risk Assessment (HRA) is available at www.apwuhp.com and via the Member
(HRA) 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.
When you complete the HRA, we will enroll you in the CignaPlus Savings discount
dental program. For Self Only coverage, we will pay the Self Only CignaPlus Savings
discount dental premium; and for Self Plus One and Self and Family, when at least two
family members complete the HRA, we will pay the family CignaPlus Savings discount
dental premium. We will pay these discount dental premiums for the remainder of the
calendar year in which the HRAs were completed provided you remain enrolled in our
Plan.
CignaPlus Savings is a discount dental program that provides members access to

discounted fees with participating dental providers. For more information on this program,
call 877-521-0244 or visit www.cignaplussavings.com.
Consumer choice Access by Internet (www.apwuhp.com) is provided to support your important health and
information 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
2023 APWU Health Plan 76 High Option Section 5(h)

CDHP
Consumer Driven Health Plan Benefits

See page 15 for how our benefits changed this year and page 152 for a benefits summary.
Consumer Driven Health Plan Overview....................................................................................................................................79
Section 5. In-Network Preventive Care ......................................................................................................................................80
Preventive care, adult ........................................................................................................................................................80
Preventive care, children ...................................................................................................................................................81
Section 5. Personal Care Account (PCA)....................................................................................................................................83
Personal Care Account (PCA)...........................................................................................................................................84
Section 5. Traditional Health Coverage Overview .....................................................................................................................86
Deductible before Traditional Health Coverage begins ....................................................................................................86
Section 5 (a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals .............................89
Diagnostic and treatment services.....................................................................................................................................89
TeleHealth services ...........................................................................................................................................................90
Lab, X-ray and other diagnostic tests................................................................................................................................90
Maternity care ...................................................................................................................................................................90
Family Planning ................................................................................................................................................................91
Infertility services .............................................................................................................................................................92
Allergy care .......................................................................................................................................................................92
Treatment therapies ...........................................................................................................................................................93
Physical and occupational therapies .................................................................................................................................93
Applied behavioral analysis (ABA) ..................................................................................................................................94
Speech therapy ..................................................................................................................................................................94
Hearing services (testing, treatment, and supplies)...........................................................................................................94
Vision services (testing, treatment, and supplies) .............................................................................................................94
Foot care ............................................................................................................................................................................95
Orthopedic and prosthetic devices ....................................................................................................................................95
Durable medical equipment (DME) ..................................................................................................................................96
Home health services ........................................................................................................................................................97
Chiropractic .......................................................................................................................................................................97
Alternative treatments .......................................................................................................................................................97
Educational classes and programs.....................................................................................................................................98
Section 5 (b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals .........................99
Surgical procedures ...........................................................................................................................................................99
Reconstructive surgery ....................................................................................................................................................100
Oral and maxillofacial surgery ........................................................................................................................................102
Organ/tissue transplants ..................................................................................................................................................103
Anesthesia .......................................................................................................................................................................106
Section 5 (c). Services Provided by a Hospital or Other Facility, and Ambulance Services ....................................................107
Inpatient hospital .............................................................................................................................................................107
Cancer Centers of Excellence .........................................................................................................................................108
Outpatient hospital or ambulatory surgical center ..........................................................................................................109
Extended care benefits/Skilled nursing care facility benefits .........................................................................................109
Hospice care ....................................................................................................................................................................110
End of life care ................................................................................................................................................................110
Ambulance ......................................................................................................................................................................110
Section 5 (d). Emergency Services/Accidents...........................................................................................................................111
Accidental injury .............................................................................................................................................................111
2023 APWU Health Plan 77 CDHP Section 5

CDHP
Medical emergency .........................................................................................................................................................112

Ambulance ......................................................................................................................................................................112
Air ambulance .................................................................................................................................................................112
Section 5 (e). Mental Health and Substance Use Disorder Benefits .........................................................................................113
Professional services .......................................................................................................................................................113
TeleHealth Services .........................................................................................................................................................114
Diagnostics ......................................................................................................................................................................114
Inpatient hospital or other covered facility .....................................................................................................................115
Outpatient hospital or other covered facility ...................................................................................................................115
Section 5 (f). Prescription Drug Benefits ..................................................................................................................................116
Covered medications and supplies ..................................................................................................................................117
Preventive care medications ............................................................................................................................................119
Section 5 (g). Dental Benefits ...................................................................................................................................................122
Section 5 (h). Wellness and Other Special Features..................................................................................................................123
Section 5 (i). Health Education Resources and Account Management Tools ...........................................................................124
Online tools and resources ..............................................................................................................................................124
Consumer choice information .........................................................................................................................................124
Special Programs.............................................................................................................................................................124
Wellness Incentive ..........................................................................................................................................................124
Health Risk Assessment ..................................................................................................................................................124
Summary of Benefits for the CDHP of the APWU Health Plan - 2023....................................................................................152
2023 APWU Health Plan 78 CDHP Section 5

CDHP
Consumer Driven Health Plan Overview

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 Well
Woman 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.
2023 APWU Health Plan 79 CDHP Section 5 Overview

CDHP
Section 5. In-Network Preventive Care

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), page
83, 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
cost-sharing works. Also read Section 9 for information about how we pay if you have other
• Receive $25 when you complete an annual physical with a clinical professional each year, see
Section 5(i) for details.
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. In-network: Nothing
The following preventive services are covered at the time interval Out-of-network: Any difference between our
recommended at each of the links below: allowance and the billed amount. Uses PCA
• Receive $25 when you complete an annual physical with a clinical while funds available.
professional each year (see Section 5(i) for details)
• Immunizations such as Pneumococcal, influenza, shingles, tetanus/
DTaP, 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. For a complete list of screenings go to the U.S. Preventive
Services Task Force (USPSTF) website at: www.
uspreventiveservicestaskforce.org/uspstf/
• 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)
Preventive care, adult - continued on next page

2023 APWU Health Plan 80 CDHP Section 5 In-network preventive care
CDHP

Preventive care, adult (cont.) Consumer Driven Option
• Chest X-ray In-network: Nothing
• Hemoglobin A1C, age 18 and above Out-of-network: Any difference between our
• At home Colorectal Cancer Screening Cologuard Kit provided allowance and the billed amount. Uses PCA
through Exact Sciences Laboratories, every three years starting at age while funds available.
45, prescription needed from physician
Routine mammogram - covered for women, including 3D mammograms In-network: Nothing

covered for women age 35 and older; as follows:
Out-of-network: Any difference between our
• From age 35 through 39, one during this five year period allowance and the billed amount. Uses PCA
• From age 40 through 64, one every calendar year while funds available.
• At age 65 and older, one every two consecutive calendar years
Immunizations, such as: In-network: Nothing
Adult immunizations endorsed by the Centers for Disease Control and Out-of-network: Any difference between our
Prevention (CDC): based on the Advisory Committee on Immunization allowance and the billed amount. Uses PCA
Practices (ACIP) schedule. while funds available.

subject to the applicable member copayments, coinsurance, and
deductible.
Preventive care, children Consumer Driven Option
• Well-child visits, examinations, and other preventive services as In-network: Nothing
described in the Bright Future Guidelines provided by the American
Academy of Pediatrics. For a complete list of the American Academy Out-of-network: Any difference between our
of Pediatrics Bright Futures Guidelines go to: https://brightfutures. allowance and the billed amount. Uses PCA
aap.org while funds available.
• Immunizations such as DTaP, 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/

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.
Preventive care, children - continued on next page

CDHP

Preventive care, children (cont.) Consumer Driven Option
• Examinations limited to: In-network: Nothing
- Examinations for amblyopia and strabismus - limited to one Out-of-network: Any difference between our
screening examination (ages 3 through 5) allowance and the billed amount. Uses PCA
- Examinations done on the day of immunizations (ages 3 through while funds available.
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

• 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

CDHP
Section 5. Personal Care Account (PCA)

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.
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.
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.
2023 APWU Health Plan 83 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 In-network and Out-of-network: Nothing up to
enrollment. Each year the Plan adds to your account: $1,200 for a Self Only enrollment or $2,400 for
• $1,200 per year for a Self Only enrollment or a Self Plus One or Self and Family enrollment
• $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
Personal Care Account (PCA) - continued on next page
CDHP
Benefit Description You pay

Personal Care Account (PCA) (cont.) Consumer Driven Option
• 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
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.
CDHP
Section 5. Traditional Health Coverage Overview

• 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.
Deductible before Traditional Health Coverage begins Consumer Driven Option
If your Personal Care Account has been exhausted, you are responsible In-network: $1,000 per Self Only enrollment,
to pay your Deductible before your Traditional Health Coverage begins. $2,000 for Self Plus One enrollment or $2,000
per Self and Family enrollment
Traditional Health Coverage benefits begin for in-network after covered
eligible expenses (deductible) total $2,200 for Self Only, $4,400 for Self Out-of-network: $1,500 per Self Only
Plus One or $4,400 for Self and Family (the combination of eligible enrollment, $3,000 for Self Plus One and
expenses paid out of your PCA and your Net Deductible) each calendar $3,000 for Self and Family enrollment
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.
Deductible before Traditional Health Coverage begins - continued on next page

2023 APWU Health Plan 86 CDHP Section 5 Traditional Health Coverage
CDHP

(cont.)
Type of Plan In-network: $1,000 per Self Only enrollment,
$2,000 for Self Plus One enrollment or $2,000
In-Network Deductible per Self and Family enrollment
Self Only: $2,200 Deductible ($1,200 PCA + $1,000 Net Deductible)
Self Plus One: $4,400 Deductible ($2,400 PCA + $2,000 Net Out-of-network: $1,500 per Self Only
Deductible) enrollment, $3,000 for Self Plus One and
Self and Family: $4,400 Deductible ($2,400 PCA + $2,000 Net $3,000 for Self and Family enrollment
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
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
Deductible before Traditional Health Coverage begins - continued on next page

CDHP

(cont.)
If you decide to use your PCA for Extra PCA Expenses for other than In-network: $1,000 per Self Only enrollment,
covered dental and/or vision services, you may increase your $2,000 for Self Plus One enrollment or $2,000
Deductible. For example, if you have out-of-network preventive care per Self and Family enrollment
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 Out-of-network: $1,500 per Self Only
Extra PCA Expenses. enrollment, $3,000 for Self Plus One and
$3,000 for Self and Family enrollment

CDHP
Section 5 (a). Medical Services and Supplies Provided by Physicians and Other
will be prorated at a rate of: In-network $83.33 per month for Self Only, $166.67 per month for Self
month for Self Plus One or Self and Family, for each full month of coverage remaining in that
calendar year.
• 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.).
Diagnostic and treatment services Consumer Driven Option
Professional services of physicians In-network: 15% of the Plan allowance
• In physician's office* Out-of-network: 50% of the Plan allowance
• At home and any difference between our allowance and
• In an urgent care center the billed amount
• During a hospital stay

• In a skilled nursing facility
• Second surgical opinion
* Professional services of a physician via Telehealth/Telemedicine are

covered the same as in a physician’s office.
• At a Cancer Center of Excellence In-network Cancer Center of Excellence
(COE): 10% of the Plan allowance
Note: To receive the higher level of benefits for cancer related
treatment, you are required to visit a designated Cancer Center of
Excellence facility.
2023 APWU Health Plan 89 CDHP Section 5(a)

CDHP

TeleHealth services Consumer Driven Option
• Virtual visits are available through AmWell, Doctor on Demand, or In-network: 15% of the Plan allowance
Teladoc
Out-of-network: N/A
Please see www.apwuhp.com for information on virtual visits, or log
into www.myuhc.com.
Note: There is no out-of-network benefit for virtual visits.

Lab, X-ray and other diagnostic tests Consumer Driven Option
Tests, such as: In-network: 15% of the Plan allowance
• Blood tests Out-of-network: 50% of the Plan allowance
• Urinalysis and any difference between our allowance and
• Non-routine mammogram, including 3D mammogram the billed amount
• Pathology
• X-ray
• Non-routine Pap test
• CT/CAT Scans/MRI/MRA/NC/PET
• Ultrasound
• Electrocardiogram and EEG
Note: If your network provider uses an out-of-network lab or

radiologist, we will pay out-of-network benefits for any lab and X-ray
charges.
• Professional fees for automated lab tests
• Qualitative (definitive) urine drug panel testing that is not medically
necessary
Maternity care Consumer Driven Option

Complete maternity (obstetrical) care, such as: In-network: Nothing
• Screening for gestational diabetes Out-of-network: 50% of the Plan allowance
• Prenatal care and any difference between our allowance and
• Delivery the billed amount
• Postnatal care
• Initial examination of a newborn child covered under a Self Plus One, Note: For inpatient hospital care related to
or Self and Family enrollment maternity, we pay for covered services in full
• Breastfeeding support, supplies and counseling for each birth when you use preferred providers.
Note: Here are some things to keep in mind: Note: In-network facility and lab services
directly related to covered, in-network
• You do not need to precertify your vaginal or cesarean delivery; see maternity care will also be covered at 100%.
page 23 for other circumstances, such as extended stays for you or
your baby. Note: For out-of-network inpatient hospital, a
• You may remain in the hospital up to 48 hours after a vaginal delivery $300 per admission fee applies.
and 96 hours after a cesarean delivery.
Maternity care - continued on next page

CDHP

Maternity care (cont.) Consumer Driven Option
• We cover routine nursery care of the newborn child during the In-network: Nothing
covered portion of the mother’s maternity stay.
Out-of-network: 50% of the Plan allowance
• We pay hospitalization and surgeon services for non-maternity care, and any difference between our allowance and
as well as covering an extended stay, if medically necessary, the same the billed amount
as for illness and injury.
• Hospital services are covered under Section 5(c), and Surgical
benefits are covered under Section 5(b). Note: For inpatient hospital care related to
maternity, we pay for covered services in full
Note: When a newborn requires definitive treatment during or after the when you use preferred providers.
mother's confinement, the newborn is considered a patient in their own
right. If the newborn is eligible for coverage, regular medical or surgical Note: In-network facility and lab services
benefits apply rather than maternity benefits. directly related to covered, in-network
maternity care will also be covered at 100%.
Note: Maternity care expenses incurred by a Plan member serving as a
surrogate mother are covered by the Plan subject to reimbursement from Note: For out-of-network inpatient hospital, a
the other party to the surrogacy contract or agreement. The involved $300 per admission fee applies.
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.
• We will cover other care of an infant who requires non-routine In-network: 15% of the Plan allowance
treatment if we cover the infant under a Self Plus One or Self and
Family enrollment. Surgical benefits, not maternity benefits, apply to Out-of-network: 50% of the Plan allowance
circumcision of a covered newborn. and any difference between our allowance and
the billed amount
• Amniocentesis if for diagnosing multiple births
Family Planning Consumer Driven Option

Contraceptive counseling on an annual basis In-network: Nothing
Note: If you have concerns about the Health Plan’s compliance with the Out-of-network: 50% of the Plan allowance
ACA/HRSA requirements contact [email protected]. See OPM’s and any difference between our allowance and
web page about contraception. the billed amount
A range of voluntary family services limited to: In-network: Nothing
• Tubal ligation and tubal implant procedures Out-of-network: 50% of the Plan allowance
• Surgically implanted contraceptives and any difference between our allowance and
• Injectable contraceptive drugs (such as Depo Provera) the billed amount
• Intrauterine devices (IUDs)

• Diaphragms
Note: We cover oral contraceptives under Section 5(f), Prescription

drug benefits
• Voluntary vasectomy (see Surgical procedures, Section 5(b), page 99) In-network: 15% of the Plan allowance

the billed amount
Family Planning - continued on next page

CDHP

Family Planning (cont.) Consumer Driven Option
• Reversal of voluntary surgical sterilization
• Genetic testing and counseling
Infertility services Consumer Driven Option

• Diagnosis and treatment of infertility, except as shown in Not covered In-network: 15% of the Plan allowance and all
charges after we pay $2,500 in a calendar year
Limited benefits: We pay a maximum of $2,500 for medical and $2,500
for prescription drugs each calendar year per person to diagnose and Out-of-network: 50% of the Plan allowance
treat infertility. and all charges after we pay $2,500 in a
calendar year
See Section 5(f), Prescriptiondrug benefits
• Iatrogenic fertility preservation procedures (retrieval of and freezing In-network: 15% of the Plan allowance
of eggs or sperm) caused by chemotherapy, pelvic radiotherapy, ovary
or testicle removal and other gonadotoxic therapies for the treatment Out-of-network: 50% of the Plan allowance
of disease and gender reassignment.
Note: Fertility preservation procedures require prior approval (see

Section 3, Other services).
Limited benefits: $12,000 lifetime maximum.

