APWU Health Plan
www.apwuhp.com
Customer Service 800-222-2798

2025

A Fee-for-Service Plan (High Option), 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
page 8 for details.  This plan is accredited.  See page 13.

Sponsored and administered by: American Postal Workers Union,
AFL-CIO

Who may enroll in this Plan: All Postal Service employees and
annuitants who are eligible to enroll in the PSHB Program. To enroll,
you must be, or must become, a member or associate member of the
American Postal Workers Union, AFL-CIO.

IMPORTANT

• Rates: Back Cover
• Changes for 2025: Page 16
• Summary of Benefits: Page 171

To become a member or associate member: All active
Postal Service APWU bargaining unit employees and
annuitants must be, or must become, dues-paying
members of the APWU, to be eligible to enroll in the
Health Plan. All Postal members and annuitants must
become associate members of APWU, see page 141 for
details.

Membership dues: Associate members will be billed
by the APWU for the $35 annual membership fee,
except where exempt by law.  APWU will bill new
associate members for the annual dues when it receives
notice of enrollment. APWU will also bill continuing
associate members for the annual membership. APWU
will bill Retirees Department members $36 annual
membership. Active and retiree non-associate APWU
membership dues vary.

Enrollment codes for this Plan
 High Option:
 23A Self Only
 23C Self Plus One
 23B Self and Family

Consumer Driven Option:
 23D Self Only
 23F Self Plus One
 23E Self and Family

RI 71-019

Important Notice

Important Notice for Medicare-eligible Active Employees 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 for
active employees 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 active employees and their covered family
members do not need to enroll in an open market Medicare Part D plan 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
PSHB coverage as an active employee.

However, if you (as an active employee and your covered Medicare Part D-eligible family members) choose to enroll in an
open market Medicare Part D plan, you can keep your PSHB coverage and your PSHB plan will coordinate benefits with
Medicare.

Please be advised

If you lose or drop your PSHB 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.

Additional Premium for Medicare’s High Income Members

 Income-Related Monthly Adjustment Amount (IRMAA)

The Medicare Income-Related Monthly Adjustment Amount (IRMAA) is an amount you may pay in addition to your PSHB
premium to enroll in and maintain Medicare prescription drug coverage. This additional premium is assessed only to those
with higher incomes and is adjusted based on the income reported on your IRS tax return. You do not make any
IRMAA payments to your PSHB plan. Refer to the: https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-
drug-coverage/monthly-premium-for-drug-plans to see if you would be subject to this additional premium.

You can get more information about open market 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

Table of Contents ..........................................................................................................................................................................1
Introduction ...................................................................................................................................................................................4
Plain Language ..............................................................................................................................................................................4
Stop Health Care Fraud! ...............................................................................................................................................................4
Discrimination is Against the Law ................................................................................................................................................5
Preventing Medical Mistakes ........................................................................................................................................................7
PSHB Facts ...................................................................................................................................................................................9
Coverage information .........................................................................................................................................................9
•   No pre-existing condition limitation ...............................................................................................................................9
•   Minimum essential coverage (MEC) ..............................................................................................................................9
•   Minimum value standard ................................................................................................................................................9
•   Where you can get information about enrolling in the PSHB Program .........................................................................9
•   Enrollment types available for you and your family ......................................................................................................9
•   Family Member Coverage ............................................................................................................................................10
•   Children’s Equity Act ...................................................................................................................................................11
•   When benefits and premiums start ...............................................................................................................................12
•   When you retire ............................................................................................................................................................12
When you lose benefits .....................................................................................................................................................12
•   When PSHB coverage ends ..........................................................................................................................................12
•   Upon divorce ................................................................................................................................................................12
•   Temporary Continuation of Coverage (TCC) ...............................................................................................................13
•   Converting to individual coverage ...............................................................................................................................13
•   Health Insurance Marketplace ......................................................................................................................................13
Section 1. How This Plan Works ................................................................................................................................................14
We have Preferred Provider Organizations (PPOs) ..........................................................................................................14
General features of our High Option (HO) .......................................................................................................................14
General features of our Consumer Driven Health Plan (CDHP) ......................................................................................14
How we pay providers ......................................................................................................................................................15
Your rights and responsibilities .........................................................................................................................................15
Your medical and claims records are confidential ............................................................................................................15
Section 2. Changes for 2025 .......................................................................................................................................................16
Section 3. How You Get Care .....................................................................................................................................................17
Identification cards ............................................................................................................................................................17
Where you get covered care ..............................................................................................................................................17
Balance Billing Protection ................................................................................................................................................17
•   Covered providers .........................................................................................................................................................17
•   Covered facilities ..........................................................................................................................................................18
•   Transitional care ...........................................................................................................................................................18
•   If you are hospitalized when your enrollment begins ...................................................................................................18
You need prior Plan approval for certain services ............................................................................................................19
•   Inpatient hospital admission, inpatient residential treatment center admission or skilled nursing
facility admission ..............................................................................................................................................................19
•   Other services ...............................................................................................................................................................19
How to request precertification for an admission or get prior authorization for Other services ......................................21
•   Non-urgent care claims .................................................................................................................................................23
•   Urgent care claims ........................................................................................................................................................23
•   Concurrent care claims .................................................................................................................................................23

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•   Emergency inpatient admission ....................................................................................................................................24
•   Maternity care ...............................................................................................................................................................24
•   If your hospital stay needs to be extended ....................................................................................................................24
•   If your treatment needs to be extended .........................................................................................................................24
If you disagree with our pre-service claim decision .........................................................................................................24
•   To reconsider a non-urgent care claim ..........................................................................................................................25
•   To reconsider an urgent care claim ...............................................................................................................................25
•   To file an appeal with OPM ..........................................................................................................................................25
Section 4. Your Costs for Covered Services ...............................................................................................................................26
Cost-sharing ......................................................................................................................................................................26
Copayment ........................................................................................................................................................................26
Deductible .........................................................................................................................................................................26
Coinsurance .......................................................................................................................................................................27
If your provider routinely waives your cost ......................................................................................................................27
Waivers ..............................................................................................................................................................................28
Differences between our allowance and the bill ...............................................................................................................29
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments ...........................29
Carryover ..........................................................................................................................................................................31
If we overpay you .............................................................................................................................................................31
When Government facilities bill us ..................................................................................................................................31
Important Notice About Surprise Billing – Know Your Rights ........................................................................................32
Section 5. High Option Health Plan Table of Contents ..............................................................................................................33
High Option Health Plan Overview ............................................................................................................................................35
Consumer Driven Option Benefits Table of Contents ................................................................................................................85
Consumer Driven Health Plan Overview ....................................................................................................................................87
Non-PSHB Benefits Available to Plan Members ......................................................................................................................141
Section 6. General Exclusions - services, drugs and supplies we do not cover ........................................................................142
Section 7. Filing a claim for covered services ..........................................................................................................................144
Section 8. The disputed claims process .....................................................................................................................................147
Section 8(a). Medicare PDP EGWP Disputed Claims Process .................................................................................................150
Section 9. Coordinating benefits with Medicare and other coverage .......................................................................................152
When you have other health coverage ............................................................................................................................152
•   TRICARE and CHAMPVA ........................................................................................................................................152
•   Workers’ Compensation ..............................................................................................................................................153
•   Medicaid .....................................................................................................................................................................153
When other Government agencies are responsible for your care ...................................................................................153
When others are responsible for injuries .........................................................................................................................153
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) ........................................................155
Clinical trials ...................................................................................................................................................................155
•   The Original Medicare Plan (Part A or Part B) ...........................................................................................................156
•   Tell us about your Medicare coverage ........................................................................................................................157
•   Private contract with your physician ..........................................................................................................................157
•   Medicare Advantage (Part C) .....................................................................................................................................158
•   Medicare Part D Prescription Drug Plans ...................................................................................................................159
•   Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP) .....................................................160
When you are age 65 or over and do not have Medicare ................................................................................................162
When you have the Original Medicare Plan (Part A, Part B, or both) ............................................................................163
Section 10. High Option Health Plan Definitions .....................................................................................................................164
Section 10. Consumer Driven Health Plan Definitions ............................................................................................................170

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Summary of Benefits for the High Option Plan - 2025 ............................................................................................................171
Summary of Benefits for the Consumer Driven Option Plan - 2025 ........................................................................................173
Index ..........................................................................................................................................................................................176
2025 Rate Information for for the APWU Health Plan .............................................................................................................178

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Introduction

This brochure describes the benefits of APWU Health Plan under contract (CS 1370 PS) between APWU Health Plan and the
United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits (FEHB) law, as
amended by the Postal Service Reform Act, which created the Postal Service Health Benefits (PSHB) Program. 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 offices is:

APWU Health Plan
6514 Meadowridge Road, Elkridge, MD 21075

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. If you are a Postal Service
annuitant and you are eligible for Medicare Part D, or a covered Medicare Part D-eligible family member of a Postal Service
annuitant, your prescription drug benefits are provided under our Medicare Part D Prescription Drug Plan (PDP) Employer
Group Waiver Plan (EGWP) or our High Option Medicare Advantage Prescription Drug (MAPD) EGWP if you choose to
enroll in our MAPD EGWP. You do not have a right to benefits that were available before January 1, 2025, under the FEHB
Program unless those benefits are also shown in this PSHB Plan brochure.

OPM negotiates benefits and rates for each plan annually. Benefits are effective January 1, 2025. Rates are shown at the end
of this brochure.

Plain Language

All PSHB 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. OPM is the United States Office of Personnel Management. The FEHB Program is
the Federal Employees Health Benefits Program administered by OPM and established under 5 U.S.C. chapter 89. The
PSHB Program is the Postal Service Health Benefits Program established within the FEHB Program under 5 U.S.C.
section 8903c. PSHB Plan means a health benefits plan offered under the PSHB Program. PSHB means Postal Service
Health Benefits. If we use others, we tell you what they mean.

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

Stop Health Care Fraud!

Fraud increases the cost of healthcare for everyone and increases your Postal Service Health Benefits Program premium.
OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the PSHB Program
regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud – Here are some things that 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.

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• 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.

• 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 us at 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 towww.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 family members on your policy:

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

• 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
PSHB 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 PSHB 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 not 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

We comply with applicable Federal nondiscrimination laws and do not discriminate on the basis of race, color, national
origin, age, disability, religion, or sex (including pregnancy, sexual orientation, and gender identity). We do not exclude
people or treat them differently because of race, color, national origin, age, disability, religion, or sex (including pregnancy,
sexual orientation, and gender identity).

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Introduction/Plain Language/Advisory

The health benefits described in this brochure are consistent with applicable laws prohibiting discrimination. All coverage
decisions will be based on nondiscriminatory standards and criteria. An individual’s protected trait or traits, for example a
member’s gender identity or the fact that the covered benefit is sought in connection with gender-affirming care, will not be
used to deny health benefits for items, supplies, or services that are otherwise covered and determined to be medically
necessary.

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Introduction/Plain Language/Advisory

Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most
tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer
recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost
of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical
mistakes by their accrediting bodies.
You can also improve the quality and safety of your own healthcare and that of your family members by learning more about
and understanding your risks. Take these simple steps:

  1.  Ask questions if you have doubts or concerns.

• Ask questions and make sure you understand the answers.

• Choose a doctor with whom you feel comfortable talking.

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

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

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

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

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

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

doctor or pharmacist says.

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

you expected.

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

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

be taken.

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

• Understanding 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?”

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Introduction/Plain Language/Advisory

• 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.jointcommission.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.

• http://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.

• https://psnet.ahrq.gov/issue/national-patient-safety-foundation 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 PSHB 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.

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Introduction/Plain Language/Advisory

Coverage information

PSHB Facts

•  No pre-existing

condition limitation

We will not refuse to cover the treatment of a condition you had before you enrolled in
this Plan solely because you had the condition before you enrolled.

•  Minimum essential
coverage (MEC)

•  Minimum value

standard

Coverage under this plan qualifies as minimum essential coverage. 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.

Our health coverage meets the minimum value standard of 60% established by the ACA.
This means that we provide benefits to cover at least 60% of the total allowed costs of
essential health benefits. The 60% standard is an actuarial value; your specific out-of-
pocket costs are determined as explained in this brochure.

•  Where you can get
information about
enrolling in the PSHB
Program

See https://health-benefits.opm.gov/ for enrollment information as well as:

•  Information on the PSHB Program and plans available to you

•  A health plan comparison tool

Note: Contact the USPS for information on how to enroll in a PSHB Program Plan
through the PSHB System.

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
PSHB 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. You will be responsible for making
changes to your enrollment status through the PSHB System.  In some cases, your
employing or retirement office may need to submit documentation. For information on
your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your PSHB Program Plan, you should contact your carrier directly for
updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and
one eligible family member. Self and Family coverage is for the enrollee and one or more
eligible family members. Family members include your spouse and your dependent
children under age 26, including any foster children authorized for coverage by your
employing agency or retirement office. Under certain circumstances, you may also
continue coverage for a disabled child 26 years of age or older who is incapable of self-
support.

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.

•  Enrollment types

available for you and
your family

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PSHB Facts

You enroll in a PSHB Program Plan and make enrollment changes in the PSHB System
located at https://health-benefits.opm.gov/. For assistance with the PSHB System, call
the PSHBP Helpline at (844) 451-1261.  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 request. 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
PSHB enrollment.

Use the PSHB System if you want to change from Self Only to Self Plus One or Self and
Family, and to add or remove a family member.

Your employing or retirement office will not notify you when a family member is no
longer eligible to receive benefits. Please report changes in family member status,
including your marriage, divorce, annulment, or when your child reaches age 26 through
the PSHB System. We will send written notice to you 60 days before we proactively
disenroll your child on midnight of their 26th birthday unless your child is eligible for
continued coverage because they are incapable of self-support due to a physical or mental
disability that began before age 26.

If you or one of your family members is enrolled in one PSHB plan you or they
cannot be enrolled in or covered as a family member by another enrollee in another
PSHB or 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
PSHB Program, change your enrollment, or cancel coverage using the PSHB System. For
a complete list of QLEs, visit the PSHB website at www.opm.gov/healthcare-insurance/
life-events. If you need assistance, please contact your employing agency, personnel/
payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse
(including your spouse by a valid common-law marriage from a state that recognizes
common-law marriages) and children as described in the chart below. A Self Plus One
enrollment covers you and your spouse, or one other eligible family member as described
below.

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

Family Member
Coverage

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PSHB Facts

•  Children’s Equity Act

Newborns of covered children are insured only for routine nursery care during the covered
portion of the mother’s maternity stay.

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

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000.
This law mandates that you be enrolled for Self Plus One or Self and Family coverage in
the PSHB 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 PSHB coverage, your employing office will enroll you for Self Plus
One or Self and Family coverage, as appropriate, in 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 PSHB 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 PSHB coverage, you must continue your PSHB 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

For annuitants who are required to be enrolled in Medicare Part B as a condition to
continue PSHB coverage in retirement: If you enroll in Medicare Part B and continue
PSHB coverage in retirement, the child equity law applies to you and you cannot cancel
your coverage, change to Self Only, or change to a plan that does not serve the area in
which your child(ren) live as long as the court/administrative order is in effect. You cannot
be compelled to enroll or remain enrolled in Medicare Part B to maintain your PSHB
enrollment as a condition to satisfy a court/administrative order. However, if you do not
enroll (or remain enrolled) in Medicare Part B as required to continue your PSHB
coverage in retirement (notwithstanding an existing court/administrative order), you will
not be able to continue your PSHB coverage in retirement.

2025 APWU Health Plan

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PSHB Facts

•  Medicare

Prescription Drug
Plan (PDP) Employer
Group Waiver Plan
(EGWP)

Our PDP EGWP is only available to Postal Service annuitants who are Medicare Part D-
eligible and their covered Medicare Part D-eligible family members. Our PDP EGWP is
not an open market Medicare Part D Plan.  If you are an active Postal Service employee,
or covered family member, and become eligible to enroll in Medicare Part D, you are not
eligible to enroll in our PDP EGWP.  Please contact the Centers for Medicare  at 1-800-
MEDICARE or 1-800-633-4227 (TTY 1-877-486-2048).

•  When benefits and
premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open
Season, your coverage and premiums begin on January 1. If you joined at any other time
during the year, your employing or retirement 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.

When you retire, you can usually stay in the PSHB Program. Generally, you must have
been enrolled in the FEHB and/or PSHB Program for the last five years of your Federal
service. If you do not meet this requirement, you may be eligible for other forms of
coverage, such as Temporary Continuation of Coverage (TCC).

•  When you retire

When you lose benefits

•  When PSHB 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 are a family member no longer eligible for coverage.

•  Upon divorce

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.

If you are eligible for coverage under spouse equity, you are only eligible to enroll in the
FEHB Program. If you are not eligible for coverage under spouse equity and you are
otherwise eligible for Temporary Continuation of Coverage (TCC), then you could enroll
in TCC under the PSHB Program.

If you are an enrollee and your divorce or annulment is final, your ex-spouse cannot
remain covered as a family member under your Self Plus One or Self and Family
enrollment. You must enter the date of the divorce or annulment and remove your ex-
spouse in the PSHB System. We may ask for a copy of the divorce decree as proof. If you
need to change your enrollment type, you must use the PSHB System. A change will not
automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not
remain covered as a family member under your former spouse’s enrollment. This is the
case even when the court has ordered your former spouse to provide health coverage for
you. However, you may be eligible for your own coverage under the spouse equity law or
Temporary Continuation of Coverage (TCC). Former spouses eligible for coverage under
the spouse equity law are not eligible to enroll in the PSHB Program. However, former
spouses eligible for coverage under the spouse equity law may enroll in the FEHB
Program. (Former Spouses seeking but not yet adjudicated as eligible for Spouse Equity
may be entitled to TCC under a PSHB plan in the interim).

2025 APWU Health Plan

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PSHB Facts

Former spouses not meeting the spouse equity requirements may be eligible for TCC
under the PSHB Program provided you otherwise meet the eligibility requirements for
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,
https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-
getting-divorced/#url=Health. We may request that you verify the eligibility of any or all
family members listed as covered under the enrollee’s PSHB enrollment.

When a Postal Service annuitant who is Medicare Part D-eligible or their covered
Medicare-eligible family member opts out of or disenrolls from our PDP EGWP, they will
not have our prescription drug coverage under this plan. If you do not maintain creditable
coverage, re-enrollment in our PDP EGWP may be subject to a late enrollment penalty.
Contact us for additional information at 800-222-2798.

If you leave Federal service, or if you lose coverage because you no longer qualify as a
family member, you may be eligible for Temporary Continuation of Coverage (TCC). For
example, you can receive TCC if you are not able to continue your PSHB 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 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. 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
PSHB Program coverage.

If you leave Federal service, your employing office will notify you of your right to
convert. You must contact us in writing within 31 days after you receive this notice.
However, if you are a family member who is losing coverage, the employing or retirement
office will not notify you. You must contact us in writing within 31 days after you are no
longer eligible for coverage.

Your benefits and rates will differ from those under the PSHB 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.

If you would like to purchase health insurance through the ACA’s Insurance Marketplace,
please visit www.HealthCare.gov. This is a website provided by the U.S. Department of
Health and Human Services that provides up-to-date information on the Marketplace.

The APWU Health Plan's Notice of Privacy Practices describes how medical information
about you may be used by the Health Plan, your rights concerning your health information
and how to exercise them, and APWU Health Plan's responsibilities in protecting your
health information. The Notice is posted on the Health Plan's website. If you need to
obtain a copy of the Health Plan's Notice of Privacy Practices, you may either contact the
Health Plan via email through the website, www.apwuhp.com, or by calling
800-222-2798.

•  Medicare PDP EGWP

•  Temporary

Continuation of
Coverage (TCC)

•  Converting to

individual coverage

•  Health Insurance

Marketplace

•  APWU Health
Plan Notice of
Privacy Practices

2025 APWU Health Plan

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PSHB Facts

Section 1. How This Plan Works

This Plan is a fee-for-service (FFS) plan. OPM requires that PSHB plans be accredited to validate that plan operations and/or
care management meet or exceed nationally recognized standards. APWU Health Plan holds the following accreditations:
Accreditation Association for Ambulatory Health Care (www.aaahc.org); National Committee for Quality Assurance
(www.ncqa.org); URAC (www.urac.org). To learn more about this plan's accreditation(s), please visit the following website:
www.apwuhp.com.

You can choose your own physicians, hospitals, and other healthcare providers. We give you a choice of enrollment in a High
Option or a Consumer Driven Health Plan (CDHP).

We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The
type and extent of covered services, and the amount we allow, may be different from other plans. Read brochures carefully.

We have Preferred Provider Organizations (PPOs)

Our fee-for-service plans offer services through PPO networks. This means that certain hospitals and other healthcare
providers are “preferred providers." When you use our network providers, you will receive covered services at a reduced
cost. APWU Health Plan is solely responsible for the selection of PPO providers in your area.

The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. Provider
networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialty in all
areas. If no PPO provider is available, or you do not use a PPO provider, the standard non-PPO benefits apply.

General features of our High Option (HO)

High Option PPO Network: You can go to our website, www.apwuhp.com to access an online High Option PPO directory.
If you need assistance in identifying a participating provider, call the APWU Health Plan at 800-222-2798. The Plan uses
UnitedHealthcare as its PPO network in all states and the U.S. Virgin Islands, as well as its mental health/substance use
disorder treatment provider network (all states).

When out of your state of residence, if you do not use a UnitedHealthcare PPO provider or a UnitedHealthcare PPO provider
is not available, standard non-PPO benefits apply. For assistance in identifying a provider in the network, call the APWU
Health Plan at 800-222-2798.

General features of our Consumer Driven Health Plan (CDHP)

Consumer Driven Option PPO Network: If you need assistance identifying a participating provider or to verify their
continued participation, call the Plan's Consumer Driven Option administrator, UnitedHealthcare, at 800-718-1299 or you
can go to their website, www.whyuhc.com/apwu, for a full nationwide online provider directory. UnitedHealthcare is the
PPO network for all states and Puerto Rico, and the U.S. Virgin Islands. Printed provider directories are not available.

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

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

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

Solutions toll-free 800-718-1299.

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

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

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

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

2025 APWU Health Plan

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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 PSHB plans provide certain information to their PSHB members. You may get information about us,
our networks, and our providers. OPM’s PSHB 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 8660, Elkridge, MD 21075. 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 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.

2025 APWU Health Plan

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Section 1

Section 2. Changes for 2025

This is the first year for the Postal Service Health Benefits Program (PSHBP). This Section is not an official statement of
benefits. For that, go to Section 5 Benefits.

2025 APWU Health Plan

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Section 2

Identification cards

Section 3. How You Get Care

We will send you an identification (ID) card when you enroll. You should carry your ID
card with you at all times. You must show it whenever you receive services from a Plan
provider or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your
copy of the PSHB System enrollment confirmation.

Note:  If you are enrolled in our Medicare Part D PDP EGWP, you may receive a second
ID card for your prescription drug benefits. 

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 PO Box
8660, Elkridge, MD 21075 or through our website at www.apwuhp.com. You may
print or request an Identification Card via the Member Portal at www.apwuhp.com.

•  Consumer Driven Option: Call UnitedHealthcare at 800-718-1299 or write to us at
PO Box 740800, Atlanta, GA 30374-0800 or request replacement cards through the
website at www.myuhc.com.

Where you get covered
care

You can get care from any “covered provider” or “covered facility”. How much we pay –
and you pay – depends on the type of covered provider or facility you use. If you use our
preferred providers, you will pay less.

Balance Billing
Protection

Covered providers

PSHB Carriers must have clauses in their in-network (participating) provider agreements.
These clauses provide that, for a service that is a covered benefit in the plan brochure or
for services determined not medically necessary, the in-network provider agrees to hold
the covered individual harmless (and may not bill) for the difference between the billed
charge and the in network contracted amount. If an in-network provider bills you for
covered services over your normal cost share (deductible, copay, co-insurance) contact
your Carrier to enforce the terms of its provider contract.

Covered providers are medical practitioners who perform covered services when acting
within the scope of their license or certification under applicable state law and who
furnish, bill, or are paid for their healthcare services in the normal course of business.
Covered services must be provided in the state in which the practitioner is licensed or
certified.

Benefits are provided under this Plan for the services of covered providers, in accordance
with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not
determined by your state’s designation as a medically underserved area.

We list network-contracted covered providers in our network provider directory, which we
update periodically, and make available on our website.

This plan recognizes that transgender, non-binary, and other gender diverse members
require health care delivered by healthcare providers experienced in gender affirming
health. Benefits described in this brochure are available to all members meeting medical
necessity guidelines regardless of race, color, national origin, age, disability, religion, sex
or gender.

This plan provides Care Coordinators for complex conditions through UnitedHealthcare
and can be reached at 866-569-2064 for the High Option Plan and 800-718-1299 for the
Consumer Driven Option Plan for assistance.

2025 APWU Health Plan

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Section 3

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 your coverage changed from the FEHB to the

PSHB and your health plan does not participate in the PSHB, or

•  lose access to your specialist because we drop out of the Postal Service Health

Benefits (PSHB) Program and you enroll in another PSHB Plan, or

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

specialist for reasons other than for 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 in the second or third trimester of pregnancy and you lose access to your
specialist based on the above circumstances, you can continue to see your specialist and
your PPO benefits continue until the end of your postpartum care, even if it is beyond the
90 days.