• Infertility services afer voluntary sterilization
• Assisted reproductive technology (ART) procedures, such as:
- Artificial insemination (all procedures) (AI)
- In vitro fertilization (IVF)
- Embryo transfer and gamete intra-fallopian transfer (GIFT) and
zygote intra-fallopian transfer (ZIFT)
- Intravaginal insemination (IVI)
- Intracervical insemination (ICI)
- Intrauterine insemination (IUI)
• Services and supplies related to ART procedures
• Cost of donor sperm
• Cost of donor egg
Allergy care Consumer Driven Option

• Testing and treatment, including materials (such as allergy serum) In-network: 15% of the Plan allowance
• Allergy injections Out-of-network: 50% of the Plan allowance
the billed amount
• Provocative food testing
• Sublingual allergy desensitization

CDHP

Treatment therapies Consumer Driven Option
• Chemotherapy and radiation therapy In-network: 15% of the Plan allowance
Note: High dose chemotherapy in association with autologous bone Out-of-network: 50% of the Plan allowance
marrow transplants is limited to those transplants listed on pages and any difference between our allowance and
103-105. the billed amount
• Dialysis – hemodialysis and peritoneal dialysis

• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We only cover IV/Infusion therapy and GHT when we are pre-
notified of the treatment. We will ask you to submit information that
establishes that the GHT is medically necessary. Ask us to authorize
GHT before you begin treatment. We will only cover GHT services and
related services and supplies that we determine are medically necessary,
(see Other services, Section 3, page 19).
• Respiratory and inhalation therapies
• Cardiac rehabilitation following qualifying event/condition
• Medical food formulas ordered by a healthcare provider that are In-network: 15% of the Plan allowance and all
medically necessary to treat specific nutritional risks, including charges after we pay $2,500 in a calendar year
Phenylketonuria (PKU) and other inborn errors of metabolism (IEM).
Limited benefits: We pay a maximum of $2,500 for each calendar year. and all charges after we pay $2,500 in a
calendar year
• Medical foods for conditions other than permanent inborn errors of
metabolism.
Physical and occupational therapies Consumer Driven Option

Physical therapy and occupational therapy provided by a licensed In-network: 15% of the Plan allowance
registered therapist or physician up to a combined 60 visits per calendar
year Out-of-network: 50% of the Plan allowance
We cover rehabilitative and habilitative therapies; a physician should: the billed amount
• Order the care;
• Identify the specific professional skills the patient requires and the
medical necessity for skilled services; and
• Indicate the length of time services are needed.
• Maintenance therapies
• Exercise programs

CDHP

Applied behavioral analysis (ABA) Consumer Driven Option
Outpatient Applied Behavioral Analysis (ABA) services, for the In-network: 15% of the Plan allowance
treatment of Autism Spectrum Disorder. Services must be provided
under the supervision of a Board Certified Behavior Analyst who is Out-of-network: All charges
contracted with UHC Behavioral Health Solutions, or agrees to
participate with UHC Behavioral Health Solutions' care management
activities. Preauthorization required by UHC Behavioral Health
Solutions.
Note: UHC Behavioral Health Solutions' review of ABA services is

based on an intensive care management model that monitors treatment
plans, objectives, and progress milestones.
Note: We have the right to deny services for treatment when outcomes
do not meet the defined treatment plan objectives and milestones.
Speech therapy Consumer Driven Option
Speech therapy where medically necessary and provided by a licensed In-network: 15% of the Plan allowance
therapist
Note: Speech therapy is combined with 60 visits per calendar year for and any difference between our allowance and
the services of physical and/or occupational therapy (see above). the billed amount
Hearing services (testing, treatment, and supplies) Consumer Driven Option
• For treatment related to illness or injury, including evaluation and In-network: 15% of the Plan allowance
diagnostic hearing tests performed by an M.D., D.O., or audiologist
• One examination and testing for hearing aids every 2 years and any difference between our allowance and
the billed amount
Note: For routine hearing screening performed during a child's
preventive care visit see Section 5, Preventive care, children, pages
81-82.
• External hearing aids Note: For benefits for the devices, see Section
• Implanted hearing-related devices, such as bone anchored hearing 5(a), Orthopedic and prosthetic devices, page
aids (BAHA) and cochlear implants for bilateral hearing loss 95.

• Hearing services that are not shown as covered
Vision services (testing, treatment, and supplies) Consumer Driven Option

• Internal (implant) ocular lenses and/or the first contact lenses required In-network: 15% of the Plan allowance
to correct an impairment caused by accident or illness. The services of
an optometrist are limited to the testing, evaluation and fitting of the Out-of-network: 50% of the Plan allowance
first contact lenses required to correct an impairment caused by and any difference between our allowance and
accident or illness. the billed amount
Note: See Preventive care, children, for eye exams for children.
• Eyeglasses or contact lenses and examinations for them except under
PCA
Vision services (testing, treatment, and supplies) - continued on next page

CDHP

Vision services (testing, treatment, and supplies) (cont.) Consumer Driven Option
• Eye exercises and visual training All charges
• Refraction
Foot care Consumer Driven Option

Routine foot care when you are under active treatment for a metabolic or In-network: 15% of the Plan allowance
peripheral vascular disease, such as diabetes
Note: See Orthopedic and prosthetic devices for information on and any difference between our allowance and
podiatric shoe inserts. the billed amount
• 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)
Orthopedic and prosthetic devices Consumer Driven Option

• Artificial limbs and eyes In-network: 15% of the Plan allowance
• Prosthetic sleeve or sock Out-of-network: 50% of the Plan allowance
• Externally worn breast prostheses and surgical bras, including and any difference between our allowance and
necessary replacements following a mastectomy the billed amount
• 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, such as artificial joints, pacemakers, and
surgically implanted breast implant following mastectomy
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).
External hearing aids In-network: All charges in excess of $1,500
• Covered every 3 years limited to $1,500 Out-of-network: All charges in excess of
$1,500
Note: Excluding batteries, benefits for hearing aid dispensing fees,
accessories, supplies, and repair service are included in the benefit limit
described above.
• 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

CDHP

Durable medical equipment (DME) Consumer Driven Option
Durable medical equipment (DME) is equipment and supplies that: In-network: 15% of the Plan allowance
1) Are prescribed by your attending physician (i.e., the physician who is Out-of-network: 50% of the Plan allowance
treating your illness or injury) and any difference between our allowance and
the billed amount
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
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: 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.
• 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

CDHP

Home health services Consumer Driven Option
Services for skilled nursing care up to 25 visits per calendar year, not to In-network: 15% of the Plan allowance
exceed two hours per day, when preauthorized and:
Out-of-network: 50% of the Plan allowance; all
• a registered nurse (R.N.), licensed practical nurse (L.P.N.) or licensed charges in excess of two hours, and any
vocational nurse (L.V.N.) provides the services; difference between our allowance and the
• the attending physician orders the care; billed amount
• 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
Note: Skilled nursing care must be preauthorized. Call UnitedHealthcare

at 800-718-1299.
• 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
Chiropractic Consumer Driven Option

Chiropractic treatment limited to 24 visits and/or manipulations per year In-network: 15% of the Plan allowance
Note: X-ray covered under Lab, X-ray and other diagnostic tests, page Out-of-network: 50% of the Plan allowance
90. and any difference between our allowance and
the billed amount
• Massage therapy
• Maintenance therapy
Alternative treatments Consumer Driven Option

Acupuncture - by a doctor of medicine or osteopathy or licensed In-network: 15% of the Plan allowance
acupuncturist
the billed amount
• Services of any provider not listed as covered (see Covered providers,
Section 3, page 16)

CDHP

Educational classes and programs Consumer Driven Option
You may enroll in a Tobacco Cessation program as follows: In-network: Nothing
• Telephonic counseling sessions with UnitedHealthcare or; Out-of-network: 50% of the Plan allowance
• Group therapy sessions or; and any difference between our allowance and
• Educational sessions with a physician the billed amount
Note: Enrollment in the UnitedHealthcare program must be initiated by

the member. For more information contact UnitedHealthcare at
800-718-1299.
Select over-the-counter and prescription Tobacco Cessation medications In-network: Nothing
approved by the FDA to treat tobacco dependence. For a listing of
medications go to our website at: Out-of-network: All charges
www.apwuhp.com/members/consumer-driven-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.
Childhood obesity screening programs and treatment interventions In-network: Nothing

the billed amount
Diabetes self-management training services, up to 10 hours initial In-network: 15% of the Plan allowance
training the first year and 2 hours subsequent training annually.
the billed amount

CDHP
Section 5 (b). Surgical and Anesthesia Services Provided by Physicians and Other
calendar year.
information shown in Section 3, to confirm which services require precertification.
Surgical procedures Consumer Driven Option
A comprehensive range of services, such as: In-network: 15% of the Plan allowance
• Operative procedures Out-of-network: 50% of the Plan allowance
• Treatment of fractures, including casting and any difference between our allowance and
• Normal pre- and post-operative care by the surgeon the billed amount
• Correction of amblyopia and strabismus

• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery, page
100)
• Surgical treatment of morbid obesity (bariatric surgery) (requires
preauthorization), (see Other services, Section 3, page 19).
• Insertion of internal prosthetic devices (see Section 5(a), Orthopedic
and prosthetic devices, page 95 for device coverage information)
• Voluntary vasectomy
• Treatment of burns
• Assistant surgeons - We cover up to 20% of our allowance for the
surgeon’s charge
Surgical procedures - continued on next page

2023 APWU Health Plan 99 CDHP Section 5(b)
CDHP

Surgical procedures (cont.) Consumer Driven Option
• Tubal ligation and tubal implant procedures In-network: Nothing
• Surgical implanted contraceptives Out-of-network: 50% of the Plan allowance
• Intrauterine devices (IUDs) and any difference between our allowance and
the billed amount
When multiple or bilateral surgical procedures performed during the In-network: 15% of the Plan allowance for the
same operative session add time or complexity to patient care, our primary procedure and 15% of one-half of the
benefits are: Plan allowance for the secondary procedure(s)
• For the primary procedure: Out-of-network: 50% of the Plan allowance for
- In-network: 85% of the Plan allowance or the primary procedure and 50% of one-half of
- Out-of-network: 50% of the Plan allowance the Plan allowance for the secondary procedure
(s); and any difference between our payment
• For the secondary procedure(s): and the billed amount
- In-network: 85% of one-half of the Plan allowance or
- Out-of-network: 50% 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 63% 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.

• 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
• Routine treatment of conditions of the foot (see Foot care, Section 5
(a))
Reconstructive surgery Consumer Driven Option

• Surgery to correct a functional defect In-network: 15% of the Plan allowance
• Surgery to correct a condition caused by injury or illness if: Out-of-network: 50% of the Plan allowance
- The condition produced a major effect on the member’s appearance and any difference between our allowance and
and the billed amount
- The condition can reasonably be expected to be corrected by such
surgery

CDHP

Reconstructive surgery (cont.) Consumer Driven Option
• Surgery to correct a condition that existed at or from birth and is a In-network: 15% of the Plan allowance
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft Out-of-network: 50% of the Plan allowance
palate; birth marks (including port wine stains); and webbed fingers and any difference between our allowance and
and toes. the billed amount
• All stages of breast reconstruction surgery following a mastectomy,

such as:
- Surgery to produce a symmetrical appearance of breast
- Treatment of any physical complications, such as lymphedema
- Breast prostheses; and surgical bras and replacements (see Section
5(a), Prosthetic devices, page 95, 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.
• Surgical treatment of gender affirmation such as surgical change of In-network: 15% of the Plan allowance
sex characteristics. For female to male surgery: mastectomy,
hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, Out-of-network: 50% of the Plan allowance
phalloplasty, urethroplasty, scrotoplasty, and placement of testicular and any difference between our allowance and
and erectile prosthesis. For male to female surgery: penectomy, the billed amount
orchiectomy, vaginoplasty, clitoroplasty, labiaplasty
- Benefits are limited to once per covered procedure, per lifetime
- Benefits are not available for repeat or revision procedure when
benefits were provided for initial procedure
• Gender affirming surgery benefits are only available for the diagnosis
of gender
Requirements:
1. Prior approval is required.
2. Must be at least 18 years of age at time prior approval is requested
and treatment plan is submitted.
3. Must have diagnosis of gender dysphoria by a qualified healthcare
professional.
4. New gender identity has been present for at least 24 continuous
months.
5. Member has a strong desire to be rid of primary and/or secondary sex
characteristics because of a marked in-congruence with the member’s
identified gender.
6. Member’s gender dysphoria is not a symptom of another mental
disorder or chromosomal abnormality.
7. Gender dysphoria causes clinical distress or impairment in social,
occupational, or other important areas of functioning.
8. 12 months of continuous hormone therapy appropriate to the
member's gender identity.

CDHP

Reconstructive surgery (cont.) Consumer Driven Option
9. Two referral letters from qualified mental health professionals, one of In-network: 15% of the Plan allowance
them being a psychiatrist or clinical psychologist (PhD). One must be
from the psychotherapist who has treated the member for at least 12 Out-of-network: 50% of the Plan allowance
continuous months. Letters must document: diagnosis of persistent and any difference between our allowance and
and chronic gender dysphoria; any existing co-morbid conditions are the billed amount
stable; member is prepared to undergo surgery and understands all
practical aspects of the planned surgery.
10.If medical or mental health concerns are present, they are being
optimally managed and are reasonably well-controlled.