We pay for covered services from the effective date of your enrollment. However, if you
are in the hospital when your enrollment in our High Option begins, call our Customer
Service Department immediately at 800-222-2798. For the Consumer Driven Option,
please call UnitedHealthcare at 800-718-1299. If you are new to the PSHB 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 this PSHB plan, 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.

If you are hospitalized
when your enrollment
begins

2025 APWU Health Plan

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Section 3

These provisions apply only to the benefits of the hospitalized person. If your plan
terminates participation in the PSHB in whole or in part, or if OPM orders an enrollment
change, this continuation of coverage provision does not apply. In such cases, the
hospitalized family member’s benefits under the new plan begin on the effective date of
enrollment.

The pre-service claim approval processes for inpatient hospital admissions (called
precertification) and for other services, are detailed in this Section. A pre-service claim is
any claim, in whole or in part, that requires approval from us in advance of obtaining
medical care or services. In other words, a pre-service claim for benefits 1) requires
precertification, prior approval or a referral and 2) will result in a reduction of benefits if
you do not obtain precertification, prior approval or a referral.

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).

Precertification is the process by which – prior to your inpatient hospital admission – we
evaluate the medical necessity of your proposed stay and the number of days required to
treat your condition. Unless we are misled by the information given to us, we won’t
change our decision on medical necessity.

In most cases, your physician or hospital will take care of requesting precertification.
Because you are still responsible for ensuring that your care is precertified, you should
always ask your physician or hospital whether they have contacted us.

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.

You need prior Plan
approval for certain
services

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

Warning

Exceptions

You do not need precertification in these cases:

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

•  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 and outpatient surgeries require prior approval.

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

•  Applied Behavioral Analysis (ABA)

•  Bariatric surgery (severe obesity)

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

artificial limbs (prosthetic devices) and braces

•  Gender affirming surgery

•  Gene Therapy

•  Genetic testing, including BRCA testing (see Definitions, Section 10)

•  Hysterectomy

•  Functional endoscopic sinus surgery

•  Iatrogenic fertility preservation procedures

•  Intensive outpatient treatment

2025 APWU Health Plan

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Section 3

•  Minimally invasive treatment of back and neck pain. This requirement applies to both
the physician services and the facility. The following services require prior approval:
epidural steroid injections and sacroiliac joint injections.

•  Orthognathic surgery (Oral maxillofacial surgery)

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

•  Organic impotence

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

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

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

Therapy and Stereotactic Radiation Therapy

•  Residential Treatment Center (RTC)

•  Services and supplies which may be experimental/investigational

•  Skilled Nursing Facilities (SNF)

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

needed

Under the Consumer Driven Option, call UnitedHealthcare at 800-718-1299 if you need
any of the services listed below:

•  Air Ambulance - Non emergent

•  Applied Behavioral Analysis (ABA)

•  Bariatric surgery (severe obesity)

•  Cardiology services (outpatient diagnostic catheterizations, echocardiograms, stress

echocardiograms and outpatient electrophysiology implant procedures)

•  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

2025 APWU Health Plan

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Section 3

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

•  Prior approval is required for certain classes of drugs and coverage authorization is
required for some medications. This authorization uses Plan rules based on FDA-
approved prescribing and safety information, clinical guidelines, and uses that are
considered reasonable, safe, and effective. For example, prescription drugs used for
cosmetic purposes such as Retin A or Botox may not be covered. Other medications
might be limited to a certain amount (such as quantity or dosage) within a specific
time period, or require authorization to confirm clinical use based on FDA labeling.
To inquire if your medication requires prior approval or authorization, call Express
Scripts Customer Service at 800-841-2734 for the High Option (see Section 5(f)), and
Optum Rx at 800-718-1299 for the Consumer Driven Option (see Section 5(f)).

•  Prior approval is also required for mental health and substance use disorder benefits,
inpatient, in-network or out-of-network. Prior approval is required for psychological
and neuropsychological testing (CDHP Option only), Electroconvulsive therapy
(CDHP Option only), Transcranial Magnetic Stimulation (TMS), and services such as
partial or full day hospitalization or facility-based intensive outpatient treatment. For
questions, call UnitedHealthcare at 866-569-2064 for the High Option Plan and
800-718-1299 for the Consumer Driven Option Plan.

•  High Option:  First you, you or your representative, your physician, or your hospital

must call UnitedHealthcare at 866-569-2064 at least 2 business days before admission.
For other services that require prior approval, call UnitedHealthcare at 866-569-2064
prior to those services being rendered. For mental health and substance use disorder
inpatient treatment, your physician or your hospital must call UnitedHealthcare at
866-569-2064 at least 2 business days before admission or services requiring prior
authorization.  These numbers are available 24 hours every day.

•  Consumer Driven Option:  First you, your representative, your physician, or your
hospital must call UnitedHealthcare at 800-718-1299 at least 2 business days before
admission or services requiring prior authorization are rendered. For mental health and
substance use disorder inpatient treatment, your doctor or your hospital must call
UnitedHealthcare Behavioral Health Solutions at 800-718-1299 at least 2 business
days before admission or services requiring prior authorization.  These numbers
are available 24 hours every day.

•  If you have an emergency admission due to a condition that you reasonably believe
puts your life in danger or could cause serious damage to bodily function, you, your
representative, the physician, or the hospital must telephone the above number at least
2 business days for the High Option and the Consumer Driven Option following the
day of the emergency admission, even if you have been discharged from the hospital.

•  Next, provide the following information:

-   enrollee’s name and Plan identification number

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

-   reason for hospitalization, proposed treatment, or surgery

-   name and phone number of admitting physician

-   name of hospital or facility; and

-   number of days requested for hospital stay

•  We will then tell the physician and/or hospital the number of approved inpatient days
and we will send written confirmation of our decision to you, your physician, and the
hospital.

What happens when
you do not follow
the precertification rules

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

necessary.

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

charges, less the $500 penalty.

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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
procedures
precertification

High Option: Radiology precertification is required prior to scheduling specific imaging
procedures. We evaluate the medical necessity of your proposed procedure to ensure that
the appropriate procedure is being requested for your condition. In most cases your
physician will take care of the precertification. Because you are responsible for ensuring
that precertification is done, you should ask your doctor to contact us.

The following outpatient radiology services require precertification:

•  CT/CAT Scan – Computerized Axial Tomography

•  MRI – Magnetic Resonance Imaging

•  MRA – Magnetic Resonance Angiography

•  PET – Positron Emission Tomography

Consumer Driven Option: Radiology services subject to prior authorization include:

•  Computerized Tomography (CT)

•  Magnetic Resonance Imaging (MRI)

•  Magnetic Resonance Angiography (MRA)

•  Positron-Emission Tomography (PET)

•  Nuclear Medicine and Nuclear Cardiology studies

How to precertify a
radiology/imaging
procedure

For these outpatient studies, you, your representative or doctor must call
UnitedHealthcare before scheduling the procedure. For the High Option call
866-569-2064 and for the Consumer Driven Option call 800-718-1299.

•  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
(High Option only).

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Exceptions

You do not need precertification in these cases:

Non-urgent care claims

Urgent care claims

Concurrent care claims

•  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

For non-urgent care claims, we will tell the physician and/or hospital the number of
approved inpatient days, or the care that we approve for other services that must have
prior authorization. We will make our decision within 15 days of receipt of the pre-service
claim.

If matters beyond our control require an extension of time, we may take up to an
additional 15 days for review and we will notify you of the need for an extension of time
before the end of the original 15-day period. Our notice will include the circumstances
underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you,
our notice will describe the specific information required and we will allow you up to 60
days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for your
medical care or treatment could seriously jeopardize your life, health, or ability to regain
maximum function, or in the opinion of a physician with knowledge of your medical
condition, would subject you to severe pain that cannot be adequately managed without
this care or treatment), we will expedite our review and notify you of our decision within
72 hours. If you request that we review your claim as an urgent care claim, we will review
the documentation you provide and decide whether or not it is an urgent care claim by
applying the judgment of a prudent layperson that possesses an average knowledge of
health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we
receive the claim to let you know what information we need to complete our review of the
claim. You will then have up to 48 hours to provide the required information. We will
make our decision on the claim within 48 hours of (1) the time we received the additional
information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up
with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us
and OPM. Please let us know that you would like a simultaneous review of your urgent
care claim by OPM either in writing at the time you appeal our initial decision, or by
calling us at 800-222-2798. You may also call OPM's Postal Service Insurance Operations
(PSIO) at 202-936-0002 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).

A concurrent care claim involves care provided over 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.

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Section 3

Emergency inpatient
admission

Maternity care

If your hospital stay
needs to be extended

If you request an extension of an ongoing course of treatment at least 24 hours prior to the
expiration of the approved time period and this is also an urgent care claim, we will make
a decision within 24 hours after we receive the claim.

If 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 call 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 call 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.

You do not need precertification of a maternity admission for a routine delivery. However,
if your medical condition requires you to stay more than 48 hours after a vaginal delivery
or 96 hours after a cesarean section, then your physician or the hospital must contact us
for precertification of additional days. Further, if your baby stays after you are discharged,
your physician or the hospital must contact us for precertification of additional days for
your baby.

Note: When a newborn requires definitive treatment during or after the mother’s hospital
stay, the newborn is considered a patient in their own right. If the newborn is eligible for
coverage, regular medical or surgical benefits apply rather than maternity benefits.

High Option: If your hospital stay – including for maternity care – needs to be extended,
you, your representative, your physician or the hospital must ask us to approve the
additional days by calling the precertification vendor UnitedHealthcare at 866-569-2064.
If you remain in the hospital beyond the number of days we approved and did not get the
additional days precertified, then

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

benefits, but

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

medical services and supplies otherwise payable on an outpatient basis and will not
pay inpatient benefits.

Consumer Driven Option: If your hospital stay – including for maternity care – needs to
be extended, you, your representative, your doctor or the hospital must ask us to approve
the additional days by calling UnitedHealthcare at 800-718-1299. If you remain in the
hospital beyond the number of days we approved and did not get the additional days
precertified, then

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

benefits, but

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

medical services and supplies otherwise payable on an outpatient basis and will not
pay inpatient benefits for out-of-network services only.

If your treatment needs
to be extended

If you request an extension of an ongoing course of treatment at least 24 hours prior to the
expiration of the approved time period and this is also an urgent care claim, we will make
a decision within 24 hours after we receive the claim.

If you disagree with our
pre-service claim decision

If you have a pre-service claim and you do not agree with our decision regarding
precertification of an inpatient admission or prior approval of other services, you may
request a review in accord with the procedures detailed below. If your claim is in
reference to a contraceptive, call 800-841-2734 for the High Option and 800-718-1299 for
the Consumer Driven Option.

If you have already received the service, supply, or treatment, then you have a post-
service claim and must follow the entire disputed claims process detailed in Section 8

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Section 3

To reconsider a non-
urgent care claim

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial
decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this
brochure.

In the case of a pre-service claim and 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 urgent
care claim

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial
decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the
disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72
hours after receipt of your reconsideration request. We will expedite the review process,
which allows oral or written requests for appeals and the exchange of information by
telephone, electronic mail, fax, or other expeditious methods.

To file an appeal with
OPM

After we reconsider your pre-service claim, if you do not agree with our decision, you
may ask OPM to review it by following Step 3 of the disputed claims process detailed in
Section 8 of this brochure.

Note: If you are enrolled in our Medicare PDP EGWP and do not agree with our benefit
coverage decision you have the right to appeal.  See Section. 8(a) for information about
the PDP EGWP appeal process.

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Section 4. Your Costs for Covered Services

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

Cost-sharing

Copayment

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.

High Option: A copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc., when you receive certain services.

Deductible

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.

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 PSHB plans during Open Season, the effective date of your new
PSHB plan is January 1 of the next year and a new deductible starts on January 1. If you
change plans at another time during the year, you must begin a new deductible under your
new plan.

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Section 4

If you change from Self Plus One or Self and Family to Self Only, or from Self Only to
Self Plus One or Self and Family during the year, we will credit the amount of covered
expenses already applied toward the deductible of your old enrollment to the deductible of
your new enrollment. However, if you change from High Option to Consumer Driven
Option or from Consumer Driven Option to High Option, during the year, expenses
incurred as of the effective date of the option change are subject to the benefit provisions
of your new option.

Consumer Driven Option

Your Deductible is the amount of eligible expenses you are required to meet before
Traditional Health Coverage begins.  Your plan's deductible is reduced by applying the
funds in your Personal Care Account (PCA) which is funded in January by the APWU
Health Plan.  Your Net Deductible is the remaining deductible amount you have to pay
once the funds in your PCA have been exhausted.  By using the funds in your PCA to pay
for eligible medical expenses you decrease your total deductible and out-of-pocket
expenses.  Your Net Deductible for in-network providers is generally $1,000 for a Self
Only enrollment or $2,000 for a Self Plus One or a Self and Family enrollment.  For Self
Plus One or Self and Family coverage, once one individual meets the Self Only Net
Deductible of $1,000, Traditional Health Coverage begins for that individual.  Once the
other covered members meet the additional $1,000 Net Deductible, Traditional Health
Coverage begins for them. If you use out-of-network providers, your calendar year Net
Deductible increases to $1,500 Self Only and $3,000 for Self Plus One and Self and
Family.  Your Deductible in subsequent years may be reduced by rolling over any unused
portion of your Personal Care Account remaining at the end of the calendar year(s).