• Cosmetic surgery – any surgical procedure (or any portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury if
repair is initiated within two years of the accident
Oral and maxillofacial surgery Consumer Driven Option

Oral surgical procedures, limited to: In-network: 15% of the Plan allowance
• Reduction of fractures of the jaw or facial bones Out-of-network: 50% of the Plan allowance
• Surgical correction of cleft lip, cleft palate or severe functional and any difference between our allowance and
malocclusion the billed amount
• 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
Oral and maxillofacial surgery - continued on next page

CDHP

Oral and maxillofacial surgery (cont.) Consumer Driven Option
Note: Call UnitedHealthcare at 800-718-1299 to determine if a In-network: 15% of the Plan allowance
procedure is covered.
the billed amount
• 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
Organ/tissue transplants Consumer Driven Option

These solid organ transplants are subject to medical necessity and In-network Transplant Center of Excellence
experimental/investigational review by the Plan. Refer to Other (COE): 10% of the Plan allowance
services, Section 3, for prior authorization procedures.
In-network: 15% of the Plan allowance
Solid organ transplants are limited to:
• Autologous pancreas islet cell transplant (as an adjunct to total or near and any difference between our allowance and
total pancreatectomy) only for patients with chronic pancreatitis the billed amount and any amount over
• Cornea $100,000
• 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
These tandem blood or marrow stem cell transplants for covered In-network Transplant Center of Excellence
transplants are subject to medical necessity review by the Plan. Refer to (COE): 10% of the Plan allowance
Section 3, Other services, page 19, for prior authorization procedures.
• Autologous tandem transplants for
- AL Amyloidosis Out-of-network: 50% of the Plan allowance
- Multiple myeloma (de novo and treated) the billed amount and any amount over
- Recurrent germ cell tumors (including testicular cancer) $100,000

CDHP

Organ/tissue transplants (cont.) Consumer Driven Option
Blood or marrow stem cell transplants In-network Transplant Center of Excellence
(COE): 10% of the Plan allowance
The Plan extends coverage for the diagnoses as indicated below:
• Allogeneic transplants for In-network: 15% of the Plan allowance
- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) Out-of-network: 50% of the Plan allowance
leukemia and any difference between our allowance and
- Acute myeloid leukemia the billed amount and any amount over
$100,000
- Advanced Myeloproliferative Disorders (MPDs)
- Advanced neuroblastoma
- Amyloidosis
- Beta Thalassemia Major
- Chronic inflammatory demyelination polyneuropathy (CIDP)
- 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

CDHP

- Advanced Hodgkin's lymphoma with recurrence (relapsed) In-network Transplant Center of Excellence
- Advanced non-Hodgkin’s lymphoma with recurrence (relapsed) (COE): 10% of the Plan allowance
- Amyloidosis In-network: 15% of the Plan allowance

- Aggressive non-Hodgkin's lymphomas Out-of-network: 50% of the Plan allowance
- Breast cancer and any difference between our allowance and
- Childhood rhabdomyosarcoma the billed amount and any amount over
$100,000
- Ependymoblastoma
- Epithelial ovarian cancer
- Ewing's sarcoma
- Mantle cell (non-Hodgkin's lymphoma)
- Medulloblastoma
- Multiple myeloma
- Neuroblastoma
- Pineoblastoma
- Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell
tumors
- Waldenstrom's macroglobulinemia
Mini-transplants (non-myeloablative, reduced intensity conditioning or In-network Transplant Center of Excellence

RIC) are subject to medical necessity review by the Plan. (COE): 10% of the Plan allowance

the billed amount and any amount over
$100,000
These blood or marrow stem cell transplants are covered only in a In-network Transplant Center of Excellence
National Cancer Institute or National Institutes of Health approved (COE): 10% of the Plan allowance
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, Out-of-network: 50% of the Plan allowance
lab tests, X-rays and scans, and hospitalization related to treating the and any difference between our allowance and
patient's condition) if it is not provided by the clinical trial. Section 9 has the billed amount and any amount over
additional information on costs related to clinical trials. We encourage $100,000
you to contact the Plan to discuss specific services if you participate in a
clinical trial.
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 UnitedHealthcare at
800-718-1299 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.

CDHP

Limited Benefits – If you don’t use a Plan-designated transplant facility, In-network Transplant Center of Excellence
benefits for pretransplant evaluation, organ procurement, inpatient (COE): 10% of the Plan allowance
hospital, surgical and medical expenses for covered transplants, whether
incurred by the recipient or donor, are limited to a maximum of In-network: 15% of the Plan allowance
$100,000 for each listed transplant, including multiple organ transplants. Out-of-network: 50% of the Plan allowance
Note: We cover related medical and hospital expenses of the donor and any difference between our allowance and
when we cover the recipient. the billed amount and any amount over
$100,000
• Donor screening tests and donor search expenses, except as shown
above
• Transplants not listed as covered
• Implants of artificial organs
Anesthesia Consumer Driven Option

Professional services for administration of anesthesia In-network: 15% of the Plan allowance
Note: If surgical services are rendered at an in-network hospital or an in- Out-of-network: 50% of the Plan allowance
network freestanding ambulatory facility, we will pay the services of and any difference between our allowance and
out-of-network anesthesiologists at the in-network rate, based on Plan the billed amount
allowance.

CDHP
Section 5 (c). Services Provided by a Hospital or Other Facility, and Ambulance

Services
calendar year.
• You must get prior approval for gender affirming surgery. See page 19 for prior approval and page
101 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 admits you to the hospital as
inpatient.
Inpatient hospital Consumer Driven Option
Room and board, such as: In-network: 15% of the Plan allowance
• Ward, semiprivate, or intensive care accommodations Out-of-network: 50% of the Plan allowance
• General nursing care and any difference between our allowance and
• Meals and special diets the billed amount

Note: We only cover a private room when you must be isolated to maternity, we pay for covered services in full
prevent contagion. Otherwise, we will pay the hospital’s average charge when you use preferred providers, (see Section
for semiprivate accommodations. If the hospital only has private rooms, 5(a), Maternity care, page 90).
we will consider a semiprivate equivalent allowance of up to 90% of the
private room charge.
Note: When the out-of-network 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.
Inpatient hospital - continued on next page
2023 APWU Health Plan 107 CDHP Section 5(c)

CDHP

Inpatient hospital (cont.) Consumer Driven Option
Other hospital services and supplies, such as: In-network: 15% of the Plan allowance
• Operating, recovery, maternity and other treatment rooms Out-of-network: 50% of the Plan allowance
• Prescribed drugs and medications and any difference between our allowance and
• Diagnostic laboratory tests and X-rays the billed amount
• Blood or blood plasma, if not donated or replaced Note: For inpatient hospital care related to
• Dressings, splints, casts, and sterile tray services maternity, we pay for covered services in full
• Medical supplies and equipment, including oxygen 5(a), Maternity care, page 90).
• Anesthetics, including nurse anesthetist services
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.
• Any part of a hospital admission that is not medically necessary (see
Definitions, Section 10), 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 for out-of-network services only
• Custodial care (see Definitions, Section 10, page 145)
• Non-covered facilities, 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
Cancer Centers of Excellence Consumer Driven Option

The Plan provides access to designated Cancer Centers of Excellence. In-network Cancer Centers of Excellence
To locate a Cancer Center of Excellence, contact UnitedHealthcare at (COE): 10% of the Plan allowance
800-718-1299 and enroll in the program prior to obtaining covered
services. The Plan will only pay the higher level of benefits if
UnitedHealthcare provides the proper notification to the designated
facility/provider performing the services.
To receive the higher level of benefits for a cancer-related treatment, you

are required to visit a designated facility. Cancer treatment includes the
following:
• Physician's office services;
• Professional fees for surgical and medical services;
• Hospital - inpatient stay; and
• Outpatient surgery, diagnostic and therapeutic services.
If you decide to use a designated Center of Excellence, you may receive

prior approval for travel and lodging costs.

CDHP

Outpatient hospital or ambulatory surgical center Consumer Driven Option
• Operating, recovery, and other treatment rooms In-network: 15% of the Plan allowance
• Prescribed drugs and medications Out-of-network: 50% of the Plan allowance
• Diagnostic laboratory tests, X-rays, and pathology services and any difference between our allowance and
• Administration of blood, blood plasma, and other biologicals the billed amount
• Blood and blood plasma, if not donated or replaced Note: For inpatient hospital care related to
• Pre-surgical testing maternity, we pay for covered services in full
when you use preferred providers (see Section
• Dressings, casts, and sterile tray services 5(a), Maternity care, page 90).
• 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.
Extended care benefits/Skilled nursing care facility Consumer Driven Option
benefits
When APWU Health Plan is Primary In-network: 15% of the Plan allowance
Semiprivate room, board, services and supplies provided in a skilled Out-of-network: 50% of the Plan allowance
nursing care facility (SNF) for up to 30 days per person per calendar and any difference between our allowance and
year when you are admitted directly from a covered inpatient hospital the billed amount
stay.
Note: Prior approval for these services is required. Call

UnitedHealthcare at 800-718-1299, (see Other services, Section 3, page
19).
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 21st day (when Medicare Part A copayments begin) and will end
on the 30th day.
• Custodial care (see Section 10, Definitions)
• All charges after 30 days per person per calendar year

CDHP

Hospice care Consumer Driven Option
Hospice is a coordinated program of home and inpatient supportive care Any amount over the annual maximums shown
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 bereavement benefit per family unit (no deductible or
coinsurance).
End of life care Consumer Driven Option

End of life care Any amount over the annual maximums shown
• See Hospice care benefit which includes advance care planning,
above
Ambulance Consumer Driven Option

Local professional ambulance service when medically appropriate In-network: 15% of the Plan allowance
immediately before, during or after an inpatient admission
the billed amount
• Ambulance service used for routine transport

CDHP
Section 5 (d). Emergency Services/Accidents

calendar year.
• 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.
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.
Accidental injury Consumer Driven Option
If you receive care for your accidental injury within 24 hours, we cover: In-network: 15% of the Plan allowance
• Physician services and supplies Out-of-network: 15% of the Plan allowance
• Related outpatient hospital services
Note: We pay hospital benefits if you are admitted.
If you receive care for your accidental injury after 24 hours, we cover:
• Physician services and supplies
Note: We pay hospital benefits if you are admitted.
2023 APWU Health Plan 111 CDHP Section 5(d)

CDHP

Medical emergency Consumer Driven Option
• Outpatient facility charges in an Urgent Care Center In-network: 15% of the Plan allowance
Note: For out-of-network 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 In-network: 15% of the Plan allowance
Urgent Care Center
Ambulance Consumer Driven Option
Professional ambulance service within 24 hours of an accidental injury In-network: 15% of the Plan allowance
or medical emergency
the billed amount
Note: See Hospital benefits, Section 5(c), page 110, for non-emergency
service.
Air ambulance Consumer Driven Option
Air ambulance to nearest facility where necessary treatment is available In-network: 15% of the Plan allowance
is covered if no emergency ground transportation is available or suitable
and the patient's condition warrants immediate evacuation. Air Out-of-network: 15% of the Plan allowance
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
• Air ambulance if transport is beyond the nearest available suitable
facility, but is requested by patient or physician for continuity of care
or other reasons
2023 APWU Health Plan 112 CDHP Section 5(d)

CDHP
Section 5 (e). Mental Health and Substance Use Disorder Benefits

• 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.
• If you join at any time during the year other than Open Season, your Net 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.
• YOU MUST GET PREAUTHORIZATION FOR HOSPITAL STAYS; FAILURE TO DO SO
• To obtain preauthorization of an admission for mental conditions or substance use disorder
treatment, call UHC Behavioral Health Solutions at 800-718-1299.
• We will provide medical review criteria or reasons for treatment plan denials to enrollees, members
or providers upon request or as 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. UHC Behavioral Health Solutions will provide you with a choice of network providers at
800-718-1299 or visit our website at www.myuhc.com.
• Schools or other educational institutions are not covered.
Benefits Description You Pay
Professional services Consumer Driven Option
We cover professional services by licensed professional mental health Your cost-sharing responsibilities are no greater
and substance use disorder treatment practitioners when acting within than for other illnesses or conditions.
the scope of their license, such as psychiatrists, psychologists, clinical
social workers, licensed professional counselors, or marriage and family
therapists.
• In a physician's office* In-network: 15% of the Plan allowance
• Professional charges for intensive outpatient treatment in a provider's Out-of-network: 50% of the Plan allowance
office or other professional setting and any difference between our allowance and
the billed amount
* Professional services of a physician via Telehealth/Telemedicine are
covered the same as in a physician’s office.
Professional services - continued on next page
2023 APWU Health Plan 113 CDHP Section 5(e)

CDHP

Professional services (cont.) Consumer Driven Option
Diagnosis and treatment of psychiatric conditions, mental illness, or In-network: 15% of the Plan allowance
mental disorders. Services include:
• Diagnostic evaluation and any difference between our allowance and
• Crisis intervention and stabilization for acute episodes the billed amount
• Medication evaluation and management (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine
the appropriate psychiatric treatment (preauthorization required by
UHC Behavioral Health Solutions)
• Treatment and counseling (including individual or group therapy
visits)
• Diagnosis and treatment of substance use disorders, including
detoxification, treatment and counseling
• 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 UHC Behavioral Health Solutions)
• Electroconvulsive therapy (preauthorization required by UHC
Behavioral Health Solutions)
• Professional charges for intensive outpatient treatment in a provider's
office or other professional setting (preauthorization required by UHC
Behavioral Health Solutions)
• Diagnosis and treatment to address gender dysphoria (in-network
only). See Sections 5(b) and 5(c) for exclusions.
TeleHealth Services Consumer Driven Option

• Virtual visits through UHC Behavioral Health Solutions for non- In-network: 15% of the Plan allowance
emergency visits
Out-of-network: N/A
Covered services include consultation, diagnosis and prescriptions
(when appropriate) through the web or your mobile device.
Please see www.myuhc.com, or call 800-718-1299 to start your virtual

visit.
Note: There is no out-of-network benefit for virtual visits.

Diagnostics Consumer Driven Option
• Outpatient diagnostic tests provided and billed by a licensed mental In-network: 15% of the Plan allowance
health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, and any difference between our allowance and
hospital or other covered facility the billed amount

CDHP

Inpatient hospital or other covered facility Consumer Driven Option
Inpatient services provided and billed by a hospital, Residential In-network: 15% of the Plan allowance
Treatment Center (RTC), or other covered facility (preauthorization
required by UHC Behavioral Health Solutions) Out-of-network: 50% of the Plan allowance
• Room and board, such as semiprivate or intensive accommodations, the billed amount
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

• 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.
Outpatient hospital or other covered facility Consumer Driven Option

Outpatient services provided and billed by a hospital or other covered In-network: 15% of the Plan allowance
facility
• Services such as partial hospitalization, or facility-based intensive and any difference between our allowance and
outpatient treatment (preauthorization required by UHC Behavioral the billed amount
Health Solutions)

• 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 educational institutions

CDHP
Section 5 (f). Prescription Drug Benefits

• We cover prescribed drugs and medications, as described in the chart below.
• 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.
cost-sharing works. Also read Section 9 for information about how we pay if you have other
• Prior authorization/medical necessity review is required for certain drugs and must be renewed
periodically. Prior authorization 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 page 120 for more
information about this program.
• Specialty drugs must be obtained through Optum Rx specialty pharmacy. Any discount associated
with a manufacturer coupon for specialty medications does not apply toward your Deductible or
out-of-pocket expenses.
There are important features you should be aware of. These include:
Who can write your prescription. A licensed prescriber or dentist, and in states allowing it, licensed providers with
prescriptive authority prescribing within their scope of practice.
Where can you obtain them. You can fill the prescription at an Optum Rx 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.
• We use a formulary. Our formulary is the Traditional Prescription Drug Formulary through OptumRx. 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, visit www.myuhc.com to view 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 physicians if they feel the
formulary alternatives are not appropriate. Physicians may request a clinical exception by calling 800-718-1299.
• 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.
- 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
2023 APWU Health Plan 116 CDHP Section 5(f)

CDHP
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 physician specifically requires a brand name drug.
Covered medications and supplies Consumer Driven Option
Each new enrollee will receive a combined prescription drug/Plan • Network Retail:
identification card. - Tier 1 and Tier 2 - 25% of charge with a
You may purchase the following medications and supplies prescribed by minimum of $15 and a maximum per
a doctor from either a network pharmacy or by mail: prescription of $200 for a 30-day supply,
$400 for a 60-day supply, $600 for a 90-
• Drugs and medications, including those for Tobacco Cessation day supply;
programs, for use at home that are obtainable only upon a doctor’s
prescription - Tier 3 - 40% of charge with a minimum
$15 and a maximum per prescription of
• Drugs and medications (including those administered during a non- $300 for a 30-day supply, $600 for a 60-
covered admission or in a non-covered facility) that by Federal law of day supply, $900 for a 90-day supply
the United States require a physician’s prescription for their purchase,
except those listed as not covered • Network Home Delivery:
• Insulin and test strips for known diabetics - Tier 1 and Tier 2 - 25% of charge with a
minimum of $10 and a maximum per
• FDA approved drugs for weight management. Prior approval is prescription of $200 for a 30-day supply,
required, see page 120 $400 for a 60-day supply, $600 for a 90-
• Disposable needles and syringes for the administration of covered day supply;
medications - Tier 3 - 40% of charge with a minimum
• Prior authorization/medical necessity review is required for certain $10 and a maximum per prescription of
drugs and must be renewed periodically. Prior authorization/medical $300 for a 30-day supply, $600 for a 60-
necessity review uses Plan rules based on FDA-approved prescribing day supply, $900 for a 90-day supply
and safety information, clinical guidelines and uses that are
considered reasonable, safe and effective. For example, approved
drugs for organic impotence are subject to prior Plan approval and
limitations on dosage and quantity. See Section 3, Other services,
page 19 and page 120 for more information about this program.
• Drugs to treat gender dysphoria
Contraceptive drugs and devices as listed on the ACA/HRSA site. Network Retail: $0
Contraceptive coverage is available at no cost to FEHB members. The Network Home Delivery: $0
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 physicians if they feel
the formulary alternatives are not appropriate. Prescribers should
request a clinical exception by calling 800-718-1299. Once your
physician receives prior authorization, the contraceptive drug not on
the PPACA list will be dispensed and you will pay $0.