In-Network Plan Deductible:
Self Only: $2,200
Self Plus One: $4,400
Self and Family: 4,400

In-Network PCA (APWU HP Funded)
Self Only: $1,200
Self Plus One: $2,400
Self and Family: $2,400

In-Network Net Deductible (You Pay)
Self Only: $1,000
Self Plus One: $2,000
Self and Family: $2,000

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
waives your cost

If your provider routinely waives (does not require you to pay) your copayments,
deductibles, or coinsurance, the provider is misstating the fee and may be violating the
law. In this case, when we calculate our share, we will reduce the provider’s fee by the
amount waived.

For example, if your physician ordinarily charges $100 for a service but routinely waives
your 40% coinsurance, the actual charge is $60. We will pay $36 (60% of the actual
charge of $60).

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Section 4

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.

High Option:  Our “Plan allowance” is the amount we use to calculate our payment for
covered services. Fee-for-service plans arrive at their allowances in different ways, so
their allowances vary. For more information about how we determine our Plan allowance,
see the definition of Plan allowance in Section 10.

Often, the provider’s bill is more than a fee-for-service plan’s allowance. Whether or not
you have to pay the difference between our allowance and the bill will depend on the
provider you use.

•  PPO providers agree to limit what they will bill you. Because of that, when you use a
preferred provider, your share of covered charges consists only of your deductible and
coinsurance or copayment. Here is an example about coinsurance: You see a PPO
physician who charges $150, but our allowance is $100. If you have met your
deductible, you are only responsible for your coinsurance. That is, you pay just -- 15%
of our $100 allowance ($15). Because of the agreement, your PPO physician will not
bill you for the $50 difference between our allowance and the bill.

•  Non-PPO providers, on the other hand, have no agreement to limit what they will bill
you. When you use a non-PPO provider, you will pay your deductible and coinsurance
-- plus any difference between our allowance and charges on the bill. Here is an
example: You see a non-PPO physician who charges $150 and our allowance is again
$100. Because you’ve met your deductible, you are responsible for your coinsurance,
so you pay 40% of our $100 allowance ($40). Plus, because there is no agreement
between the non-PPO physician and us, the physician can bill you for the $50
difference between our allowance and the bill.

The information below illustrates the examples of how much you have to pay out-of-
pocket for services from a PPO physician vs. a non-PPO physician. The information uses
our example of a service for which the physician charges $150 and our allowance is $100.
The example shows the amount you pay if you have met your calendar year deductible.

EXAMPLE

PPO physician
Physician's charge: $150
Our allowance: We set it at:  $100
We pay: 85% of our allowance:  $85
You owe: Coinsurance: 15% of our allowance: $15
+ Difference up to charge?: No:  0
TOTAL YOU PAY: $15

Non-PPO physician
Physician's charge: $150
Our allowance: We set it at:  $100
We pay: 60% of our allowance:  $60
You owe: Coinsurance: 40% of our allowance: $40
+ Difference up to charge?: Yes:  $50
TOTAL YOU PAY: $90

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Section 4

Differences between our
allowance and the bill

Your catastrophic
protection out-of-pocket
maximum for
deductibles, coinsurance,
and copayments

Consumer Driven Option:

In-network providers agree to accept our Plan allowance so if you use an in-network
provider, you never have to worry about paying the difference between the Plan allowance
and the billed amount for covered services. If your covered expenses are being paid out of
your Personal Care Account or if you are receiving in-network covered preventive
services, the Plan will pay 100%. If you have exhausted your Personal Care Account, you
will be responsible for paying your Deductible and also coinsurance under the Traditional
Health Coverage.

Out-of-network providers - If you use an out-of-network provider, you will have to pay
the difference between the Plan allowance and the billed amount only if you use up
your Personal Care Account for the year. Note that it usually makes sense to use in-
network providers because it will make your Personal Care Account go much further since
money left in your Personal Care Account can be rolled over to be used in the next year.

You should also see section Important Notice About Surprise Billing - Know Your Rights
below that describes your protections against surprise billing under the No Surprises Act.

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

High Option:

PPO benefit:  Your out-of-pocket maximum is $6,500 for combined medical and
prescription drugs for Self Only enrollment or $13,000 for a Self Plus One or a Self and
Family enrollment if you are using PPO providers and in-network pharmacies. Only
eligible expenses for PPO providers and in-network pharmacies count toward this limit.

Non-PPO benefit:  Your out-of-pocket maximum is $12,000 for combined medical and
prescription drugs for Self Only enrollment, or $24,000 for a Self Plus One or a Self and
Family enrollment if you are using non-PPO providers or out-of-network pharmacies.
Eligible expenses for network providers or in-network pharmacies also count toward this
limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you
use network providers.

Note:  For Self Plus One or Self and Family coverage, the maximum out-of-pocket for any
individual in the family will not exceed the maximum out-of-pocket for Self Only
coverage. When an individual meets the Self Only out-of-pocket maximum, they pay no
coinsurance for covered services for the remainder of the calendar year.  Once the other
covered members in the family meet the remaining out-of-pocket family maximum, then
they pay no coinsurance for covered services for the remainder of the calendar year.

Out-of-pocket expenses for the purposes of this benefit are:

•  The 15% you pay (or the 5% you pay for Cancer Centers of Excellence) for PPO;
inpatient medical services and supplies, surgical and anesthesia services, services
provided by a hospital or other facility and ambulance services, emergency services/
accidents, mental health and substance use disorder treatment; and the medical
deductible

•  The 40% you pay for non-PPO; medical services and supplies, surgical and anesthesia
services, services provided by a hospital or other facility and ambulance services,
mental health and substance use disorder treatment, dental (30%); and the medical
deductible

•  The copayment of $25 for outpatient visits to PPO physicians and $10 for virtual visits

•  The copayment of $30 for outpatient facility charges in a PPO Urgent Care Center

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Section 4

•  The 25% you pay for in-network preferred brand name prescription drugs (Tier 2),

45% for in-network non-preferred brand name prescription drugs (Tier 3) and the $10
and $20 you pay for in-network generic prescription drugs (Tier 1), and 25% for
generic specialty drugs (Tier 4), 25% for preferred brand name drugs (Tier 5) and 45%
non-preferred brand name drugs (Tier 6)

 The following cannot be included in the accumulation of out-of-pocket expenses:

•  Expenses in excess of our allowance or maximum benefit limitations

•  Any amounts you pay because benefits have been reduced for non-compliance with

this Plan's cost containment requirements, (see Section 3)

•  The $300 per admission for non-PPO inpatient hospital charges or skilled nursing

facility

•  Expenses in excess of visit maximums for physical, occupational and speech therapy,

and acupuncture

•  Expenses in excess of Hospice care and preventive care maximums

•  The difference in cost when brand name drugs are purchased and a generic is available

•  Drugs reimbursed at the non-network pharmacy level

•  50% coinsurance for retail drugs after the first two fills if mail order is not used

•  100% of the cost for targeted drugs if the Plan's step therapy is not followed

•  Any associated costs when you purchase medications in excess of the Plan's

dispensing limitations

•  Cost associated with non-covered drugs and supplies

Consumer Driven Option:

If you have exceeded your Personal Care Account and met your Deductible the following
would apply:

In-network benefit:  Your out-of-pocket maximum is $6,500 for combined medical and
prescription drugs for a Self Only enrollment or $13,000 for a Self Plus One or Self and
Family enrollment if you are using in-network providers and pharmacies. Only eligible
expenses for network providers and pharmacies count toward this limit.

Out-of-network benefit:  Your out-of-pocket maximum is $12,000 for combined medical
and prescription drugs for a Self Only enrollment or $24,000 for a Self Plus One or Self
and Family enrollment if you are using out-of-network providers. Eligible expenses for
network providers and pharmacies also count toward this limit. Your eligible out-of-
pocket expenses will not exceed this amount whether or not you use network providers.

Note:  For Self Plus One or Self and Family coverage, the maximum out-of-pocket for any
individual in the family will not exceed the maximum out-of-pocket for Self Only
coverage. When an individual meets the Self Only out-of-pocket maximum, they pay no
coinsurance for covered services for the remainder of the calendar year.  Once the other
covered members in the family meet the remaining out-of-pocket family maximum, then
they pay no coinsurance for covered services for the remainder of the calendar year.

Out-of-pocket expenses for the purposes of this benefit are:

•  The 15% you pay (or the 10% you pay for Cancer Centers of Excellence) for in-

network inpatient and outpatient hospital charges, surgical, medical, virtual visits and
emergency services under the Traditional Health Coverage; and the Deductible

•  The 50% you pay for out-of-network inpatient and outpatient hospital charges,

surgical, medical, and maternity services under the Traditional Health Coverage; and
the Deductible

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Section 4

•  The 25% you pay for in-network Tier 1 and Tier 2 prescription drugs; and 40% for in-

network Tier 3 drugs

•  The Personal Care Account (PCA) of $1,200 for Self Only or $2,400 for Self Plus One

or Self and Family

The following cannot be included in the accumulation of out-of-pocket expenses:

•  Any expenses paid by the Plan under your in-network Preventive Care benefit

•  Expenses in excess of our allowance or maximum benefit limitations or expenses not

covered under the Traditional Health Coverage

•  Dental care or Vision care expenses above the limitations provided under

your Personal Care Account

•  Any amounts you pay because benefits have been reduced for non-compliance with

this Plan’s cost containment requirements (see Section 3)

•  Expenses in excess of Hospice care maximums

•  Drugs purchased at a non-network pharmacy

•  The difference in cost when brand name drugs are purchased and a generic is available

•  Any associated costs when you purchase medications in excess of the Plan's

dispensing limitations

•  Cost associated with non-covered drugs and supplies

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.

For members enrolled in our Plan's associated MA-PD or PDP EGWP, we are required to
accumulate all members’ actual out-of-pocket costs for Medicare-covered drugs, services
and supplies toward the PSHB catastrophic maximum(s), unless specifically excluded
below. Non-covered services, Part B drugs, IRMAA and late enrollment penalties are
excluded from catastrophic maximum.

If you are enrolled in our Medicare Prescription Drug Plan (PDP) Employer Group
Waiver Plan (EGWP), the prescription drug out-of-pocket maximum is $2,000.  After this
maximum is met, we pay 100% of all eligible covered prescription drug benefits.

If you changed to this PSHB Plan during Open Season from a plan with a catastrophic
protection benefit, the effective date of the change is January 1, and covered expenses that
apply to this plan’s catastrophic protection benefit start on January 1.

Note: If you change PSHB plans during Open Season the effective date of your new
PSHB plan is January 1 of the next year, and a new catastrophic protection accumulation
starts on January 1.  If you change plans at another time during the year, you must begin a
new catastrophic protection accumulation under your new plan.

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.

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.

Facilities of the Department of Veteran Affairs, the Department of Defense, and the Indian
Health Service are entitled to seek reimbursement from us for certain services and
supplies they provide to you or a family member. They may not seek more than their
governing laws allow. You may be responsible to pay for certain services and charges.
Contact the government facility directly for more information.

Carryover

If we overpay you

When Government
facilities bill us

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Section 4

Important Notice About
Surprise Billing – Know
Your Rights

The No Surprises Act (NSA) is a federal law that provides you with protections against
"surprise billing" and "balance billing" for out-of-network emergency services; out-of-
network non-emergency services provided with respect to a visit to a participating
healthcare facility; and out-of-network air ambulance services.

A surprise bill is an unexpected bill you receive for:

•  emergency care – when you have little or no say in the facility or provider from whom

you receive care, or for

•  non-emergency services furnished by nonparticipating providers with respect to

patient visits to participating healthcare facilities, or for

•  air ambulance services furnished by nonparticipating providers of air ambulance

services.

Balance billing happens when you receive a bill from the nonparticipating provider,
facility, or air ambulance service for the difference between the nonparticipating
provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from
surprise bills.

For specific information on surprise billing, the rights and protections you have, and your
responsibilities go to www.apwuhp.com and click on Members or contact the Health Plan
at 800-222-2798.