CDHP

Covered medications and supplies (cont.) Consumer Driven Option
• Reimbursement for over-the-counter contraceptives can be submitted Network Retail: $0
by filling out an OptumRX direct member reimbursement (DMR)
form (prescription required) which can be found on www.myuhc. Network Home Delivery: $0
com or by contacting customer service at 800-718-1299.
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.
• In-network devices approved by the FDA for contraception Nothing
• Naloxone 0.4 mg/ml vial and Naloxone 2 mg/ml syringe; and Narcan Network Retail: Nothing
nasal spray for the prevention of opioid overdose related deaths
Network Home Delivery: Nothing
• 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 physician prescribes or administers them
• Medical supplies such as dressings and antiseptics
• Nonprescription medicines/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
- Certain new prescription drug products until they are reviewed and
evaluated
• Prescription drugs approved by the U.S. Food and Drug
Administration when an over-the-counter equivalent is available.
Note: Over-the-counter and prescription drugs approved by the FDA to

treat tobacco dependence are covered under the Tobacco Cessation
programs, see Educational classes and programs.
Note: Prescription drugs approved by the FDA for contraception, see In-
network preventive care, Section 5, and for devices for birth control
see Family planning, Section 5(a).

CDHP

Preventive care medications Consumer Driven Option
• Medications to promote better health as recommended by ACA. • Network Retail: Nothing
• Network Home Delivery: Nothing
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

CDHP
Coverage Authorization
• The information below describes a feature of your prescription drug plan known as coverage authorization. Coverage
authorization determines how your prescription drug plan will cover certain medications.
• Some medications are not covered unless you receive approval through a coverage review (prior authorization/medical
necessity review). Examples of drug categories that require a coverage review include but are not limited to, specialty
cholesterol, growth hormones, Botox, Interferons, rheumatoid arthritis agents, Retin A, drugs for organic impotence, and
FDA approved drugs for weight management, gender dysphoria and gender transition (in-network only). 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, Optum Rx asks your
prescriber 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/coinsurance for the medication. If coverage is not approved,
you will be responsible for the full cost of the medication.
• To determine if a prescription drug product requires prior authorization/medical necessity review visit www.myuhc.com or
call 800-718-1299.
• 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. One method that has proved effective
in saving members money is “Step Therapy.” Step therapy ensures that a first-line generic or brand alternative within a
therapeutic category is used first, before the use of a similar but more expensive drug. Specific therapeutic categories are
identified as appropriate for step therapy. Currently, the Plan offers step therapy programs on adrenal agents, specialty
cholesterol drugs, Amino Acid Disorder, Asthma, Anticonvulsants, Benign Prostatic Hyperplasia/Erectile Dysfunction,
depression, Diabetes, fungal infections, heartburn/reflux/ulcer, hemophilia, Hepatitis C, high cholesterol, infertility,
Methotrexate, skin conditions, sleep aids, Opioids and Lyrica. In situations where a targeted drug is prescribed, the
pharmacist will be notified to discuss Step 1 alternatives with the prescribing physician. If a first line therapy is not
appropriate, your physician may contact OptumRx’s coverage review unit. If the coverage is approved, the normal
coinsurance and a letter of explanation will be sent to both you and your physician. If the coverage is not approved, you
will be responsible for the full cost of the prescription. If you do not first obtain the Plan’s approval, you will pay the full
cost of the prescription. The prescriber can request a notification/prior authorization with OptumRx by logging into www.
optumrx.com, Healthcare Professionals, Prior Authorization to submit an online notification/prior authorization request or
by calling 800-711-4555. You may determine whether a particular prescription is subject to Step Therapy by visiting www.
myuhc.com or by calling the number on the back of your ID card.
• Some Prescription Drugs are subject to supply limits that may restrict the amount dispensed per prescription order or refill
and/or the amount dispensed per month’s supply. To determine if a Prescription Drug has been assigned a maximum
quantity level for dispensing, either visit www.myuhc.com or call the toll-free number on your ID card. Supply limits are
subject to periodic review and modification. Supply limits are based upon the dosing recommendations included in the
United States Food and Drug Administration (FDA) labeling, manufacturer’s package size, and information in the medical
literature or guidelines. If your current prescription is more than the supply limit, you have the following options: Accept
the supply limit; either pay the full cost or an extra copayment for the additional supply; talk to your doctor about
medication alternatives. To determine if your prescription drug product has been assigned a supply limit for dispensing,
visit www.myuhc.com or call 800-718-1299.
• 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 compound
prescriptions unless FDA approved. To avoid paying the full cost of these medications, you should ask your prescriber for
a new prescription for an FDA-approved drug before your next fill. Your compound medication may require notification/
prior authorization. The prescriber can request a notification/prior authorization with OptumRx by logging into www.
optumrx.com, Healthcare Professionals, Prior Authorization to submit an online notification/prior authorization request or
by calling 800-711-4555. If coverage of the medication is approved, you may continue to fill your prescription at the
Plan’s normal coinsurance. If the coverage of the medication is not approved, you will be responsible for the full cost of
the prescription.
• 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.

CDHP
• To find out more about your prescription drug plan, please visit www.myuhc.com or call Member Services at
800-718-1299.
• “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 or increased probability for beneficial treatment outcomes; (2) need for 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 the Optum Rx specialty pharmacy programs include cancer, cystic
fibrosis, growth hormone deficiency, hemophilia, hypercholesterolemia, immune deficiency, hepatitis C, infertility, multiple
sclerosis and rheumatoid arthritis. 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 Coverage Authorization.
To determine if your prescription drug product is a Specialty Drug, visit www.myuhc.com or call 800-718-1299.
Specialty medications must be obtained through the Optum Rx specialty pharmacy. You can send your prescription through
your normal mail service process or have your physician fax your prescription to Optum Rx.
Note: If you do not use your identification card at a network pharmacy, or if you use a non-network pharmacy, the Plan
provides no benefit and you must pay the full cost of your purchases. Non-network retail drugs will be covered under the in-
network benefit only if necessary and prescribed for sudden illness while traveling outside of the United States (including
Puerto Rico).

CDHP
Section 5 (g). Dental Benefits

• Refer to Personal Care Account (PCA).
Dental Consumer Driven Option
No benefit See Personal Care Account, page 83
2023 APWU Health Plan 122 CDHP Section 5(g)

CDHP
Section 5 (h). Wellness and Other Special Features

Special features Description
Flexible benefits option 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 decision under the OPM
disputed claim process, see Section 8.
2023 APWU Health Plan 123 CDHP Section 5(h)

CDHP
Section 5 (i). Health Education Resources and Account Management Tools

Special features Description
Online tools and • Your Personal Care Account balance and activity (also mailed quarterly)
resources • Your complete claims payment history
• A consumer health encyclopedia and interactive services
• Online health risk assessment to help determine your risk for certain conditions and
steps to manage them
• Personal Health Record
• You can also download UHC Mobile app for the same great features
Consumer choice Each member is provided access by Internet (www.myuhc.com) or telephone

information 800-718-1299 to information which you may use to support your important health and
wellness decisions, including:
• Online provider directory with complete national network and provider information
(i.e., address, telephone, specialty, practice hours, languages spoken)
• Network provider discounted pricing for comparative shopping
• Pricing information for prescription drugs
• General cost information for surgical and diagnostic procedures and for comparison of
different treatment options
• Provider quality information
• Health calculators on medical and wellness topics
Special Programs Online programs and services provide extra support and savings, at www.myuhc.com or
call 800-718-1299.
• Maternity Support Program (Maven) - Mothers-to-be receive support through every
stage of pregnancy and delivery.
• Kidney Resources Program - For those diagnosed with end-stage renal disease or
those who are currently receiving dialysis treatment, this program will help you
manage your care for the best outcome.
• Orthopedic Health Support - Orthopedic health support provides support for back,
hip, knee, shoulder and neck conditions.
• Cancer Support Program - Enroll in the program, and receive enhanced benefits at
Cancer Centers of Excellence.
• AbleTo - Customized Behavioral Health 6-8 week digital treatment program. Includes
evidence-based treatment, care plan, digital reinforcement, and clinician/coaching.
24/7 access. Members are provided access to this program based on medical history
and treatment plan.
Wellness Incentive Receive $25 when you complete an annual physical with a clinical professional each year.
When you complete an annual physical, if you have Self Only coverage, we will add $25
to your Personal Care Account (PCA). If you have Self Plus One or Self and Family
coverage we will add $25 to the Personal Care Account (PCA) for the member, spouse,
and each covered dependent who completes the Wellness Exam. We will add these
amounts in the calendar year in which the physical was completed.
Health Risk Assessment A Health Risk Assessment (HRA) is available at www.myuhc.com or call 800-718-1299.
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.
2023 APWU Health Plan 124 CDHP Section 5(i)

Non-FEHB Benefits Available to Plan Members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file a FEHB disputed claim about
them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket
maximums. These programs and materials are the responsibility of the Plan, and all appeals must follow the Plan’s
guidelines. For additional information contact the Plan at 800-222-2798 or visit their website at www.apwuhp.com.
Conversion Plan Health Insurance
When coverage as an employee or family member ends with any Plan in the Federal Employees Health Benefits Program
(FEHB), or when Temporary Continuation of Coverage (TCC) ends (except by cancellation or non-payment of premium),
you may be eligible to convert to the APWU Health Plan Conversion Plan. There is no waiting period, no limitation of
coverage for preexisting conditions, and no evidence of good health is necessary. For additional information, please contact
us by calling 800-222-2798 or by going to https://www.apwuhp.com/members/for-all-members/conversion-option/
Start Hearing
The Start Hearing program is an optional program with no additional premium that supplements the benefits in your APWU
Health Plan coverage. All participants of the APWU Health Plan, either High Option or Consumer Driven Option, who
enroll in the Start Hearing Plan through this offer will receive a discount on hearing aid devices and free hearing
consultations annually offered through Starkey Hearing Technologies. To enroll in the plan you must call Start Hearing toll
free at 888-863-7222 or visit www.starthearing.com/partners/APWU. Please specify that you are an APWU Health Plan
participant.
Enroll in our Dental Plans
Anyone who is eligible to sign up for an APWU Health Plan can enroll in the following Dental Plans. These are optional
programs with an additional premium that supplements the dental benefits in your medical coverage. FEHB members have
two options, APWU Health Plan Dental Insurance Plan or Voluntary Benefits Plan Dental Plan. Insured members may
use any dentist they choose. The cost of these benefits are not included in the FEHB premium and any charges for these
services do not count toward any FEHB deductibles, out-of-pocket maximum, copay, charges, etc. These benefits are not
subject to the FEHB disputed claims review procedure. For the APWU Health Plan Dental Insurance Plan visit www.
apwuhp.com for a brochure and enrollment forms. All participants of the APWU Health Plan, either High Option or
Consumer Driven Option, who enroll in the Voluntary Benefits Plan Dental Plan automatically receive a 7.5% premium
reduction off this dental plan's rates. The Plan is available to all APWU Active, Retired, Associate, PSE and Private Sector
due-paying members. To enroll in this additional coverage, complete and sign the Voluntary Benefits Plan Dental Plan
enrollment form, which you can obtain from your APWU Health Plan representative or by calling the Voluntary Benefits
Plan office at 800-422-4492; or visit www.voluntarybenefitsplan.com; or email [email protected]. Please specify that
you are an APWU Health Plan participant. This optional dental plan is an indemnity insurance plan underwritten by the
United States Life Insurance Company.
The Supplemental Discount Drug Program
The Supplemental Discount Drug Program will provide discounts to High Option members on all FDA-approved
prescription drugs that are dispensed through Express Scripts Mail Order and Retail pharmacies, yet are not covered on the
prescription drug plan administered by Express Scripts; www.express-scripts.com, 800-818-6717.
APWU Membership Information
Any annuitant who was in the bargaining unit represented by the APWU prior to retirement must be, or must become,
members of the APWU Retirees Department. All Federal employees, other Postal Service employees in non-APWU
bargaining Units, and annuitants will automatically become associate members of the APWU upon enrollment in the APWU
Health Plan. Associate members will be billed by the APWU for annual membership dues, except where exempt by law
(survivor annuitant or someone who is eligible for coverage under Spouse Equity Law or TCC).
2023 APWU Health Plan 125 Non-FEHB benefits available to Plan members Section 5
Section 6. General Exclusions - Services, Drugs and Supplies We Do Not Cover
The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this
brochure. Although we may list a specific service as a benefit, we will not cover it unless we determine it is medically
necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior
approval for specific services, such as transplants, (see Section 3, You need prior Plan approval for certain services).
We do not cover the following:
• Services, drugs, or supplies you receive while you are not enrolled in this Plan.
• Services, drugs, or supplies that are not medically necessary.
• Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.
• Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding transplants).
• Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus was
carried to term, or when the pregnancy is the result of an act of rape or incest.
• Services, drugs, or supplies related to sexual dysfunction or sexual inadequacy except for organic impotence, see pages
18-19, 68, 72, 117 and 120.
• Unless otherwise specified in Section 5, services and supplies for weight reduction/control or treatment of obesity.
• Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
• Services, drugs and supplies for which no charge would be made if the covered individual had no health insurance
coverage.
• Services or supplies we are prohibited from covering under Federal Law.
• Computer “story boards,” “light talkers,” or other communication aids for communication-impaired individuals.
• Services, drugs, or supplies you receive without charge while in active military service.
• Services, drugs and supplies furnished by yourself, immediate relatives or household members, such as spouse, parent,
child, brother, or sister by blood, marriage, or adoption.
• Services and supplies furnished or billed by a non-covered facility, except medically necessary prescription drugs and
physical, speech and occupational therapy rendered by a qualified professional therapist on an outpatient basis are covered
subject to Plan limits.
• General anesthetics for dental services unless due to an underlying medical condition.
• Services, drugs and supplies billed by schools or other education institutions.
• Prolotherapy
• Naturopathic and homeopathic services such as naturopathic medications.
• Services, supplies and drugs not specifically listed as covered.
• Services, supplies and drugs furnished or billed by someone other than a covered provider as defined on page 16.
• Any portion of a provider’s fee or charge ordinarily due from the enrollee that has been waived. If a provider routinely
waives (does not require the enrollee to pay) a deductible, copay or coinsurance, we will calculate the actual provider fee
or charge by reducing the fee or charge by the amount waived.
• Charges which you or we have no legal obligation to pay, such as excess charges for an annuitant age 65 or older who is
not covered by Medicare Parts A and/or B, see pages 138-140, doctor charges exceeding the amount specified by the
Department of Health and Human Services when benefits are payable under Medicare limiting charge, see page 143, or
State premium taxes however applied.
• Biofeedback; non-medical self care or self help training, such as recreational, educational, or milieu therapy unless
specifically listed.

• Charges that we determine to be in excess of the Plan allowance.
• "Never Events" are errors in patient care that can and should be prevented. The APWU Health Plan will follow the policy
of the Centers for Medicare and Medicaid Services (CMS). The Plan will deny payments for care that fall under these
policies. For additional information, please visit www.cms.gov, and enter "Never Events" into SEARCH box.

Section 7. Filing a Claim For Covered Services
This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received).
See Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval),
including urgent care claims procedures.
How to claim benefits High Option: To obtain claim forms, claims filing advice or answers about our benefits,
contact us at 800-222-2798, or at our website at www.apwuhp.com.
Mail to:
• Cigna Healthcare, P.O. Box 188004, Chattanooga, TN 37422, or Payor ID 62308
Express Scripts claims mail to:

• APWU Health Plan, P.O. Box 1358, Glen Burnie, MD 21060-1358
Consumer Driven Option: Contact UnitedHealthcare at 800-718-1299 or visit their

website at www.myuhc.com.
Mail to:
• UnitedHealthcare, P.O. Box 740800, Atlanta, GA 30374-0800
Mental Health/Substance Use Disorder Treatment: Mail to:
High Option
• Cigna Healthcare, P.O. Box 188004, Chattanooga, TN 37422 or Payor ID 62308
Consumer Driven Option

• UnitedHealthcare, P.O. Box 740800, Atlanta, GA 30374-0800
In most cases, providers and facilities file claims for you. Your provider must file on the
form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form.
For claims questions and assistance, call us at 800-222-2798.
When you must file a claim - such as when you use non-PPO providers, for services you
received overseas or when another group health plan is primary - submit it on the
CMS-1500 or a claim form that includes the information shown below. Bills and receipts
should be itemized and show:
• Patient’s name, date of birth, address, phone number and relationship to enrollee
• Patient’s plan identification number
• Name and address of person or company providing the service or supply
• Dates that services or supplies were furnished
• Diagnosis
• Type of each service or supply
• Charge for each service or supply
Note: Canceled checks, cash register receipts, or balance due statements are not
acceptable substitutes for itemized bills.
In addition:
• If another health plan is your primary payor, you must send a copy of the explanation
of benefits (EOB) statement you received from your primary payor (such as the
Medicare Summary Notice (MSN)) with your claim.

• If your claim is for the rental or purchase of durable medical equipment; skilled
nursing visits; physical therapy, occupational therapy, or speech therapy, you must
provide a written statement from the provider specifying the medical necessity for the
service or supply and the length of time needed.
• Claims for prescription drugs and supplies must include receipts that show the
prescription number, name of drug or supply, prescribing provider name, date, and
charge.
• We will provide translation and currency conversion services for claims for overseas
(foreign) services.
Post-service claims We will notify you of our decision within 30 days after we receive your post-service
procedures claim. 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 before the expiration of the original
30-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 do not agree with our initial decision, you may ask us to review it by following the
disputed claims process detailed in Section 8 of this brochure.
Records Keep a separate record of the medical expenses of each covered family member as
deductibles and maximum allowances apply separately to each person. Save copies of all
medical bills, including those you accumulate to satisfy a deductible. In most instances
they will serve as evidence of your claim. We will not provide duplicate or year-end
statements.
Deadline for filing your Send us all the documents for your claim as soon as possible. You must submit the claim
claim by December 31 of the year after the year you received the service. If you could not file
on time because of Government administrative operations or legal incapacity, you must
submit your claim as soon as reasonably possible. Once we pay benefits, there is a three-
year limitation on the re-issuance of uncashed checks.
Overseas claims For covered services you receive by providers and hospitals outside the United States and
Puerto Rico, send a completed Claim Form and the itemized bills to the following address.
Also, send any written inquiries concerning the processing of overseas claims to:
• High Option: APWU Health Plan, P.O. Box 1358, Glen Burnie, MD 21060-1358.
• Consumer Driven Option: UnitedHealthcare at the claims address shown on the back
of your UnitedHealthcare ID card.
When we need more Please reply promptly when we ask for additional information. We may delay processing
information or deny benefits for your claim if you do not respond. Our deadline for responding to
your claim is stayed while we await all of the additional information needed to process
your claim.
Authorized You may designate an authorized representative to act on your behalf for filing a claim or
Representative to appeal claims decisions to us. For urgent care claims, a healthcare professional with
knowledge of your medical condition will be permitted to act as your authorized
representative without your express consent. For the purposes of this section, we are also
referring to your authorized representative when we refer to you.

Notice Requirements The Secretary of Health and Human Services has identified counties where at least 10% of
the population is literate only in certain non-English languages. The non-English
languages meeting this threshold in certain counties are Spanish, Chinese, Navajo and
Tagalog. If you live in one of these counties, we will provide language assistance in the
applicable non-English language. You can request a copy of your Explanation of Benefits
(EOB) statement, related correspondence, oral language services (such as telephone
customer assistance), and help with filing claims and appeals (including external reviews)
in the applicable non-English language. The English versions of your EOBs and related
correspondence will include information in the non-English language about how to access
language services in that non-English language.
Any notice of an adverse benefit determination or correspondence from us confirming an

adverse benefit determination will include information sufficient to identify the claim
involved (including the date of service, the healthcare provider, and the claim amount, if
applicable), and a statement describing the availability, upon request, of the diagnosis and
procedure codes and its corresponding meaning, and the treatment code and its
corresponding meaning.

Section 8. The Disputed Claims Process
You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes. For
more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including
additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plan's customer service
representative at the phone number found on your enrollment card, plan brochure, or plan website.
Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your post-service claim (a claim where services, drugs or supplies have already been provided). In Section 3, If you disagree
with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals,
drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.
To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan
documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To
make your request, please contact our Customer Service Department by writing to APWU Health Plan, Public Relations
Department, P.O. Box 1358, Glen Burnie, MD 21060-1358 or calling 800-222-2798.
Our reconsideration will take into account all comments, documents, records, and other information submitted by you
relating to the claim, without regard to whether such information was submitted or considered in the initial benefit
determination.
When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/
investigational), we will consult with a healthcare professional who has appropriate training and experience in the field of
medicine involved in the medical judgment and who was not involved in making the initial decision.
Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or
their subordinate, who made the initial decision.
We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect
to any individual (such as a claims adjustor or medical expert) based upon the likelihood that the individual will support the
denial of benefits.
Disagreements between you and the CDHP fiduciary regarding the administration of a Personal Care Account (PCA) are not
subject to the disputed claims process.
Step Description
Ask us in writing to reconsider our initial decision. You must:
1
1. Write to us within 6 months from the date of our decision; and
2. Send your High Option request to us at: APWU Health Plan, P.O. Box 1358, Glen Burnie, MD
21060-1358 or send your Consumer Driven Option request to: UnitedHealthcare Appeals, P.O. Box
740816, Atlanta, GA 30374-0816; and
3. Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and
4. Include copies of documents that support your claim, such as physicians’ letters, operative reports, bills,
medical records, and explanation of benefits (EOB) statements.
5. Include your email address (optional), if you would like to receive our decision via email. Please note
that by giving us your email, we may be able to provide our decision more quickly.
We will provide you, free of charge and in a timely manner, with any new or additional evidence considered,
relied upon, or generated by us or at our direction in connection with your claim and any new rationale for
our claim decision. We will provide you with this information sufficiently in advance of the date that we are
required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond
to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time
to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that
new evidence or rationale at the OPM review stage described in step 4.
In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or
2
b) Write to you and maintain our denial or
c) Ask you or your provider for more information.
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.
If you do not agree with our decision, you may ask OPM to review it.
3
You must write to OPM within:
• 90 days after the date of our letter upholding our intial decision; or
• 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.
Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal
Employee Insurance Operations, FEHB2, 1900 E Street, NW, Washington, DC 20415-3620.
Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this
brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical
records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call;
• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing
your email address, you may receive OPM’s decision more quickly.
Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the
review request. However, for urgent care claims, a healthcare professional with knowledge of your medical
condition may act as your authorized representative without your express consent.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because
of reasons beyond your control.
OPM will review your disputed claim request and will use the information it collects from you and us to
4 decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you
must file the suit against OPM in Federal court by December 31 of the third year after the year in which you
received the disputed services, drugs, or supplies or from the year in which you were denied precertification
or prior approval. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law
governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record
that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the
amount of benefits in dispute.
Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily
functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for
urgent care, then, call us at 800-222-2798. We will expedite our review (if we have not yet responded to your
claim): or we will inform OPM so they can quickly review your claim on appeal. You may call FEHB2 at
202-606-3818 between 8 a.m. and 5 p.m. Eastern Time.
Please remember that we do not make decisions about plan eligibility issues. For example, we do not
determine whether you or a family member is covered under this Plan. You must raise eligibility issues with
your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant
or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.

Section 9. Coordinating Benefits with Medicare and Other Coverage
When you have other You must tell us if you or a covered family member has coverage under any other health
health coverage plan or has automobile insurance that pays healthcare expenses without regard to fault.
This is called “double coverage.”
When you have double coverage, one plan normally pays its benefits in full as the primary
payor and the other plan pays a reduced benefit as the secondary payor. We, like other
insurers, determine which coverage is primary according to the National Association of
Insurance Commissioners’ (NAIC) guidelines. For example:
• If you are covered under our Plan as a dependent, any group health insurance you have
from your employer will pay primary and we will pay secondary,
• If you are an annuitant under our Plan and also are actively employed, any group
health insurance you have from your employer will pay primary and we will pay
secondary.
This Plan always pays secondary to:

• Any medical payment, PIP or No-Fault coverage under any automobile policy
available to you,
• Any plan or program which is required by law. You should review your automobile
insurance policy to ensure that uncoordinated medical benefits have been chosen so
that the automobile insurance policy is the primary payer.
For more information on NAIC rules regarding the coordinating of benefits, visit our
website at www.apwuhp.com.
When we are the primary payor, we will pay the benefits described in this brochure.
When we are the secondary payor, we will determine our allowance. After the primary
plan processes the benefit, we will pay what is left of our allowance, up to our regular
benefit. We will not pay more than our allowance. When we are the secondary payor, we
will not waive specified visit limits.
Please see Section 4, Your Costs for Covered Services, for more information about how
we pay claims.
• TRICARE and TRICARE is the healthcare program for eligible dependents of military persons, and
CHAMPVA retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and their eligible dependents. If TRICARE
or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA
Health Benefits Advisor if you have questions about these programs.
Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an

annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any
applicable plan premiums). For information on suspending your FEHB enrollment,
contact your retirement or employing office. If you later want to re-enroll in the FEHB
Program, generally you may do so only at the next Open Season unless you involuntarily
lose coverage under TRICARE or CHAMPVA.

• Workers' Every job-related injury or illness should be reported as soon as possible to your
Compensation supervisor. Injury also means any illness or disease that is caused or aggravated by the
employment as well as damage to medical braces, artificial limbs and other prosthetic
devices. If you are a federal or postal employee, ask your supervisor to authorize medical
treatment by use of form CA-16 before you obtain treatment. If your medical treatment is
accepted by the Dept. of Labor Office of Workers’ Compensation (OWCP), the provider
will be compensated by OWCP. If your treatment is determined not job-related, we will
process your benefit according to the terms of this plan, including use of in-network
providers. Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send
it to your provider as soon as possible after treatment, to avoid complications about
whether your treatment is covered by this plan or by OWCP.
We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or
injury that the Office of Workers’ Compensation Programs (OWCP) or a similar
federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other
similar proceeding that is based on a claim you filed under OWCP or similar laws.
• Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored

program of medical assistance: If you are an annuitant or former spouse, you can
suspend your FEHB coverage to enroll in one of these State programs, eliminating your
FEHB premium. For information on suspending your FEHB enrollment, contact your
retirement or employing office. If you later want to re-enroll in the FEHB Program,
generally you may do so only at the next Open Season unless you involuntarily lose
coverage under the State program.
When other Government We do not cover services and supplies when a local, State, or Federal government agency
agencies are responsible directly or indirectly pays for them.
for your care
When others are The terms “Reimbursement” and “Subrogation” are defined by the U.S. Office of
responsible for injuries Personnel Management in Part 890 of the Code of Federal Regulations, 89 C.F.R.
§ 890.101(a), and those definitions are hereby incorporated into this brochure. Our
subrogation and reimbursement rights arise when the individual who suffers an injury or
illness has a right to be compensated from another source for that injury or illness as
described below.
Reimbursement means a carrier’s pursuit of a recovery if a covered individual has

suffered an illness or injury and has received, in connection with that illness or injury, a
payment from any party that may be liable, any applicable insurance policy, or a Workers'
Compensation program or insurance policy, and the terms of the carrier’s health insurance
plan require the covered individual, as a result of such payment, to reimburse the carrier
out of the payment to the extent of the benefits initially paid or provided. The right of
reimbursement is cumulative with and not exclusive of the right of subrogation.
Subrogation means a carrier’s pursuit of a recovery from any party that may be liable, any
applicable insurance policy, or a Workers' compensation program or insurance policy, as
successor to the rights of a covered individual who suffered an illness or injury and has
obtained benefits from that carrier’s health benefits plan.

The terms reimbursement and subrogation have the same meaning in this brochure as they
do in the OPM Rules. Our right to pursue and receive subrogation and reimbursement
recoveries is a condition of and a limitation on the nature of benefits or benefit payments
and on the provision of benefits under our coverage. This section explains your basic
obligations and procedures related to this reimbursement requirement. The funds the Plan
recovers through reimbursement and subrogation help lower the subscription charges for
all enrollees.
If we pay benefits for an injury or illness suffered by a covered individual, and monetary
compensation related to that injury or illness is received from someone else (referred to as
a “third party”), the Plan must be reimbursed out of the compensation received for the
total amount of benefits it paid or reasonably expects to pay. The amount the Plan is
entitled to recover is sometimes referred to as the Plan’s "lien", and the Plan may ask a
court to issue an order confirming the Plan’s lien. Reimbursement to the Plan is a
requirement and condition on a covered individual obtaining benefits from the Plan under
this brochure. The Plan’s recoveries through reimbursement and subrogation help lower
subscription charges for all enrollees in the Plan.
By enrolling in the Plan and in accordance with the FEHB Program and this brochure, you
agree that the Plan’s right to pursue and receive subrogation and reimbursement recoveries
is a condition of and a limitation on the nature of benefits or benefit payments and on the
provision of benefits under our coverage, and you agree to the following:
• The Plan must be reimbursed in any and all situations where a covered individual, or
their representatives, heirs, administrators, successors or assignees receive payment
from any source related to an injury or illness for which the individual has received
benefits or benefit payments from the Plan. This may include money recovered from
another party who may be liable, a third party’s insurance policy, your own insurance
policy, or a Workers' Compensation program or policy, through a lawsuit, a judgment,
settlement, or other recovery. The Plan must be reimbursed to the extent of the
benefits we have paid or provided, or reasonably expect to pay or provide, in
connection with the injury or illness.
• Reimbursement of the Plan must be done on a first priority basis (before any of the
rights of any other party are honored) out of any recovery obtained no matter the
source (litigation, judgment, settlement, insurance claim or otherwise) and no matter
how the recovery is characterized, designated, or apportioned (such as your claim
against the third party being for “pain and suffering”).
• The Plan’s right to reimbursement applies even if the Plan paid benefits before we
knew of the accident or illness.
• Restrictive endorsements or other statements on checks accepted by the Plan or its
agents to reimburse the Plan in a subrogation matter will not bind the Plan.
• Neither you nor your representatives, heirs, administrators, successors or assignees
will do anything that would prevent us from being fully reimbursed for the benefits we
paid, and you and your representatives, heirs, administrators, successors and assignees
will cooperate in assisting us in recovering the cost of the benefits we paid.
• You agree and authorize the Plan to communicate directly with any involved insurance
carriers regarding your injury or illness and their reimbursements.
• This reimbursement responsibility covers benefits for you and any other person on
your membership.
The Plan is entitled to be reimbursed fully even if the amount received does not
compensate the injured individual fully or if there are other liens or expenses. We are
entitled to be reimbursed for our benefit payments even if the injured individual is not
legally “made whole” for all damages arising out of the injury or illness. Our right of
recovery is also not subject to reductions for attorney’s fees or costs in recovering the
money under the “common fund” or other legal doctrines.