2025 APWU Health Plan

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Section 4

High Option

Section 5. High Option Health Plan Table of Contents

See page 171 for 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 Health Plan Overview ............................................................................................................................................35
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals ..............................36
Diagnostic and treatment services .....................................................................................................................................36
TeleHealth Services ...........................................................................................................................................................37
Lab, X-ray and other diagnostic tests ................................................................................................................................37
Preventive care, adult ........................................................................................................................................................38
Preventive care, children ...................................................................................................................................................39
Maternity care ...................................................................................................................................................................41
Family planning ................................................................................................................................................................42
Infertility services .............................................................................................................................................................43
Allergy care .......................................................................................................................................................................44
Treatment therapies ...........................................................................................................................................................44
Physical and occupational therapies .................................................................................................................................45
Applied behavioral analysis (ABA) ..................................................................................................................................45
Speech therapy ..................................................................................................................................................................45
Hearing services (testing, treatment, and supplies) ...........................................................................................................45
Vision services (testing, treatment, and supplies) .............................................................................................................46
Foot care ............................................................................................................................................................................46
Orthopedic and prosthetic devices ....................................................................................................................................46
Durable medical equipment (DME) ..................................................................................................................................47
Home health services ........................................................................................................................................................48
Chiropractic .......................................................................................................................................................................49
Alternative treatments .......................................................................................................................................................49
Educational classes and programs .....................................................................................................................................49
Section 5(b). Surgical and Anesthesia Services  Provided by Physicians and Other Healthcare Professionals .........................50
Surgical procedures ...........................................................................................................................................................50
Reconstructive surgery ......................................................................................................................................................52
Oral and maxillofacial surgery ..........................................................................................................................................53
Organ/tissue transplants ....................................................................................................................................................54
Anesthesia .........................................................................................................................................................................57
Section 5(c). Services provided by a hospital or other facility, and ambulance services ...........................................................58
Inpatient hospital ...............................................................................................................................................................58
Cancer Centers of Excellence ...........................................................................................................................................60
Outpatient hospital or ambulatory surgical center ............................................................................................................60
Extended care benefits/Skilled nursing care facility benefits ...........................................................................................60
Hospice care ......................................................................................................................................................................61
End of life care ..................................................................................................................................................................61
Ambulance ........................................................................................................................................................................61
Section 5(d). Emergency services/accidents ...............................................................................................................................62
Accidental injury ...............................................................................................................................................................63
Medical emergency ...........................................................................................................................................................63
Ambulance ........................................................................................................................................................................63
Air ambulance ...................................................................................................................................................................63
Section 5(e). Mental Health and Substance Use Disorder Benefits ............................................................................................65

2025 APWU Health Plan

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High Option Section 5

High Option

Professional services .........................................................................................................................................................66
TeleHealth services ...........................................................................................................................................................67
Diagnostics ........................................................................................................................................................................67
Inpatient hospital or other covered facility .......................................................................................................................67
Outpatient hospital or other covered facility .....................................................................................................................67
Section 5(f). Prescription drug benefits ......................................................................................................................................69
Covered medications and supplies ....................................................................................................................................71
Preventive care medications ..............................................................................................................................................74
Section 5(f)(a). PDP EGWP Prescription Drug Benefits ............................................................................................................77
Covered medications and supplies ....................................................................................................................................79
Preventive medications .....................................................................................................................................................81
Section 5(g). Dental Benefits ......................................................................................................................................................82
Accidental injury benefit ...................................................................................................................................................82
Dental benefits service ......................................................................................................................................................82
Section 5(h). Wellness and Other Special Features .....................................................................................................................83
Flexible benefits option .....................................................................................................................................................83
24-hour NurseLine ............................................................................................................................................................83
Services for deaf and hearing impaired .............................................................................................................................83
Disease Management Program ..........................................................................................................................................83
Review and Reward Program ...........................................................................................................................................83
Weight Management  ........................................................................................................................................................83
Special Programs ...............................................................................................................................................................83
Online tools and resources ................................................................................................................................................84
Health Risk Assessment (HRA) ........................................................................................................................................84
Consumer choice information ...........................................................................................................................................84
Summary of Benefits for the High Option Plan - 2025 ............................................................................................................171

2025 APWU Health Plan

34

High Option Section 5

High Option

High Option Health Plan 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 Preventive Care benefit that
provides 100% coverage for a full range of in-network preventive services, preventive tests and screenings, counseling
services and generic and single source brand FDA approved prescription contraceptives.

Medical and Surgical services

The Plan provides coverage for doctors’ visits and surgical services and supplies. You pay only a flat copayment for office
visits to a network physician, including visits for chiropractic and acupuncture treatment. In-network maternity care is
covered 100%, including breastfeeding support.  Mental health and substance use disorder treatment has the same
comprehensive coverage as is provided for medical care.

Hospitalization and Emergency care

We offer extensive benefits for hospital and other inpatient healthcare services. There is no deductible or per admission
charge for in-network hospital care. You also receive 100% coverage for unexpected outpatient care when you need it most
with the Plan’s Accidental Injury benefit.

Prescription drugs

Our prescription drug program offers prescription savings with no deductible and low copayments for (Tier 1) generic drugs.
The prescription drug program is easy to use, with a huge network of pharmacies and a mail order service where medications
are delivered right to your door. The Plan’s prescription drug program provides savings and convenience for generic and
brand name drugs, and you never have to file a claim.

UnitedHealthcare Medicare Advantage (PPO)

We also offer the UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan for High Option retiree/annuitants
with primary Medicare Part A and B. Membership is voluntary and members may opt-in or out of this plan at any time.
Members have access to a nationwide PPO network and may seek care within the network or out-of-network. Members that
join will have access to certain benefit enhancements that are noted in Section 9.

Special features

Obtaining help from a medical professional is quick, confidential, and free with the Plan’s voluntary 24-hour NurseLine,
available anywhere in the country. Online access to claims information is available through the APWU Health Plan Member
Portal. We help members navigate the healthcare system with an online Preferred Provider Organization (PPO) directory,
Hospital Quality Ratings Guide, Treatment Cost Estimator, and prescription drug information. We also offer online tools and
resources.

2025 APWU Health Plan

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High Option Section 5 Overview

Section 5(a). Medical Services and Supplies Provided by Physicians and Other
Healthcare Professionals

High Option

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in

this brochure and are payable only when we determine they are medically necessary.

• The calendar year deductible is: PPO - $450 per person ($800 per Self Plus One enrollment, or
$800 per Self and Family enrollment); non-PPO - $1,000 per person ($2,000 per Self Plus One
enrollment, or $2,000 per Self and Family enrollment). The calendar year deductible applies to
almost all benefits in this Section. We added “(No deductible)” to show when the calendar year
deductible does not apply.

• The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you

use a PPO provider. When no PPO provider is available, non-PPO benefits apply.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how
cost-sharing works. Also, read Section 9 for information about how we pay if you have other
coverage, or if you are age 65 or over.

• YOU MUST GET PRECERTIFICATION FOR CERTAIN OUTPATIENT

IMAGING PROCEDURES. FAILURE TO DO SO WILL RESULT IN A MINIMUM OF A
$100 PENALTY. Please refer to precertification information in Section 3 to be sure which
procedures require precertification.

• If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is

primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our
PSHB members.  This plan enhances your PSHB 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 a $100 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.).

Benefits Description

You pay
After the calendar year deductible…

Note: The calendar year deductible applies to almost all benefits in this Section.
We say “(No deductible)” when it does not apply.

Diagnostic and treatment services

High Option

Professional services of physicians

•  In physician’s office*

•  Medical consultations in the office

PPO: $25 copayment (No deductible)

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

* Professional services of a physician via Telehealth/Telemedicine are
covered the same as in a physician's office.

Professional services of physicians

PPO: 15% of the Plan allowance

•  During a hospital stay

•  In a skilled nursing facility

•  Second surgical opinion

•  At home

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

Diagnostic and treatment services - continued on next page

2025 APWU Health Plan

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Section 5(a)

Benefits Description

Diagnostic and treatment services (cont.)

At Cancer Centers of Excellence

Note:  To receive the higher level of benefits for cancer related
treatment, you are required to visit a designated Cancer Center of
Excellence facility.
TeleHealth Services

High Option

You pay
After the calendar year deductible…
High Option

PPO Cancer Center of Excellence (COE):  5%
of the Plan allowance

High Option

•  Virtual visits are available through Teladoc

Teladoc:

You can receive treatment from board-certified doctors for your non-
emergency conditions such as the flu, strep throat, eye infections,
bronchitis, and much more.  Covered services include visits through the
web or your mobile device to obtain a consultation, diagnosis and
prescriptions (when appropriate).  The service is available 24 hours a
day, 7 days a week.

Note:  Telehealth services are available in most states, but some states do
not allow telehealth or prescriptions per state regulations.

Please visit  www.teladoc.com, or call 800-835-2362 for information on
virtual visits

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

Lab, X-ray and other diagnostic tests

Tests, such as:

•  Blood tests

•  Urinalysis

•  Non-routine Pap test

•  Pathology

•  X-ray

•  Non-routine mammogram, including 3D mammogram

•  CT/CAT Scan/MRI/MRA/NC/PET (Outpatient requires

precertification – see Section 3, except for NC)

•  Ultrasound

•  Electrocardiogram and EEG

Nothing (no deductible) for first 2 visits

$10 copayment (no deductible) after first 2
visits

High Option

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

Note: If your PPO provider uses a non-PPO lab
or radiologist, we will pay non-PPO benefits
for lab and X-ray charges billed by these non-
PPO providers.

If LabCorp or Quest Diagnostics performs your covered lab services,
you will have no out-of-pocket expense and you will not have to file a
claim. To find a location near you, in all states, call APWU Health Plan
at 800-222-2798 or visit our website at www.apwuhp.com.

Note: Not available in the U.S. Virgin Islands.

Nothing (No deductible)

Not covered:

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

2025 APWU Health Plan

37

Section 5(a)

Benefits Description

Preventive care, adult

You pay
After the calendar year deductible…
High Option

•  Routine physical every calendar year.

PPO: Nothing (No deductible)

High Option

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

The following preventive services are covered at the time interval
recommended at each of the links below:

•  U.S. Preventive Services Task Force (USPSTF) A and B

recommended screenings such as cancer, osteoporosis, depression,
diabetes, high blood pressure, total blood cholesterol, HIV, and
colorectal cancer. For a complete list of screenings go to the website
at https://www.uspreventiveservicestaskforce.org/uspstf/
recommendation-topics/uspstf-a-and-b-recommendations

•  Individual counseling on prevention and reducing health risks

•  Well woman care 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 Well
Women preventive care services go to the Health and Human Services
(HHS) website at www.hrsa.gov/womens-guidelines.

•  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

•  Adult Immunizations endorsed by the Centers for Disease Control and

Prevention (CDC): based on the Advisory Committee on
Immunization Practices (ACIP) schedule. For a complete list of
endorsed immunizations go to the Centers for Disease Control (CDC)
website at https://www.cdc.gov/vaccines/schedules/

•  To build your personalized list of preventive services go to

https://health.gov/myhealthfinder

Note: Any procedure, injection, diagnostic service, laboratory, or x-ray
service done in conjunction with a routine examination and is not
included in the preventive recommended listing of services will be
subject to the applicable member copayments, coinsurance, and
deductible.

•  Routine mammogram - covered for women, including 3D

PPO: Nothing (No deductible)

mammograms covered for women age 35 and older; as follows:

-   From age 35 through 39, one during this five year period

-   From age 40, one every calendar year

•  To build your personalized list of preventive services go to

https://health.gov/myhealthfinder

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

Preventive care, adult - continued on next page

2025 APWU Health Plan

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Section 5(a)

High Option

You pay
After the calendar year deductible…
High Option

PPO: Nothing (No deductible)

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

Benefits Description

Preventive care, adult (cont.)

Obesity counseling, screening and referral for those persons at or above
the USPSTF obesity prevention risk factor level, to intensive nutrition
and behavioral weight-loss therapy, counseling, or family-centered
programs under the USPSTF A and B recommendations are covered as
part of prevention and treatment of obesity as follows:

•  Intensive nutrition and behavioral weight-loss counseling therapy:

-   Unlimited preventive medical nutrition therapy (assessment and

intervention)

-   Unlimited preventive medical counseling for the purpose of

promoting health and preventing illness

-   Unlimited visits to a registered dieticians/nutritionist

•  Family-centered programs when medically identified to support
obesity prevention and management by an in-network provider:

-   Unlimited preventive medical counseling group (including family

counseling)

•  When anti-obesity medication is prescribed as indicated by the FDA
obesity medication treatment guidelines. See Section 5(f) for cost
share requirements for anti-obesity medications.

•  When Bariatric or Metabolic surgical treatment or intervention is

indicated for severe obesity. See Section 5(b) for surgery requirements
and cost share. For coverage policy, visit www.apwuhp.com and click
on Member Resources.

Obesity screening and referral, for those persons below the USPSTF
obesity prevention risk factor level, see Section 5(h) for Weight
Management and Special Programs.