If you wish to discuss the amount of reimbursement to pay to the Plan, please contact
Customer Service (High Option, 800-222-2798; Consumer Driven Option, 800-718-1299)
or our subrogation representatives at the contact information at the end of this section.
If you or your representatives, heirs, administrators, successors or assignees do not pursue

a claim or demand against a third party, we may, at our option, choose to exercise our
right of subrogation and pursue a recovery from any liable party as successor to your
rights.
What to communicate to the Plan

• Promptly inform us if a covered individual has an injury or illness for which benefits
paid by the Plan might be reimbursed or subrogated as described here. This includes
reporting third party cases to Customer Service or responding to any questionnaires or
surveys inquiring about benefit claims paid by the Plan. We or our subrogation
representatives will communicate with you about whether you owe the Plan any
reimbursement. Failure to provide information related to reimbursements may delay
the processing of your benefits.
• If you or your representatives, heirs, administrators, successors or assignees make a
claim or demand on a third party for compensation for an injury or illness for which
the Plan has paid benefits, notify us immediately. We will communicate with you to
keep the status of the claim or demand updated in our systems so that there is no delay
in processing your claims. We may seek a first priority lien on the proceeds of your
claim in order to ensure that the Plan is reimbursed for the benefits we paid or will
pay. We may also require you to assign to us (1) your claim or demand or (2) your
right to the proceeds of your claim or demand. In all cases, we may enforce our right
of recovery and reimbursement by offsetting any undisputed amount owed the Plan as
a result of recovering money from a third party against future benefit payments by the
Plan.
If you need more information or wish to report or discuss a subrogation or reimbursement

matter, please contact Customer Service or our subrogation representatives.
High Option: ODSA, P.O. Box 34188, Washington, DC 20043-4188; or

[email protected], 877-535-1075 or 202-898-1075
Consumer Driven Option: UnitedHealthcare, 800-718-1299
When you have Federal Some FEHB plans already cover some dental and vision services. When you are covered
Employees Dental and by more than one vision/dental plan, coverage provided under your FEHB plan remains as
Vision Insurance Plan your primary coverage. FEDVIP coverage pays secondary to that coverage. When you
(FEDVIP) enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 877-888-3337,
(TTY 877-889-5680), you will be asked to provide information on your FEHB plan so
that your plans can coordinate benefits. Providing your FEHB information may reduce
your out-of-pocket cost.
Clinical trials An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial
that is conducted in relation to the prevention, detection, or treatment of cancer or other
life-threatening disease or condition, and is either Federally-funded; conducted under an
investigational new drug application reviewed by the Food and Drug Administration
(FDA); or is a drug trial that is exempt from the requirement of an investigational new
drug application.
If you are a participant in a clinical trial, this health plan will provide related care as
follows, if it is not provided by the clinical trial:
• Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays
and scans, and hospitalizations related to treating the patient's condition, whether the
patient is in a clinical trial or is receiving standard therapy

• Extra care costs - costs related to taking part in a clinical trial such as additional tests
that a patient may need as part of the trial, but not as part of the patient's routine care
• Research costs - costs related to conducting the clinical trial such as research physician
and nurse time, analysis of results, and clinical tests performed only for research
purposes. These costs are generally covered by the clinical trials. This Plan does not
cover these costs
When you have Medicare For more detailed information on "What is Medicare?" and "Should I Enroll in
Medicare?" please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY
1-877-486-2048) or at www.medicare.gov.
• The Original The Original Medicare Plan (Original Medicare) is available everywhere in the United
Medicare Plan (Part States. It is the way everyone used to get Medicare benefits and is the way most people
A or Part B) get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or
hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share.
All physicians and other providers are required by law to file claims directly to Medicare
for members with Medicare Part B, when Medicare is primary. This is true whether or not
they accept Medicare.
When you are enrolled in Original Medicare along with this Plan, you still need to follow
the rules in this brochure for us to cover your care.
Claims process when you have the Original Medicare Plan – You will probably not
need to file a claim form when you have both our Plan and the Original Medicare Plan.
When we are the primary payor, we process the claim first. In this case, we do not waive
any out-of-pocket costs.
When Original Medicare is the primary payor, Medicare processes your claim first. In
most cases, your claim will be coordinated automatically and we will then provide
secondary benefits for covered charges. To find out if you need to do something to file
your claim, call us at 800-222-2798 or see our website at www.apwuhp.com.
We waive some costs if the Original Medicare Plan is your primary payor.
Under the High Option, we will waive some out-of-pocket costs as follows:
• Inpatient hospital service. If you are enrolled in Medicare Part A, we will waive the
deductible and coinsurance.
• Medical services and supplies provided by physicians and other healthcare
professionals. If you are enrolled in Medicare Part B, we will waive the deductible,
coinsurance and copayment.
• We offer a Medicare Advantage plan, UnitedHealthcare Medicare Advantage (PPO)
for APWU Health Plan for Federal members. Please review the information on
coordinating benefits with Medicare Advantage plans below.
Under the Consumer Driven Option, when Original Medicare (either Medicare Part A
or Medicare Part B) is the primary payer, we will not waive any out-of-pocket costs.
Note: We do not waive our deductible, copayments or coinsurance for prescription drugs
or for services and supplies that Medicare does not cover. Also, we do not waive benefit
limitations, such as the 24-visit limit for chiropractic services or the 60-visit limit
for physical, occupational or speech therapy.
You can find more information about how our Plan coordinates benefits with Medicare in
APWU Health Plan's Blueprint to Medicare at www.apwuhp.com. We do not waive any
costs if the Original Medicare Plan is your primary carrier.

Please review the information on page 140. It illustrates your cost share if you are
enrolled in Medicare Part B. Medicare will be primary for all Medicare eligible services.
Members must use providers who accept Medicare's assignment.
• Tell us about your You must tell us if you or a covered family member has Medicare coverage, and let us
Medicare coverage obtain information about services denied or paid under Medicare if we ask. You must also
tell us about other coverage you or your covered family members may have, as this
coverage may affect the primary/secondary status of this Plan and Medicare.
• Private contract with If you are enrolled in Medicare Part B, a physician may ask you to sign a private contract
your physician agreeing that you can be billed directly for services ordinarily covered by Original
Medicare. Should you sign an agreement, Medicare will not pay any portion of the
charges, and we will not increase our payment. We will still limit our payment to the
amount we would have paid after Original Medicare’s payment. You may be responsible
for paying the difference between the billed amount and the amount we paid.
• Medicare Advantage If you are eligible for Medicare, you may choose to enroll and get your Medicare benefits
(Part C) from a Medicare Advantage plan. These are private healthcare choices (like HMOs and
regional PPOs) in some areas of the country. To learn more about Medicare Advantage
plans, contact Medicare at 800-MEDICARE (800-633-4227), (TTY: 877-486-2048) or at
www.medicare.gov.
If you enroll in a Medicare Advantage plan, the following options are available to you:
This Plan and our Medicare Advantage plan: You may enroll in our Medicare
Advantage plan and also remain enrolled in our FEHB plan. For more information on our
Medicare Advantage plan, please contact 855-383-8793. Enrollment in UnitedHealthcare
Medicare Advantage (PPO) for APWU Health Plan is voluntary. Members must complete
an application for enrollment. Eligible enrollees voluntarily opt into UnitedHealthcare
Medicare Advantage (PPO) for APWU Health Plan and may opt out at any time. You may
enroll in the UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan, if:
• You are a retiree or annuitant enrolled in the High Option and have both Medicare Part
A and Part B.
• You are a United States citizen or are lawfully present in the United States.
• You do NOT have End-Stage Renal Disease (ESRD). Enrollees who have ESRD
cannot enroll until after the 30-month grace period has expired. Members diagnosed
with ESRD while enrolled in UnitedHealthcare Medicare Advantage (PPO) for APWU
Health Plan may remain enrolled and ESRD services will be covered.
• You complete an application for enrollment in the UnitedHealthcare Medicare
Advantage (PPO) for APWU Health Plan.
Medicare B Premium Reimbursement

• We offer a plan designed to help members with their Medicare Part B premium. This
plan is called UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan. If
you have Medicare Part A and B and enroll in this plan, you will be reimbursed
$85.00 of your Medicare Part B monthly premium. This will be sent from Centers
for Medicare and Medicaid Services (CMS) directly to your Social Security. Please
review the information below. It illustrates your cost share if you are enrolled in the
High Option only, the High Option with Medicare Part B or the UnitedHealthcare
Medicare Advantage (PPO) for APWU Health Plan. Medicare will be primary for all
Medicare eligible services. Members must use providers who accept Medicare's
assignment.
Please review the following examples which illustrate your cost share if you are enrolled
in Medicare Part B. If you purchase Medicare Part B, your provider is in our network and
participates in Medicare, then we waive some costs because Medicare will be the primary
payor.

Benefit Description: Deductible
High Option You Pay without Medicare (In-Network): $450 Self Only/$800 Family
High Option You Pay with Medicare B (In-Network): $0
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -
(UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $0
Benefit Description: Out-of-Pocket Maximum

High Option You Pay without Medicare (In-Network): $6,500 Self Only/$13,000
Family
High Option You Pay with Medicare B (In-Network): $6,500 Self Only/$13,000 Family
Benefit Description: Part B Premium Reimbursement Offered

High Option You Pay without Medicare (In-Network): N/A
High Option You Pay with Medicare B (In-Network): N/A
per month
Benefit Description: Primary Care Physician

High Option You Pay without Medicare (In-Network): $25
Benefit Description: Specialist

High Option You Pay without Medicare (In-Network): $25
Benefit Description: Inpatient Hospital

High Option You Pay without Medicare (In-Network): 15%
Benefit Description: Outpatient Hospital

High Option You Pay without Medicare (In-Network): 15%
Benefit Description: Incentives offered

High Option You Pay without Medicare (In-Network): N/A
High Option You Pay with Medicare B (In-Network): Waive deductible, coinsurance
and copayment
(UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network):
Renew Active, Podiatry, Hearing aids, Nationwide network
To learn more about the UnitedHealthcare Medicare Advantage (PPO) for APWU Health
Plan and how to enroll, call us at 855-383-8793, 8 a.m. to 8 p.m., local time, Monday
through Friday. For TTY for the deaf, hard of hearing, or speech impaired, call 711. We
will send you additional information and an application for enrollment.

This Plan and another plan’s Medicare Advantage plan: You may enroll in another
plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still
provide benefits when your Medicare Advantage plan is primary, even out of the Medicare
Advantage plan’s network and/or service area (if you use our Plan providers). For the
High Option, we waive some costs if Medicare Advantage is your primary payor. We will
waive our copayments, coinsurance, or deductibles. For the Consumer Driven Option, we
will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a
Medicare Advantage plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits
with Medicare.
Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an

annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare
Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your
Medicare Advantage plan premium.) For information on suspending your FEHB
enrollment, contact your retirement or employing office. If you later want to re-enroll in
the FEHB Program, generally you may do so only at the next Open Season unless you
involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.
• Medicare prescription When we are the primary payor, we process the claim first. If you enroll in Medicare Part
drug coverage (Part D and we are the secondary payor, we will review claims for your prescription drug costs
D) that are not covered by Medicare Part D and consider them for payment under the FEHB
plan.

Medicare always makes the final determination as to whether they are the primary payor. The following chart illustrates
whether Medicare or this Plan should be the primary payor for you according to your employment status and other factors
determined by Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can
administer these requirements correctly. (Having coverage under more than two health plans may change the order of
benefits determined on this chart.)
Primary Payor Chart

A. When you - or your covered spouse - are age 65 or over and have Medicare and you... The primary payor for the
individual with Medicare is...
Medicare This Plan
1) Have FEHB coverage on your own as an active employee
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an
annuitant
3) Have FEHB through your spouse who is an active employee
4) Are a reemployed annuitant with the Federal government and your position is excluded from
the FEHB (your employing office will know if this is the case) and you are not covered under
FEHB through your spouse under #3 above
5) Are a reemployed annuitant with the Federal government and your position is not excluded
from the FEHB (your employing office will know if this is the case) and...
• You have FEHB coverage on your own or through your spouse who is also an active
employee
• You have FEHB coverage through your spouse who is an annuitant
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired
under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and
you are not covered under FEHB through your spouse under #3 above
7) Are enrolled in Part B only, regardless of your employment status for Part B for other
services services
8) Are a Federal employee receiving Workers' Compensation *
9) Are a Federal employee receiving disability benefits for six months or more
B. When you or a covered family member...
1) Have Medicare solely based on end stage renal disease (ESRD) and...
• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD
(30-month coordination period)
• It is beyond the 30-month coordination period and you or a family member are still entitled
to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
• This Plan was the primary payor before eligibility due to ESRD (for 30 month
coordination period)
• Medicare was the primary payor before eligibility due to ESRD
3) Have Temporary Continuation of Coverage (TCC) and...
• Medicare based on age and disability
• Medicare based on ESRD (for the 30 month coordination period)
• Medicare based on ESRD (after the 30 month coordination period)
C. When either you or a covered family member are eligible for Medicare solely due to
disability and you...
1) Have FEHB coverage on your own as an active employee or through a family member who
is an active employee
2) Have FEHB coverage on your own as an annuitant or through a family member who is an
annuitant
D. When you are covered under the FEHB Spouse Equity provision as a former spouse
*Workers' Compensation is primary for claims related to your condition under Workers' Compensation.
When you are age 65 or over and do not have Medicare
Under the FEHB law, we must limit our payments for inpatient hospital care and physician care to those payments you would
be entitled to if you had Medicare. Your physician and hospital must follow Medicare rules and cannot bill you for more
than they could bill you if you had Medicare. You and the FEHB benefit from these payment limits. Outpatient hospital care
and non-physician based care are not covered by this law; regular Plan benefits apply. The following chart has more
information about the limits.
If you:
• are age 65 or over; and
• do not have Medicare Part A, Part B, or both; and
• have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former spouse; and
• are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)
Then, for your inpatient hospital care:
• The law requires us to base our payment on an amount - the "equivalent Medicare amount" - set by Medicare's rules for
what Medicare would pay, not on the actual charge.
• You are responsible for your applicable deductibles, coinsurance, or copayments under this Plan.
• You are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the
explanation of benefits (EOB) form that we send you.
• The law prohibits a hospital from collecting more than the "equivalent Medicare amount."
And, for your physician care, the law requires us to base our payment and your coinsurance or copayment on:
• an amount set by Medicare and called the "Medicare approved amount," or
• the actual charge if it is lower than the Medicare approved amount.
If your physician:
Participates with Medicare or accepts Medicare assignment for the claim and is a member of our PPO network,
Then you are responsible for:
your deductibles, coinsurance, and copayments.
If your physician:
Participates with Medicare and is not in our PPO network,
your deductibles, coinsurance, copayments, and any balance up to the Medicare approved amount.
If your physician:
Does not participate with Medicare,
your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare approved amount.
If your physician:
Does not participate with Medicare and is not a member of our PPO network
your out-of-network deductibles, coinsurance, and any balance up to 115% of the Medicare approved amount
If your physician:
Opts-out of Medicare via private contract
your deductibles, coinsurance, copayments, and any balance your physician charges