Not covered:

All charges

•  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

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
of Pediatrics Bright Futures Guidelines go to www.brightfutures.aap.
org

•  Children’s immunizations  endorsed by the Centers for Disease

Control (CDC) including DTaP/Tdap, Polio, Measles, Mumps, and
Rubella (MMR), and Varicella. For a complete list of immunizations
go to the Centers for Disease Control (CDC) website at
https://www.cdc.gov/vaccines/schedules/index.html

Non-PPO: Any difference between the Plan
allowance and the billed charge (No
deductible)

Preventive care, children - continued on next page

2025 APWU Health Plan

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Section 5(a)

High Option

You pay
After the calendar year deductible…
High Option

PPO: Nothing (No deductible)

Non-PPO: Any difference between the Plan
allowance and the billed charge (No
deductible)

PPO: Nothing (No deductible)

Non-PPO: Any difference between the Plan
allowance and the billed charge and any
amount above $250 per child (ages 0 through
3) each year and any amount above $150 per
child (ages 4 through 18) each year (No
deductible)

PPO:  Nothing (No deductible)

Non-PPO:  40% of the Plan allowance and any
difference between our allowance and the
billed amount

Benefits Description

Preventive care, children (cont.)

You may also find a complete list of U.S. Preventive Services Task
Force (USPSTF) A and B recommendations online at
www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/
uspstf-a-and-b-recommendations

•  Examinations, limited to:

-   Examinations for amblyopia and strabismus - limited to one

screening examination (ages 3 through 5)

-   Examinations done on the day of immunizations (ages 3 through

21)

-   One Screening Examination of Premature Infants for Retinopathy

of Prematurity or infants with low birth weight or gestational age of
32 weeks or less

•  To build your personalized list of preventive services go to

www.health.gov/myhealthfinder

Note: In-network facility and lab services directly related to covered, in-
network preventive care will also be covered at 100%.

Note: Any procedure, injection, diagnostic service, laboratory, or x-ray
service done in conjunction with a routine examination and is not
included in the preventive recommended listing of services will be
subject to the applicable member copayments, coinsurance, and
deductible.

Obesity counseling, screening and referral for those persons at or above
the USPSTF obesity prevention risk factor level, to intensive nutrition
and behavioral weight-loss therapy, counseling, or family-centered
programs under the USPSTF A and B recommendations are covered as
part of prevention and treatment of obesity as follows:

•  Intensive nutrition and behavioral weight-loss counseling therapy:

-   Unlimited preventive medical nutrition therapy (assessment and

intervention)

-   Unlimited preventive medical counseling for the purpose of

promoting health and preventing illness

-   Unlimited visits to a registered dieticians/nutritionist

•  Family-centered programs when medically identified to support
obesity prevention and management by an in-network provider:

-   Unlimited preventive medical counseling group (including family

counseling)

•  When anti-obesity medication is prescribed as indicated by the FDA
obesity medication treatment guidelines. See Section 5(f) for cost
share requirements for anti-obesity medications.

•  When Bariatric or Metabolic surgical treatment or intervention is

indicated for severe obesity. See Section 5(b) for surgery requirements
and cost share. For coverage policy, visit www.apwuhp.com and click
on Member Resources.

2025 APWU Health Plan

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Section 5(a)

Preventive care, children - continued on next page

Benefits Description

Preventive care, children (cont.)

Obesity screening and referral, for those persons below the USPSTF
obesity prevention risk factor level, see Section 5(h) for Weight
Management and Special Programs.

High Option

You pay
After the calendar year deductible…
High Option

PPO:  Nothing (No deductible)

Non-PPO:  40% of the Plan allowance and any
difference between our allowance and the
billed amount

Not covered:

All charges

•  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

Maternity care

High Option

Complete maternity (obstetrical) care, such as:

PPO:  Nothing (No deductible)

Non-PPO:  40% of the Plan allowance and any
difference between our allowance and the
billed amount

Note:  For inpatient hospital care related to
maternity, we pay for covered services in full
when you use preferred providers.

Note:  In-network facility and lab services
directly related to covered, in-network
maternity care will also be covered at 100%.

Note:  For Non-PPO inpatient hospital, a $300
copayment fee applies.

•  Screening for gestational diabetes

•  Prenatal and postpartum care

•  Delivery

•  Initial examination of a newborn child covered under a Self Plus One

or Self and Family enrollment

•  Breastfeeding and lactation support, supplies and counseling for each

birth

•  Screening and counseling for prenatal and postpartum depression

Note: Maternity care expenses incurred by a Plan member serving as a
surrogate mother are covered by the Plan subject to reimbursement from
the other party to the surrogacy contract or agreement.  The involved
Plan member must execute our Reimbursement Agreement completed
by APWU Health Plan against any payment they may receive under the
surrogacy contract or agreement.  Expenses of the newborn child are not
covered under this or any other benefit in a surrogate mother situation.

Here are some things to keep in mind:

You do not need to precertify your vaginal or cesarean delivery; see
Section 3 for other circumstances, such as extended stays for you or
your baby.

•  As part of your coverage you have access to in-network certified
nurse midwives, home nurse visits and board-certified lactation
specialists during the prenatal and post-partum period.

•  Doula virtual coverage through Maven (a free wellness program). See

Section 5(h).

•  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 will cover other
care of an infant who requires non-routine treatment only if we cover
the infant under a Self Plus One or Self and Family enrollment.

2025 APWU Health Plan

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Section 5(a)

Maternity care - continued on next page

High Option

Benefits Description

Maternity care (cont.)

You pay
After the calendar year deductible…
High Option

•  We pay hospitalization and surgeon services for non-maternity care,

PPO:  Nothing (No deductible)

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).

Non-PPO:  40% of the Plan allowance and any
difference between our allowance and the
billed amount

Note:  When a newborn requires definitive treatment during or after the
mother's hospital stay, the newborn is considered a patient in their own
right.  If the newborn is eligible for coverage, regular medical or surgical
benefits apply rather than maternity benefits.  In addition, circumcision
is covered at the same rate as for regular medical or surgical benefits.

Note:  For inpatient hospital care related to
maternity, we pay for covered services in full
when you use preferred providers.

Note:  In-network facility and lab services
directly related to covered, in-network
maternity care will also be covered at 100%.

Note:  For Non-PPO inpatient hospital, a $300
copayment fee applies.

•  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.

Non-PPO:  40% of the Plan allowance and any
difference between our allowance and the
billed amount

Not covered:

All charges

•  Amniocentesis if for diagnosing multiple births

•  Genetic screening (see Definitions, Section 10)

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
ACA/HRSA requirements or have difficulty accessing contraceptive
coverage or other reproductive healthcare, you can
contact  contraception@opm.gov. See OPM’s web page about
contraception.

A range of voluntary family planning services, without cost sharing, that
includes at least one form of contraception in each of the categories on
the HRSA list. This list includes:

•  Voluntary female sterilization

•  Surgically implanted contraceptives

•  Injectable contraceptive drugs (such as Depo Provera)

•  Intrauterine devices (IUDs)

•  Diaphragms

Note: See additional Family Planning and Prescription drug coverage
Section 5(f)

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

PPO: Nothing (No deductible)

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

Family planning - continued on next page

2025 APWU Health Plan

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Section 5(a)

Benefits Description

Family planning (cont.)

Note: Your plan offers some type of voluntary female sterilization
surgery coverage at no cost to members. The contraceptive benefit
includes at least one option in each of the HRSA-supported categories of
contraception (as well as the screening, education, counseling, and
follow-up care). Any type of voluntary female sterilization surgery that
is not already available without cost sharing can be accessed through the
contraceptive exceptions process described below.

Note: All FDA approved and standard of care are covered. No exception
process is needed.

High Option

You pay
After the calendar year deductible…
High Option

PPO: Nothing (No deductible)

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

•  Voluntary male sterilization

PPO:  15% of the Plan allowance

Non-PPO:  40% of the Plan allowance and any
difference between our allowance and the
billed amount

All charges

High Option

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance

Not covered:

•  Reversal of voluntary surgical sterilization

•  Genetic testing and counseling

Infertility services

Diagnosis and treatment of infertility specific to, except as shown in Not
covered, see Section 10, Definitions

•  Artificial insemination (AI):

-   Intravaginal insemination (IVI),

-   Intracervical insemination (ICI)

-   Intrauterine insemination (IUI)

•  Infertility medications, including IVF related drugs. See Section 5

(f), Prescription drug benefits.

For coverage policy, visit www.apwuhp.com and click on Member
Resources.

•  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
of disease and gender reassignment.

Non-PPO: 40% of the Plan allowance

Note: Fertility preservation procedures require prior approval (see
Section 3, Other services).

Limited benefits: $12,000 lifetime maximum.

Not covered:

All charges

•  Infertility services after voluntary sterilization

•  Assisted reproductive technology (ART) procedures, such as:

-   In vitro fertilization (IVF) (excluding IVF drugs)

-   Embryo transfer and gamete intra-fallopian transfer (GIFT) and

zygote intra-fallopian transfer (ZIFT)

•  Services and supplies related to ART procedures

2025 APWU Health Plan

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Section 5(a)

Infertility services - continued on next page

Benefits Description

Infertility services (cont.)

•  Cost of donor sperm

•  Cost of donor egg

Allergy care

High Option

You pay
After the calendar year deductible…
High Option

All charges

High Option

•  Testing and treatment, including materials (such as allergy serum)

PPO: 15% of the Plan allowance

•  Allergy injections

Not covered:

•  Provocative food testing

•  Sublingual allergy desensitization

Treatment therapies

•  Chemotherapy

•  Radiation therapy (preauthorization required by UnitedHealthcare)

Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed in Section 5(b).

•  Dialysis – hemodialysis and peritoneal dialysis

•  Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy

•  Specialty drugs administered on an outpatient basis

Note:  For Specialty drugs, you or your prescriber must contact Accredo
at 844-581-4862 to ask if a specialty medication you are receiving from
the physician's office or outpatient setting must be obtained through
Accredo Specialty Pharmacy.  If the drugs are obtained through Accredo
Specialty Pharmacy, they will be paid at the in-network prescription
drug benefit, (see Section 5(f), Prescription drug benefits).  If your
specialty medication is available through Accredo Specialty Pharmacy
and you do not obtain your medication through Accredo Specialty
Pharmacy, you will be responsible for the full cost of your medication.

•  Respiratory and inhalation therapies

•  Cardiac rehabilitation following qualifying event/condition

•  Medical food formulas ordered by a healthcare provider that are
medically necessary to treat specific nutritional risks, including
Phenylketonuria (PKU) and other inborn errors of metabolism (IEM).

Limited benefits: We pay a maximum of $2,500 for each calendar year.

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

All charges

High Option

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

PPO: 15% of the Plan allowance and all
charges after we pay $2,500 in a calendar year

Non-PPO: 40% of the Plan allowance and all
charges after we pay $2,500 in a calendar year

•  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,
Section 3)

Non-PPO: All charges

Not covered:

All charges

•  Medical foods for conditions other than permanent inborn errors of

metabolism.

2025 APWU Health Plan

44

Section 5(a)

Benefits Description

Physical and occupational therapies

Physical therapy and occupational therapy provided by a licensed
registered therapist or physician up to a combined 60 visits per calendar
year

Note:  We also have the right to deny any type of therapy, service or
supply for the treatment of a condition which ceases to be therapeutic
treatment and is instead administered to maintain a level of functioning
or to prevent a medical problem from occurring or recurring.

Not covered:

•  Maintenance therapies

•  Exercise programs

Applied behavioral analysis (ABA)

Outpatient Applied Behavioral Analysis (ABA) services, for the
treatment of Autism Spectrum Disorder. Services must be provided
under the supervision of a Board Certified Behavior Analyst who is
contracted with UnitedHealthcare Behavioral Health, or agrees to
participate with UnitedHealthcare Behavioral Health's care management
activities. Preauthorization required by UnitedHealthcare
Behavioral Health.

Note: UnitedHealthcare Behavioral Health's review of ABA services is
based on an intensive care management model that monitors treatment
plans, objectives, and progress milestones.

We have the right to deny services for treatment when outcomes do not
meet the defined treatment plan objectives and milestones.

Speech therapy

Speech therapy where medically necessary and provided by a licensed
therapist

Note: Speech therapy is combined with 60 visits per calendar year for
the services of physical therapy and/or occupational therapy (see above).

Note: We also have the right to deny any type of therapy, service or
supply for the treatment of a condition which ceases to be therapeutic
treatment and is instead administered to maintain a level of functioning
or to prevent a medical problem from occurring or recurring.
Hearing services (testing, treatment, and supplies)

High Option

You pay
After the calendar year deductible…
High Option

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

All charges

High Option

PPO:  15% of the Plan allowance

Non-PPO:  All charges

High Option

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

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

Note:  For routine hearing screening performed during a child's
preventive care visit, (see Section 5(a), Preventive care, children).