It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are permitted
to collect only up to the Medicare approved amount.
Physicians Who Opt-Out of Medicare
A physician may have opted-out of Medicare and may or may not ask you to sign a private contract agreeing that you can be
billed directly for services ordinarily covered by Original Medicare. This is different than a non-participating doctor, and we
recommend you ask your physician if they have opted-out of Medicare. Should you visit an opt-out physician, the physician
will not be limited to 115% of the Medicare approved amount. You may be responsible for paying the difference between the
billed amount and our regular in-network/out-of-network benefits.
Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your
physician or hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If you
have paid more than allowed, ask for a refund. If you need further assistance, call us. It is generally to your financial
advantage to use a physician who participates with Medicare. Such physicians are permitted to collect only up to the
Medicare approved amount.
When you have the We limit our payment to an amount that supplements the benefits that Medicare would
Original Medicare Plan pay under Medicare Part A (Hospital insurance) and Medicare Part B (Medical insurance),
(Part A, Part B, or both) regardless of whether Medicare pays. Note: We pay our regular benefits for
emergency services to an institutional provider, such as a hospital, that does not participate
with Medicare and is not reimbursed by Medicare.
We use the Department of Veterans Affairs (VA) Medicare-equivalent Remittance Advice

(MRA) when the statement is submitted to determine our payment for covered services
provided to you if Medicare is primary, when Medicare does not pay the VA facility.
If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for
services that both Medicare Part B and we cover depend on whether your physician
accepts Medicare assignment for the claim.
High Option: If your physician accepts Medicare assignment, then you pay nothing for
covered charges up to our allowance.
Consumer Driven Option: If your physician accepts Medicare assignment, then you
pay nothing if you have unused benefits available under your Personal Care Account
(PCA) to pay the difference between the Medicare approved amount and Medicare's
payment. If your PCA is exhausted, you must pay either this full difference under your
Deductible or the lesser of your coinsurance or the full difference if your Deductible has
been met.
If your physician does not accept Medicare assignment, you pay the difference between
the “limiting charge” or the physician’s charge (whichever is less) and our payment
combined with Medicare’s payment.
It is important to know that a physician who does not accept Medicare assignment may
not bill you for more than 115% of the amount Medicare bases its payment on, called the
“limiting charge.” The Medicare Summary Notice (MSN) that Medicare will send you
will have more information about the limiting charge. If your physician tries to collect
more than allowed by law, ask the physician to reduce the charges. If the physician does
not, report the physician to the Medicare carrier that sent you the MSN form. Call us if
you need further assistance.
Please see Section 9, Coordinating benefits with Medicare and other coverage, for more
information about how we coordinate benefits with Medicare.

Section 10. Definitions of Terms We Use in This Brochure
Accidental injury An injury resulting from a violent external force.
Admission The period from entry (admission) into a hospital or other covered facility until discharge. In
counting days of inpatient care, the date of entry and the date of discharge are counted as the
same day.
Assignment Your authorization for us to pay benefits directly to the provider. We reserve the right to pay you
directly for all covered services.
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on
the effective date of their enrollment and ends on December 31 of the same year.
Clinical trials An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is
conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening
disease or condition, and is either Federally-funded; conducted under an investigational new
drug application reviewed by the Food and Drug Administration (FDA); or is a drug trial that is
exempt from the requirement of an investigational new drug application. If you are a participant
in a clinical trial, this health plan will provide related care as follows, if it is not provided by the
clinical trial:
• Routine care costs - costs for routine services such as doctors visits, lab tests, X-rays and
scans, and hospitalizations related to treating the patient's condition, whether the patient is in
a clinical trial or is receiving standard therapy
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a
patient may need as part of the trial, but not as part of the patient's routine care
• Research costs - costs related to conducting the clinical trial such as research physician and
nurse time, analysis or results, and clinical tests performed only for research purposes.
These costs are generally covered by the clinical trials. This Plan does not cover these costs.
Coinsurance See Section 4, page 26.
Copayment See Section 4, page 25.
Cost-sharing See Section 4, page 25.
Covered services Services we provide benefits for, as described in this brochure.
Custodial care Treatment or services, regardless of who recommends them or where they are provided, that
could be rendered safely and reasonably by a person not medically skilled, or that are designed
mainly to help the patient with daily living activities. These activities include, but are not limited
to:
• Personal care such as help in: walking; getting in and out of bed; bathing; eating by spoon,
tube or gastrostomy; exercising; dressing
• Homemaking, such as preparing meals or special diets
• Moving the patient
• Acting as a companion or sitter
• Supervising medication that can usually be self administered; or
• Treatment or services that any person may be able to perform with minimal instruction,
including but not limited to recording temperature, pulse, and respirations, or administration
and monitoring of feeding systems
We determine which services are custodial care. Custodial care that lasts 90 days or more is
sometimes known as long term care.
Deductible See Section 4, page 25.

Experimental or A drug, device, or biological product is experimental or investigational if the drug, device, or
investigational biological product cannot be lawfully marketed without approval of the U.S. Food and Drug
service Administration (FDA) and approval for marketing has not been given at the time it is furnished.
Approval means all forms of acceptance by the FDA.
A medical treatment or procedure, or a drug, device, or biological product is experimental or

investigational if 1) reliable evidence shows that it is the subject of ongoing phase I, II, or III
clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its
efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or 2)
reliable evidence shows that the consensus of opinion among experts regarding the drug, device,
or biological product or medical treatment or procedure is that further studies or clinical trials
are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its
efficacy as compared with the standard means of treatment or diagnosis.
Reliable evidence shall mean only published reports and articles in the authoritative medical and
scientific literature; the written protocol or protocols used by the treating facility or the protocols
of another facility studying substantially the same drug, device, or medical treatment or
procedure; or the written informed consent used by the treating facility or by another facility
studying substantially the same drug, device, or medical treatment or procedure.
Determination of experimental/investigational status may require review by a specialty

appropriate board-certified healthcare provider or appropriate government publications such as
those of the National Institutes of Health, National Cancer Institute, Food and Drug
Administration, Agency for Healthcare Research and Quality, and the National Library of
Medicine.
Gender Affirming Healthcare that can include therapy to address feelings of gender dysphoria, as well as medical
Services treatments that help individuals achieve physical characteristics that better align with their
gender identity.
Genetic screening The diagnosis, prognosis, management, and prevention of genetic disease for those patients who
have no current evidence or manifestation of a genetic disease and those who have not been
determined to have an inheritable risk of genetic disease.
Genetic testing The diagnosis and management of genetic disease for those patients with current signs and
symptoms and for those who we have determined have an inheritable risk of genetic disease.
Group health Healthcare coverage that a member is eligible for because of employment by, membership in, or
coverage connection with, a particular organization or group that provides payment for hospital, medical,
or other healthcare services or supplies, or that pays a specific amount for each day or period of
hospitalization if that specified amount exceeds $200 per day, including extension of any of
these benefits through COBRA.
Habilitative Healthcare services that help a person keep, learn or improve skills and functioning for daily
services living. Examples include therapy for a child who isn't walking or talking at the expected age.
These services may include physical and occupational therapy, speech-language pathology and
other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Healthcare A physician or other healthcare professional licensed, accredited, or certified to perform

professional specified health services consistent with state law.
Home healthcare An agency which meets all of the following:

agency • Is primarily engaged in providing, and is duly licensed or certified to provide, skilled nursing
care and therapeutic services
• Has policies established by a professional group associated with the agency or organization.
This professional group must include at least one registered nurse (R.N.) to direct the
services provided and it must provide for full-time supervision of each service by a
physician or registered nurse
• Maintains a complete medical record on each individual; and

• Has a full-time administrator
Hospice care A coordinated program of home and inpatient palliative and supportive care for the terminally ill
program 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.
Infertility Infertility is the condition of an individual who is unable to conceive or produce conception
during a period of 1 year if the female is age 35 or younger or during a period of 6 months if the
female is over the age of 35.
Maintenance Includes but is not limited to physical, occupational, or speech therapy where continued therapy
therapy is not expected to result in significant restoration of a bodily function but is utilized to maintain
the current status.
Medically Services, drugs, supplies or equipment provided by a hospital or covered provider of healthcare
necessary services that we determine:
• Are appropriate to diagnose or treat the patient's condition, illness or injury
• Are consistent with standards of good medical practice in the United States
• Are not primarily for the personal comfort or convenience of the patient, the family, or the
provider
• Are not a part of or associated with the scholastic education or vocational training of the
patient; and
• In the case of inpatient care, cannot be provided safely on an outpatient basis
The fact that a covered provider has prescribed, recommended, or approved a service, supply,
drug or equipment does not, in itself, make it medically necessary.
Plan allowance Our Plan allowance is the amount we use to determine our payment and your coinsurance for
covered services. Fee-for-service plans determine their allowances in different ways. We
determine our allowance as follows:
For PPO providers, our allowance is based on negotiated rates. PPO providers always accept the
Plan’s allowance as their charges for covered services.
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 60th percentile.
• For the Consumer Driven Option we use guides specifically prepared by Fair Health at the
80th percentile.
• If this information is not available, we will use other credible sources including our own
data.
For more information, see Differences between our allowance and the bill in Section 4.
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.
Post-service claims Any claims that are not pre-service. In other words, post-service claims are those claims where
treatment has been performed and the claims have been sent to us in order to apply for benefits.
Pre-service claims Those claims (1) that require precertification, prior approval or a referral and (2) where failure to
obtain precertification, prior approval, or a referral results in a reduction of benefits.

Rehabilitative care Treatment that reasonably can be expected to restore and/or substantially restore a bodily
function that was impaired as a result of trauma or disease.
Reimbursement A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has
received, in connection with that illness or injury, a payment from any party that may be liable,
any applicable insurance policy, or a workers' compensation program or insurance policy, and
the terms of the carrier's health benefits plan require the covered individual, as a result of such
payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or
provided. The right of reimbursement is cumulative with, and not exclusive of, the right of
subrogation.
Residential Residential Treatment Centers (RTCs) are accredited by a nationally recognized organization
Treatment Center and licensed by the state, district, or territory to provide short-term transitional residential
treatment for medical conditions, mental health conditions, and/or substance use. Accredited
healthcare facilities (excluding hospitals, skilled nursing facilities, group homes, halfway
houses, and similar types of facilities) provide 24-hour residential evaluation, treatment and
comprehensive specialized services relating to the individual's medical, physical, mental health,
and/or substance use therapy needs.
Subrogation A carrier's pursuit of a recovery from any party that may be liable, any applicable insurance
policy, or a workers' compensation program or insurance policy, as successor to the rights of a
covered individual who suffered an illness or injury and has obtained benefits from that carrier's
health benefits plan.
Us/We Us and We refer to APWU Health Plan.
You You refers to the enrollee and each covered family member.
Urgent care claims A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit
for non-urgent care claims could have one of the following impacts:
• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would
subject you to severe pain that cannot be adequately managed without the care or treatment
that is the subject of the claim.
Urgent care claims usually involve pre-service claims and not post-service claims. We will
determine whether or not a claim is an urgent care claim by applying the judgment of a prudent
layperson who possesses an average knowledge of health and medicine.
If you believe your claim qualifies as an urgent care claim, please contact our Customer Service
Department at 800-222-2798. You may also prove that your claim is an urgent care claim by
providing evidence that a physician with knowledge of your medical condition has determined
that your claim involves urgent care.
Virtual visits A virtual visit lets you see and talk to a doctor from your phone, tablet or computer. A doctor
can see and speak to you about minor medical concerns, provide a diagnosis and, if appropriate,
a prescription can be sent to your local pharmacy.

Consumer Driven Health Plan Definitions
Consumer Driven Option A fee-for-service option under the FEHB that offers you greater control over choices of
your healthcare expenditures. You decide what healthcare services will be reimbursed
under the Health Plan funded Personal Care Account (PCA). Unused funds from the PCA
will roll over at the end of the year. If you spend the entire PCA fund before the end of the
year, then you must satisfy a deductible before benefits are payable under the traditional
type of insurance covered by your Plan. You decide whether to use in-network or out-of-
network providers to reach the maximum fund allowed under your PCA.
Deductible Under the Consumer Driven Option, your plan's deductible is reduced by applying the
funds in your Personal Care Account (PCA) which is funded in January by 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. See page 25.
Personal Care Account Under the Consumer Driven Option, your Personal Care Account (PCA) is an established
benefit amount which is available for you to use first to pay for covered hospital, medical,
dental and vision care expenses. You determine how your PCA will be spent and any
unused amount at the end of the year may be rolled over to increase your available PCA in
the subsequent year(s).
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 and $10,000 per
Self Plus One or Self and Family enrollment.

Summary of Benefits for the High Option of the APWU Health Plan - 2023
Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in
this brochure. Before making a final decision, please read this FEHB Brochure. You can also obtain a copy of our Summary
of Benefits Coverage as required by the Affordable Care Act at www.apwuhp.com. On this page we summarize specific
expenses we cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on
your enrollment form.
Below, an asterisk (*) means the item is subject to the calendar year deductible, $450 (PPO) or $1,000 (Non-PPO). And, after
we pay, you generally pay any difference between our allowance and the billed amount if you use a Non-PPO physician or
other healthcare professional.
High Option Benefits You pay Page
Medical services provided by physicians:
• Diagnostic and treatment services provided in the PPO: $25 copay per visit (No deductible); 35
office* 15% of Plan allowance
Non-PPO: 40% of our allowance plus amount

over our allowance
Services provided by a hospital:
• Inpatient PPO: 15% of Plan allowance 56
Non-PPO: $300 per admission and 40% of

our allowance plus amount over our
allowance
• Outpatient* PPO: 15% of Plan allowance 58

over our allowance
Emergency benefits:
• Accidental injury PPO: Nothing 61
Non-PPO: Nothing
• Medical emergency* (other than an Urgent Care PPO: 15% of Plan allowance 61
Center)
Non-PPO: 15% of Plan allowance
Mental health and substance use disorder treatment: PPO: $25 copay per visit (No deductible); 63
15% of Plan allowance

over our allowance
Prescription drugs:
• Network pharmacy $10 Tier 1/25% Tier 2/45% Tier 3/Specialty 68

drugs 25% Tier 4/25% Tier 5/45% Tier 6
• Non-network pharmacy 50% of cost 68
• Mail order $20 Tier 1/25% Tier 2/45% Tier 3 Specialty 68

drugs 25% Tier 4/25% Tier 5/45% Tier 6
2023 APWU Health Plan 150 High Option Summary

High Option Benefits You pay Page
Dental care: 30% of Plan allowance plus amount over our 74
allowance
Wellness and other special features: See Section 5(h) 75
Flexible benefits option, 24-hour nurse line, services for

deaf and hearing-impaired, Disease Management Program,
Review and Reward program, Diabetes and Weight
Management Programs, online access to claims
information, online Preferred Provider Organization (PPO)
directories, Hospital Quality Ratings Guide, Treatment
Cost Estimator, online non-FEHB savings on health and
wellness products and Health Risk Assessment (HRA)
savings.
Protection against catastrophic costs (out-of-pocket PPO: Nothing after $6,500 for Self Only or 28
maximum): $13,000 for a Self Plus One or Self and
Family enrollment per year
Non-PPO: Nothing after $12,000 for Self