•  External hearing aids

•  Implanted hearing-related devices, such as bone anchored hearing
aids (BAHA) and cochlear implants for bilateral hearing loss

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

Note:  For benefits for the devices see Section
5(a), Orthopedic and prosthetic devices.

Hearing services (testing, treatment, and supplies) - continued on next page

2025 APWU Health Plan

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Section 5(a)

Benefits Description

Hearing services (testing, treatment, and supplies) (cont.)

High Option

You pay
After the calendar year deductible…
High Option

Not covered:

All charges

•  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 to
correct an impairment caused by accident or illness. Services are limited
to the testing, evaluation and fitting of the first contact lenses required to
correct an impairment caused by accident or illness

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

Note:  See Section 5(a), Preventive care, children, for eye exams for
children.

Not covered:

All charges

•  Eyeglasses or contact lenses and examinations for them

•  Eye exercises and visual training

•  Radial keratotomy and other refractive surgery

•  Refraction

Foot care

Routine foot care when you are under active treatment for a metabolic or
peripheral vascular disease, such as diabetes

High Option

PPO: $25 copayment for the office visit (No
deductible) plus 15% of the Plan allowance for
other services performed during the visit

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

Not covered:

All charges

•  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

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

Orthopedic and prosthetic devices

•  Artificial limbs and eyes

•  Prosthetic sleeve or sock

•  Externally worn breast prostheses and surgical bras, including

necessary replacements following a mastectomy

•  Leg, arm, neck, joint and back braces

•  Implanted hearing-related devices, such as bone anchored hearing
aids (BAHA) and cochlear implants for bilateral hearing loss

•  Internal prosthetic devices, and surgically implanted breast implant

following mastectomy

Note:  We recommend preauthorization of orthopedic and prosthetic
devices, (see Other services, Section 3).

2025 APWU Health Plan

46

Section 5(a)

Orthopedic and prosthetic devices - continued on next page

Benefits Description

Orthopedic and prosthetic devices (cont.)

Note:  We require preauthorization of artificial limbs, (see Other
services, Section 3).

Note:  For information on the professional charges for the surgery to
insert an implant, see Section 5(b), Surgical procedures.  For information
on the hospital and/or ambulatory surgery center benefits see Section 5
(c), Services provided by a hospital or other facility, and ambulance
services.

External hearing aids

•  Covered every 3 years limited to $1,500

Note:  Excluding batteries, benefits for hearing aid dispensing fees,
accessories, supplies, and repair service are included in the benefit limit
described above.

See Section 5h, Wellness and Other Special Features, for information on
UnitedHealthcare Hearing.

High Option

You pay
After the calendar year deductible…
High Option

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

PPO: All charges in excess of $1,500, up to the
PPO allowance (No deductible)

Non-PPO: All charges in excess of $1,500 (No
deductible)

Not covered:

All charges

•  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

treating your illness or injury)

2. Are medically necessary

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
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

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

2025 APWU Health Plan

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Section 5(a)

Durable medical equipment (DME) - continued on next page

High Option

You pay
After the calendar year deductible…
High Option

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

All charges

Benefits Description

Durable medical equipment (DME) (cont.)

Note: Preauthorization of durable medical equipment is required,
(see Other services, Section 3).

Note: We will pay only for the cost of the standard item. Coverage for
specialty equipment, such as all-terrain wheelchairs, is limited to the
cost of the standard equipment.

Note:  We limit the Plan allowance for DME rental benefit to an amount
no greater than what we would have considered if the equipment had
been purchased.

Not covered :

•  Whirlpool equipment

•  Sun and heat lamps

•  Light boxes

•  Heating pads

•  Exercise devices

•  Stair glides

•  Elevators

•  Air Purifiers

•  Computer “story boards,” “light talkers,” or other communication aids

for communication-impaired individuals

Home health services

High Option

Services for skilled nursing care up to 50 visits per calendar year, not to
exceed two hours per day; and

•  a registered nurse (R.N.), licensed practical nurse (L.P.N.) or licensed

vocational nurse (L.V.N.) provides the services;

PPO: 15%; all charges in excess of two hours

Non-PPO: 40%; all charges in excess of two
hours

•  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

Not covered:

All charges

•  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

•  Services of nurses' aides or home health aides

•  All charges in excess of two hours

2025 APWU Health Plan

48

Section 5(a)

Benefits Description

Chiropractic

High Option

You pay
After the calendar year deductible…
High Option

•  Chiropractic treatment limited to 24 visits and/or manipulations per

PPO: $25 copayment (No deductible)

year

•  Electrical stimulation and ultrasound therapy provided by a licensed

chiropractor

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount.

Note:  X-ray covered under Section 5(a), Lab, X-ray and other
diagnostic tests.

Not covered:

•  Massage therapy

•  Maintenance therapy

Alternative treatments

All charges

High Option

•  Acupuncture - by a doctor of medicine or osteopathy, or licensed or

PPO: $25 copayment (No deductible)

certified acupuncture practitioner, benefits are limited to 26 visits per
person per calendar year

•  Dry Needling – by a licensed or certified practitioner

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

Not covered:

All charges

•  Services of any provider not listed as covered (see Covered

providers, Section 3)

Educational classes and programs

You may enroll in Quit For Life, a tobacco cessation program, by
visiting www.quitnow.net for:

•  Telephonic and/or online counseling sessions

•  Group therapy sessions

Note: Enrollment in the Quit For Life program must be initiated by the
member.

Select over-the-counter and prescription Tobacco Cessation medications
approved by the FDA to treat tobacco dependence. For a listing of
medications go to our website at:
https://www.apwuhp.com/members/high-option/pharmacy/

To qualify for these drugs, you need to be age 18 or older; get a
prescription for these products from your doctor, even if the products are
sold over-the-counter; fill the prescription at a network pharmacy.

Diabetes self-management training services, up to 10 hours initial
training the first year and 2 hours subsequent training annually.

High Option

PPO:  Nothing (No deductible)

Non-PPO:  40% of the Plan allowance and any
difference between our allowance and the
billed amount

PPO:  Nothing (No deductible)

Non-PPO:  All charges

PPO:  15% of the Plan allowance

Non-PPO:  40% of the Plan allowance and any
difference between our allowance and the
billed amount

2025 APWU Health Plan

49

Section 5(a)

High Option

Section 5(b). Surgical and Anesthesia Services
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.

• The services listed below are for the charges billed by a physician or other healthcare professional
for your surgical care. See Section 5(c) for charges associated with a facility (i.e. hospital, surgical
center, etc.)

• YOU MUST GET PRECERTIFICATION FOR SOME SURGICAL

PROCEDURES. 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.

• 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
PSHB members. This plan enhances your PSHB 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 a $100 monthly Part B reimbursement. The
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.
(See Section 9 for additional details.)

Benefits Description

You pay
After the calendar year deductible…

Note: The calendar year deductible applies to almost all benefits in this Section.
We say “(No deductible)” when it does not apply.

Surgical procedures

High Option

A comprehensive range of services, such as:

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

•  Operative procedures

•  Treatment of fractures, including casting

•  Normal pre- and post-operative care by the surgeon

•  Correction of amblyopia and strabismus

•  Endoscopy procedures

•  Biopsy procedures

•  Removal of tumors and cysts

•  Correction of congenital anomalies (see Reconstructive  surgery)

•  Surgical treatment of severe obesity (bariatric surgery) (requires

preauthorization, see Other services, Section 3). For coverage policy,
visit www.apwuhp.com and click on Member Resources.

2025 APWU Health Plan

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Section 5(b)

Surgical procedures - continued on next page

Benefits Description

Surgical procedures (cont.)

You pay
After the calendar year deductible…
High Option

•  Insertion of internal prosthetic devices (see Section 5(a), Orthopedic

PPO: 15% of the Plan allowance

High Option

and prosthetic devices, for device coverage information)

•  Treatment of burns

•  Assistant surgeons - We cover up to 20% of our allowance for the

surgeon’s charge

Note: For female surgical family planning procedures see Family
Planning Section 5(a).

Note: For male surgical family planning procedures see Family Planning
Section 5(a).

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

When multiple or bilateral surgical procedures performed during the
same operative session add time or complexity to patient care, our
benefits are:

PPO: 15% of the Plan allowance for the
primary procedure and 15% of one-half of the
Plan allowance for the secondary procedure(s)

Non-PPO: 40% of the Plan allowance for the
primary procedure and 40% of one-half of the
Plan allowance for the secondary procedure(s);
and any difference between our allowance and
the billed amount

•  For the primary procedure:

-   PPO: 85% of the Plan allowance; or

-   Non-PPO: 60% of the Plan allowance

•  For the secondary procedure(s):

-   PPO: 85% of one-half of the Plan allowance or

-   Non-PPO: 60% of one-half of the Plan allowance

Note: When multiple or bilateral surgical procedures add complexity to
an operative session, the Plan allowance for the second or less expensive
procedure is one-half of what the Plan allowance would have been if that
procedure had been performed independently.

•  When a surgery requires two primary surgeons (co-surgeons), the Plan
allowance for each surgeon will not exceed 62.5% of our allowance.
This allowance will be further reduced by half for secondary
procedures.

•  Multiple or bilateral surgical procedures performed through the same

incision are "incidental" to the primary surgery.  That is, the procedure
would not add time or complexity to patient care.  We do not pay
extra for incidental procedures.

Not covered:

All charges

•  Cosmetic surgery and other related expenses if not preauthorized

•  Reversal of voluntary sterilization

•  Services of a standby surgeon, except during angioplasty or other high
risk procedures when we determine standbys are medically necessary

•  Radial keratotomy and other refractive surgery

•  Routine treatment of conditions of the foot (see Foot care, Section 5

(a))

2025 APWU Health Plan

51

Section 5(b)

High Option

Benefits Description

Reconstructive surgery

You pay
After the calendar year deductible…
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:

-   The condition produced a major effect on the member’s appearance

and

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
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, 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 for gender affirmation

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

•  Gender affirming surgery benefits are only available for the diagnosis

of gender dysphoria

Requirements:

•  Prior approval is required.

•  Must be at least 18 years of age at time prior approval is requested

and treatment plan is submitted.

•  Must have diagnosis of gender dysphoria by a qualified healthcare

professional.

•  Persistent, well-documented gender dysphoria.

•  Member’s gender dysphoria is not a symptom of another mental

disorder or chromosomal abnormality.

•  Continuous hormone therapy as appropriate.

•  Two clinical assessments from qualified healthcare professionals are
required for genital and gonadal surgeries, all other surgeries require
one assessment.

•  If medical or mental health concerns are present, they are being

optimally managed and are reasonably well-controlled.

For coverage policy, visit www.apwuhp.com and click on Member
Resources.

2025 APWU Health Plan

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Section 5(b)

Reconstructive surgery - continued on next page

High Option

You pay
After the calendar year deductible…
High Option

All charges

High Option

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

Benefits Description

Reconstructive surgery (cont.)

Not covered:

•  Cosmetic services that are not medically necessary

•  Travel and lodging

Oral and maxillofacial surgery

Oral surgical procedures, limited to:

•  Reduction of fractures of the jaw or facial bones

•  Surgical correction of cleft lip, cleft palate or severe functional

malocclusion

•  Removal of stones from salivary ducts

•  Excision of leukoplakia or malignancies

•  Excision of cysts and incision of abscesses when done as independent

procedures

•  Other surgical procedures that do not involve the teeth or their

supporting structures

•  Extraction of impacted (unerupted) teeth

•  Alveoplasty, partial ostectomy and radical resection of mandible with

bone graft unrelated to tooth structure

•  Excision of bony cysts of the jaw unrelated to tooth structure

•  Excision of tori, tumors, and premalignant lesions, and biopsy of hard

and soft oral tissues

•  Reduction of dislocations and excision, manipulation, arthrocentesis,

aspiration or injection of temporomandibular joints

•  Removal of foreign body, skin, subcutaneous alveolar tissue, reaction-
producing foreign bodies in the musculoskeletal system and salivary
stones

•  Incision/excision of salivary glands and ducts

•  Repair of traumatic wounds

•  Sinusotomy, including repair of oroantral and oromaxillary fistula

and/or root recovery

•  Surgical treatment of trigeminal neuralgia

•  Frenectomy or frenotomy, skin graft or vestibuloplasty-stomatoplasty

unrelated to periodontal disease

•  Incision and drainage of cellulitis unrelated to tooth structure

Note: Call UnitedHealthcare at 866-569-2064 to determine if a
procedure is covered.

Not covered:

•  Oral implants and transplants

All charges

•  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

2025 APWU Health Plan

53

Section 5(b)

Oral and maxillofacial surgery - continued on next page

High Option

Benefits Description

Oral and maxillofacial surgery (cont.)

You pay
After the calendar year deductible…
High Option

•  Treatment of periodontal disease and gingival tissues, and abscesses

All charges

•  Charges related to orthodontic treatment

Organ/tissue transplants

These solid organ transplants are subject to medical necessity and
experimental/investigational review by the Plan.  Refer to Other
services in Section 3, for prior authorization procedures.