Only, or $24,000 for a Self Plus One or
Some costs do not count toward this

protection
2023 APWU Health Plan 151 High Option Summary

Summary of Benefits for the CDHP of the APWU Health Plan - 2023
Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in
this brochure. Before making a final decision, please read this FEHB Brochure. You can also obtain a copy of our Summary
of Benefits Coverage as required by the Affordable Care Act at www.apwuhp.com. On this page we summarize specific
expenses we cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on
your enrollment form.
Below, an asterisk (*) means the item is subject to the calendar year Net Deductible, $450 (PPO) or $1,000 (Non-PPO). And,
after we pay, you generally pay any difference between our allowance and the billed amount if you use a Non-PPO physician
or other healthcare professional.
CDHP Benefits You Pay Page
In-network preventive care: Nothing 80
Personal Care Account:
• Up to $1,200 for Self Only or $2,400 for Self Plus One Nothing up to $1,200 for Self Only or $2,400 83
or Self and Family for medical, surgical, hospital, for Self Plus One or Self and Family
mental health and substance use disorder treatment
services and prescription drugs plus certain dental and
vision care
Traditional Health Coverage after Personal See Section 5 Traditional Health Overview 86
Care Account is exhausted (Net Deductible before Traditional Health
Coverage Begins)
Medical/Surgical services provided by physicians:
• Diagnostic and treatment services provided in the In-network: 15% of Plan allowance 89
office* Out-of-network: 50% of our allowance plus
amount over our allowance
• Inpatient* In-network: 15% of Plan allowance 107

Out-of-network: 50% of our allowance plus
• Outpatient* In-network: 15% of Plan allowance 109

Emergency benefits:
• Accidental injury* In-network: 15% of Plan allowance 111
Out-of-network: 15% of Plan allowance
• Medical emergency* (other than an Urgent Care In-network: 15% of Plan allowance 112
Center)
Out-of-network: 15% of Plan allowance
Mental health and substance use disorder treatment*: In-network: 15% of Plan allowance 113
2023 APWU Health Plan 152 CDHP Summary

CDHP Benefits You Pay Page
Prescription drugs:
• Network Retail* 25% minimum $15 Tier 1 & Tier 2/40% 117
minimum $15 Tier 3
• Network Home Delivery* 25% minimum $10 Tier 1 & Tier 2/40% 117
minimum $10 Tier 3
Dental Care/Vision Care (covered only under Personal Any amount over $400 per Self Only or $800 122
Care Account): per Self Plus One or Self and Family (see
Section 5 Extra PCA Expenses).
Health education resources and account management See Section 5(i) 124
tools:
Online tools and resources, Consumer choice information,

Services for deaf and hearing-impaired, online special
programs for extra support savings, $25 wellness incentive
when you complete an annual physical, and Health Risk
Assessment (HRA).
Protection against catastrophic costs (out-of-pocket In-network: Nothing after $6,500 Self Only or 28
maximum): $13,000 for a Self Plus One or Self and
Out-of-network: Nothing after $12,000 Self

Only or $24,000 for a Self Plus One or Self
and Family enrollment per year
Some costs do not count toward this

protection
2023 APWU Health Plan 153 CDHP Summary

Index
Accidental injury Congenital anomalies Federal Employees Dental and Vision
CDHP.................................................111 CDHP............................................99-102 Insurance Plan
HO............................................60-61, 74 HO..................................................48-51 Flexible benefits option
Acupuncture Consumer Driven Option...........................79 CDHP.................................................123
CDHP...................................................97 Contraceptive devices and drugs HO........................................................75
HO........................................................46 CDHP.................80-81, 99-100, 117-118 Foot care
Air Ambulance HO......................37-38, 40, 48-49, 66-73 CDHP...................................................95
CDHP..........................................111-112 Conversion Plan Health Insurance (non- HO........................................................43
HO..................................................60-62 FEHB)......................................................125 Fraud............................................................4
Allergy Coordination of benefits...................134-144 Gender Affirming Surgery...18-20, 48-55,
CDHP...................................................92 Copayment............................................25-31 64, 68-73, 99-106, 113-114, 117-121
HO........................................................41 Cost-sharing...............................................25 General exclusions............................126-127
Alternative treatments Covered providers......................................16 Health Management Programs
CDHP...................................................97 Deductible............................................25-26 CDHP.................................................124
HO........................................................46 CDHP..............................................86-88 HO........................................................75
Ambulance HO..................................................25-26 Hearing services
CDHP.........................................110, 112 Definitions........................................145-148 CDHP...................................................94
HO..................................................59, 61 Dental HO........................................................43
Anesthesia CDHP............................79, 102-103, 122 High Option...............................................34
CDHP...................................97, 106, 109 HO............................................51-52, 74 Home health services
HO............................................46, 55, 58 Diabetic supplies CDHP...................................................97
Applied Behavioral Health CDHP..........................................117-118 HO..................................................45-46
CDHP...................................................94 HO..................................................68-70 Hospice
HO........................................................42 Diagnostic Services CDHP.................................................110
APWU Health Plan CDHP...................................................89 HO........................................................59
Mailing Address..........................128-130 HO..................................................35-36 Hospital
Telephone Number.....................128-130 Dialysis Inpatient CDHP..................107-108, 115
Balance Billing Protection..................16-24 CDHP...................................................93 Inpatient HO.............................56-57, 65
Biopsy HO..................................................41-42 Outpatient CDHP.......................109, 115
CDHP............................99-100, 102-103 Disease Management Program Outpatient HO................................58, 65
HO.......................................48-49, 51-52 CDHP.................................................124 Immunizations
Blood and blood plasma HO........................................................75 Adult CDHP...................................80-81
CDHP..........................................107-109 Disputed claims process...........................131 Adult HO........................................37-38
HO..................................................56-58 Durable Medical Equipment (DME) Children CDHP...............................81-82
Breast reconstruction CDHP...................................................96 Children HO.........................................38
CDHP..........................................100-102 HO..................................................44-45 Infertility
HO..................................................50-51 Educational classes and programs CDHP...................................................92
Cancer Centers of Excellence CDHP...................................................98 HO..................................................40-41
CDHP....................................89, 107-110 HO..................................................46-47 Insulin
HO............................................35-36, 58 Effective date of enrollment.......................11 CDHP..........................................117-118
Casts Emergency HO..................................................68-70
CDHP..........................................107-109 CDHP.................................................111 Magnetic Reasonance Imagings (MRIs)
HO..................................................60-61 ..............................................................21
HO..................................................56-58
End of Life Care CDHP...................................................90
Catastrophic protection.........................28-30
CDHP.................................................110 HO........................................................36
CHAMPVA..............................................134
HO........................................................59 Mail Order prescription drugs
Chemotherapy/Radiation
Experimental or investigational...126-127, CDHP..........................................117-118
CDHP...........................................93, 109
146 HO..................................................68-70
HO............................................41-42, 58
CDHP..........................................103-106 Mammograms
Chiropractic
HO..................................................52-55 CDHP..............................................80-81
CDHP...................................................97
Eyeglasses HO..................................................36-38
HO........................................................46
CDHP..................................84-88, 94-95 Maternity
Cholesterol tests
HO........................................................43 CDHP..............................................90-91
CDHP..............................................80-81
Family planning HO........................................................39
HO..................................................37-38
CDHP..............................................91-92 Medicaid..................................................135
Claims...............................................128-129
HO........................................................40 Medical emergency
Clinical Trials...........................137-138, 145
CDHP..............................................91-92 CDHP..........................................111-112
Coinsurance..........................................25-30
HO........................................................40 HO..................................................60-61
Colorectal cancer screening
Medically necessary...................................18
CDHP..............................................80-81
HO..................................................37-38
2023 APWU Health Plan 154 Index

Medicare............................139-141, 143-144 Preferred Provider Organizations (PPO) Syringes
Mental health ........................................................13-14 CDHP..........................................117-118
CDHP..........................................113-114 Prescription drugs HO..................................................68-70
HO..................................................64-65 CDHP..........................................116-121 Telehealth
Newborn care HO..................................................66-73 CDHP...........................................90, 114
CDHP..............................................90-91 Preventive care HO............................................36, 64-65
HO........................................................39 Adult CDHP...................................80-81 Temporary Continuation of Coverage (TCC)
No Surprises Act (NSA).......................25-31 Adult HO........................................37-38 ..............................................................12
Non-FEHB.................................................31 Children CDHP...............................81-82 Therapy (Occupational, Physical, & Speech)
Nurse Children HO.........................................38 CDHP..............................................93-94
CDHP....................................97, 107-108 Prior approval.......................................18-24 HO........................................................42
HO.......................................45-46, 56-57 Prostate Cancer Screening (PSA) Tobacco cessation
Nurse help line CDHP..............................................80-81 CDHP...................................................98
HO......................................................151 HO..................................................37-38 HO..................................................46-47
Office visits Prosthetic devices Transplants
CDHP...................35-36, 89-97, 113-114 CDHP...................................................95 CDHP..........................................103-106
HO............................................36-46, 64 HO........................................................44 HO..................................................52-55
Organic impotence.............119-121, 126-127 Rate information....................................158 Treatment therapies
CDHP..........................................117-118 Review and reward program CDHP....................................93, 103-106
HO..................................................68-70 HO........................................................75 HO..................................................41-42
Orthopedic devices Rollover TRICARE................................................134
CDHP...................................................95 CDHP..............................................84-85 TTY............................................................16
HO........................................................44 Room and board Virtual Visits
Osteoporosis screening CDHP..................................107-108, 115 CDHP...................................................90
CDHP..............................................80-81 HO............................................56-57, 65 HO........................................................36
HO..................................................37-38 Second surgical opinion Vision services
Out-of-pocket expenses........................25-30 CDHP...................................................89 CDHP..............................................94-95
Overseas claims.......................................129 HO..................................................35-36 HO........................................................43
Oxygen Sigmoidoscopy Voluntary Benefits Dental Plan (non-FEHB)
CDHP....................................96, 107-109 CDHP..............................................80-81 ............................................................125
HO.......................................44-45, 56-58 HO..................................................37-38 Weight management program................75
Pap test Skilled nursing Well Woman
CDHP..............................................80-81 CDHP.....................................89, 97, 109 CDHP..............................................80-81
HO..................................................37-38 HO............................35-36, 45-46, 58-59 HO..................................................37-38
Personal Care Account (PCA) Smoking cessation Wheelchairs
CDHP..............................................83-85 CDHP....................................98, 117-118 CDHP...................................................96
Physical examination HO.......................................46-47, 68-70 HO..................................................44-45
Adult CDHP...................................80-81 Start Hearing (Non-FEHB)......................125 Workers' Compensation...........................135
Adult HO........................................37-38 Subrogation.......................................135-137 X-ray
Children CDHP...............................81-82 CDHP CDHP...................................................90
Children HO.........................................38 HO HO........................................................36
Physician Substance use disorder...34, 64-65, 79,
CDHP....................................89, 113-114 113-114
HO............................................35-36, 64 Supplemental Discount Drug Program (non-
FEHB)......................................................125
Positron Emission Tomography (PET)......21
Surgery
CDHP...................................................90
Assistant surgeon CDHP..............99-100
HO........................................................36
Assistant surgeon HO..........................48
Precertification......................................18-24
Cosmetic CDHP...........................99-102
Cosmetic HO..................................48-51
Multiple procedures CDHP..........99-100
Multiple procedures HO.................48-49
Oral CDHP.................................102-103
Oral HO..........................................51-52
Outpatient CDHP...............................109
Outpatient HO......................................58
Reconstructive CDHP.................100-102
Reconstructive HO.........................50-51
2023 APWU Health Plan 155 Index

Notes
2023 APWU Health Plan 156

Notes

2023 Rate Information for the APWU Health Plan
To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or
www.opm.gov/Tribalpremium.
APWU rates apply to career Postal employees represented by APWU that have been enrolled in FEHB for one year.
Premiums for Tribal employees are shown under the Monthly Premium Rate column. The amount shown under employee
contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium.
Please contact your Tribal Benefits Officer for exact rates.
Premium Rates:
Biweekly
Type of Enrollment Biweekly Gov’t Biweekly Your Monthly Gov’t Monthly Your
APWU
Enrollment Code Share Share Share Share
Your Share
High Option Self

471 $259.72 $121.00 $562.73 $262.16 $121.00
Only
High Option Self

473 $560.52 $238.95 $1,214.46 $517.73 $238.95
Plus One
High Option Self

472 $611.42 $302.26 $1,324.74 $654.90 $302.26
and Family
CDHP Option
474 $221.49 $73.83 $479.90 $159.96 $14.77
Self Only
CDHP Option
476 $481.40 $160.46 $1,043.03 $347.67 $32.09
Self Plus One
CDHP Option
475 $525.16 $175.05 $1,137.84 $379.28 $35.01
Self and Family

2023 APWU Health Plan Federal Brochure

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APWU Health Plan

Customer Service 800-222-2798

This plan's health coverage qualifies as minimum essential coverage

Enrollment codes for this Plan:

2023 APWU Health Plan 1 Table of Contents

2023 APWU Health Plan 2 Table of Contents

2023 APWU Health Plan 3 Table of Contents

Stop Healthcare Fraud!

2023 APWU Health Plan 4 Introduction/Plain Language/Advisory

CALL - THE HEALTHCARE FRAUD HOTLINE

You can also write to:

Discrimination is Against the Law

2023 APWU Health Plan 5 Introduction/Plain Language/Advisory

3. Get the results of any test or procedure.

2023 APWU Health Plan 6 Introduction/Plain Language/Advisory

Patient Safety Links

Preventable Healthcare Acquired Conditions ("Never Events")

2023 APWU Health Plan 7 Introduction/Plain Language/Advisory

2023 APWU Health Plan 8 FEHB Facts

Natural children, adopted children, and stepchildren

Children incapable of self-support

Children with or eligible for employer-provided health insurance

2023 APWU Health Plan 9 FEHB Facts

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

2023 APWU Health Plan 10 FEHB Facts

When you lose benefits

2023 APWU Health Plan 11 FEHB Facts

2023 APWU Health Plan 12 FEHB Facts

General features of our High Option

We have Preferred Provider Organizations (PPOs):

General features of our Consumer Driven Health Plan (CDHP)

2023 APWU Health Plan 13 Section 1

Your rights and responsibilities

Your medical and claims records are confidential

2023 APWU Health Plan 14 Section 1

Changes to our Consumer Driven Health Plan only

2023 APWU Health Plan 15 Section 2

• Covered facilities Covered facilities include:

2023 APWU Health Plan 16 Section 3

2023 APWU Health Plan 17 Section 3

Exceptions You do not need precertification in these cases:

• Other services Some services require prior approval.

2023 APWU Health Plan 18 Section 3

2023 APWU Health Plan 19 Section 3

2023 APWU Health Plan 20 Section 3

The following outpatient radiology services require precertification:

Exceptions You do not need precertification in these cases:

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

2023 APWU Health Plan 21 Section 3

2023 APWU Health Plan 22 Section 3

2. Ask you or your provider for more information.

2023 APWU Health Plan 23 Section 3

3. Write to you and maintain our denial.

2023 APWU Health Plan 24 Section 3

2023 APWU Health Plan 25 Section 4

In-Network Plan Deductible:

In-Network PCA (APWU HP Funded)

In-Network Net Deductible (You Pay)

2023 APWU Health Plan 26 Section 4

2023 APWU Health Plan 27 Section 4