Solid organ transplants are limited to:

•  Autologous pancreas islet cell transplant (as an adjunct to total or near

total pancreatectomy) only for patients with chronic pancreatitis

High Option

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount and any amount over $50,000 for
kidney transplants or $100,000 for other listed
transplants

•  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

These tandem blood or marrow stem cell transplants for covered
transplants are subject to medical necessity review by the Plan.  Refer
to Other services in Section 3, for prior authorization procedures.

•  Autologous tandem transplants for

-   AL Amyloidosis

-   Multiple myeloma (de novo and treated)

-   Recurrent germ cell tumors (including testicular cancer)

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount and any amount over $50,000 for
kidney transplants or $100,000 for other listed
transplants

Blood or marrow stem cell transplants

PPO: 15% of the Plan allowance

The Plan extends coverage for the diagnoses as indicated below:

•  Allogeneic transplants for

-   Acute lymphocytic or non-lymphocytic (i.e., myelogenous)

leukemia

-   Acute myeloid leukemia

-   Advanced Hodgkin's lymphoma with recurrence (relapsed)

-   Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)

-   Advanced Myeloproliferative Disorders (MPDs)

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount and any amount over $50,000 for
kidney transplants or $100,000 for other listed
transplants

-   Advanced neuroblastoma

-   Amyloidosis

2025 APWU Health Plan

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Organ/tissue transplants - continued on next page
Section 5(b)

Benefits Description

Organ/tissue transplants (cont.)

You pay
After the calendar year deductible…
High Option

-   Beta Thalassemia Major

PPO: 15% of the Plan allowance

High Option

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount and any amount over $50,000 for
kidney transplants or $100,000 for other listed
transplants

-   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

-   Advanced Hodgkin's lymphoma with recurrence (relapsed)

-   Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)

-   Amyloidosis

-   Aggressive non-Hodgkin's lymphomas

-   Breast cancer

-   Childhood rhabdomyosarcoma

-   Ependymoblastoma

-   Epithelial ovarian cancer

-   Ewing's sarcoma

-   Mantle cell (non-Hodgkin's lymphoma)

-   Medulloblastoma

2025 APWU Health Plan

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Organ/tissue transplants - continued on next page
Section 5(b)

Benefits Description

Organ/tissue transplants (cont.)

-   Multiple myeloma

-   Neuroblastoma

-   Pineoblastoma

-   Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell

tumors

-   Waldenstrom's macroglobulinemia

Mini-transplants (non-myeloablative, reduced intensity conditioning or
RIC) are subject to medical necessity review by the Plan.

These blood or marrow stem cell transplants are covered only in a
National Cancer Institute or National Institutes of
Health approved clinical trial or a Plan-designated center of
excellence.

If you are a participant in a clinical trial, the Plan will provide benefits
for related routine care that is medically necessary (such as doctor visits,
lab tests, X-rays and scans, and hospitalization related to treating the
patient's condition) if it is not provided by the clinical trial.  Section 9
has additional information on costs related to clinical trials.  We
encourage you to contact the Plan to discuss specific services if you
participate in a clinical trial.

High Option

You pay
After the calendar year deductible…
High Option

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount and any amount over $50,000 for
kidney transplants or $100,000 for other listed
transplants

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount and any amount over $50,000 for
kidney transplants or $100,000 for other listed
transplants

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount and any amount over $50,000 for
kidney transplants or $100,000 for other listed
transplants

Transplant Network

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount and any amount over $50,000 for
kidney transplants or $100,000 for other listed
transplants

The Plan uses specific Plan-designated organ/tissue transplant facilities.
Before your initial evaluation as a potential candidate for a transplant
procedure, you or your doctor must contact the precertification vendor
(see Other services, Section 3); UnitedHealthcare at 866-569-2064; and
ask to speak to a Transplant Case Manager. You will be provided with
information about transplant preferred providers. If you choose a Plan-
designated transplant facility, you may receive prior approval for travel
and lodging costs.

Limited Benefits – If you don’t use a Plan-designated transplant facility,
benefits for pretransplant evaluation, organ procurement, inpatient
hospital, surgical and medical expenses for covered transplants, whether
incurred by the recipient or donor, are limited to a maximum of $50,000
for kidney transplants or $100,000 for each other listed transplant,
including multiple organ transplants.

Note:  We cover related medical and hospital expenses of the donor
when we cover the recipient.

Not covered:

All charges

•  Donor screening tests and donor search expenses, except as shown

above

•  Transplants not listed as covered

2025 APWU Health Plan

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Section 5(b)

Benefits Description

Anesthesia

Professional services provided in –

•  Hospital (inpatient)

Professional services provided in –

•  Hospital outpatient department

•  Skilled nursing facility

•  Ambulatory surgical center

•  Office

High Option

You pay
After the calendar year deductible…
High Option

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

Note: If surgical services are rendered at a PPO
hospital or a PPO freestanding ambulatory
facility, we will pay the services of non-PPO
anesthesiologists at the PPO rate, based on Plan
allowance.

2025 APWU Health Plan

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Section 5(b)

High Option

Section 5(c). Services provided by a hospital or other facility,
and ambulance services

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

• In this Section, unlike Sections 5(a) and 5(b), the calendar year deductible applies to only a few
benefits. We added “(calendar year deductible applies)”. The calendar year deductible is: PPO -
$450 per person ($800 per Self Plus One enrollment, or $800 per Self and Family enrollment); Non-
PPO - $1,000 per person ($2,000 per Self Plus One enrollment, or $2,000 per Self and Family
enrollment).

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

a PPO provider. When no PPO provider is available, non-PPO benefits apply.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how
cost-sharing works. Also, read Section 9 for information about how we pay if you have other
coverage, or if you are age 65 or over.

• The services listed below are for the charges billed by the facility (i.e. hospital or surgical center) or
ambulance service for your surgery or care. Any costs associated with the professional charge (i.e.
physicians, etc.) are in Sections 5(a) or (b).

• YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO

WILL RESULT IN A MINIMUM $500 PENALTY.  Please refer to the precertification
information shown in Section 3 to be sure which services require precertification.

• You must get prior approval for gender reassignment surgery. See Section 3 for prior approval and

Section 5(b) for the surgical benefit.

• When you receive hospital observation services, we apply outpatient benefits to covered services up

to 48 hours. Inpatient benefits will apply only when your physician formally admits you to the
hospital as inpatient. Once you are formally admitted, your entire stay (including observation
services) will be processed and paid as inpatient benefits.

• If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is

primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our
PSHB members. This plan enhances your PSHB 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 a $100 monthly Part B reimbursement. The
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.
(See Section 9 for additional details.)

Benefits Description

You pay

Note: The calendar year deductible applies ONLY when we say below: “(calendar year deductible applies)”.

Inpatient hospital

Room and board, such as:

•  Ward, semiprivate, or intensive care accommodations

•  General nursing care

•  Meals and special diets

Note: We only cover a private room when you must be isolated to
prevent contagion. Otherwise, we will pay the hospital’s average charge
for semiprivate accommodations. If the hospital only has private rooms,
we will cover the private room rate.

High Option

PPO: 15% of the covered charges

Non-PPO: $300 per admission and 40% of the
covered charges and any difference between
our allowance and the billed amount

Note:  For inpatient hospital care related to
maternity, we pay for covered services in full
when you use preferred providers, (see Section
5(a), Maternity care.)

Inpatient hospital  - continued on next page

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Section 5(c)

Inpatient hospital  (cont.)

Benefits Description

You pay
High Option

High Option

Note: When the non-PPO hospital bills a flat rate, we prorate the charges
to determine how to pay them, as follows: 30% room and board and
70% other charges.

PPO: 15% of the covered charges

Non-PPO: $300 per admission and 40% of the
covered charges and any difference between
our allowance and the billed amount

Note:  For inpatient hospital care related to
maternity, we pay for covered services in full
when you use preferred providers, (see Section
5(a), Maternity care.)

Other hospital services and supplies, such as:

PPO: 15% of the covered charges

•  Operating, recovery, maternity, and other treatment rooms

•  Prescribed drugs and medications

•  Diagnostic laboratory tests and X-rays

•  Blood or blood plasma, if not donated or replaced

•  Dressings, splints, casts, and sterile tray services

•  Medical supplies and equipment, including oxygen

•  Anesthetics, including nurse anesthetist services

Non-PPO: $300 per admission and 40% of the
covered charges and any difference between
our allowance and the billed amount.

Note:  For inpatient hospital care related to
maternity, we pay for covered services in full
when you use preferred providers, (see Section
5(a), Maternity care.)

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.

Not covered:

All charges

•  Any part of a hospital admission that is not medically necessary (see
Section 10, Definitions), such as when you do not need acute hospital
inpatient (overnight) care, but could receive care in some other setting
without adversely affecting your condition or the quality of your
medical care. Note: In this event, we pay benefits for services and
supplies other than room and board and in-hospital physician care at
the level they would have been covered if provided in an alternative
setting

•  Custodial care; (see Section 10, Definitions)

•  Non-covered facilities, such as, day and evening care centers, and

schools

•  Personal comfort items such as radio, television, air conditioners,

beauty and barber services, guest meals and beds

•  Services of a private duty nurse that would normally be provided by

hospital nursing staff

•  Take-home items

2025 APWU Health Plan

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Section 5(c)

High Option

Cancer Centers of Excellence

Benefits Description

You pay
High Option

The Plan provides access to designated Cancer Centers of Excellence.
For information, you must contact UnitedHealthcare at 866-569-2064
prior to obtaining covered services.  To receive the higher level of
benefits for a cancer related treatment, you are required to visit a
designated facility.

When you contact UnitedHealthcare, you will be provided with
information about the Cancer Centers of Excellence.

PPO Cancer Centers of Excellence (COE): 5%
of the Plan allowance

Outpatient hospital or ambulatory surgical center

High Option

•  Operating, recovery, and other treatment rooms

•  Prescribed drugs and medications

•  Diagnostic laboratory tests, X-rays, and pathology services

•  Administration of blood, blood plasma, and other biologicals

•  Blood and blood plasma, if not donated or replaced

PPO: 15% of the Plan allowance (calendar year
deductible applies)

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount (calendar year deductible
applies)

•  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
benefits

High Option

When APWU Health Plan is Primary

PPO: 15% of the covered charges

Non-PPO: $300 per admission and 40% of the
covered charges and any difference between
our allowance and the billed amount

Note: If enrolled in Medicare A, we waive the
deductible and coinsurance.

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.

Your skilled nursing care is supervised by a physician and provided by
an R.N., L.P.N., or L.V.N.

Note: Prior approval for these services is required.  Call
UnitedHealthcare at 866-569-2064, (see Other services, Section 3).

When Medicare A or Other Insurance is Primary

Semiprivate room, board, services and supplies provided in a skilled
nursing care facility (SNF) for up to 30 days per person per calendar
year when you are admitted directly from a covered inpatient hospital
stay.

Extended care benefits/Skilled nursing care facility benefits - continued on next page

2025 APWU Health Plan

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Section 5(c)

Benefits Description

Extended care benefits/Skilled nursing care facility
benefits (cont.)

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.

High Option

You pay
High Option

PPO: 15% of the covered charges

Non-PPO: $300 per admission and 40% of the
covered charges and any difference between
our allowance and the billed amount

Note: If enrolled in Medicare A, we waive the
deductible and coinsurance.

Not covered:

All charges

•  Custodial care (see Section 10, Definitions)

•  All charges after 30 days per person per calendar year

Hospice care

Hospice is a coordinated program of home and inpatient supportive care
for the terminally ill patient and the patient’s family provided by a
medically supervised specialized team under the direction of a duly
licensed or certified Hospice Care Program.

•  We pay up to $15,000 lifetime maximum for combined outpatient and

inpatient services, which includes advance care planning

•  We pay a $200 annual bereavement benefit per family unit

High Option

Any amount over the maximums shown

End of life care

End of life care

High Option

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

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

Not covered:

All charges

•  Ambulance service used for routine transport

2025 APWU Health Plan

61

Section 5(c)

High Option

Section 5(d). Emergency services/accidents

Important things to keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

• The calendar year deductible is: PPO - $450 per person ($800 per Self Plus One enrollment, or $800

per Self and Family enrollment); Non-PPO - $1,000 per person ($2,000 per Self Plus One
enrollment, or $2,000 per Self and Family enrollment). The calendar year deductible applies to
almost all benefits in this Section. We added “(No deductible)” to show when the calendar year
deductible does not apply.

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

a PPO provider. When no PPO provider is available, non-PPO benefits apply.

• When you use a PPO hospital for emergency services, the emergency room physician who provides
the services to you in the emergency room may not be a preferred provider.  If they are not, they will
be paid by this Plan as a PPO provider at the PPO rate, based on the Plan allowance.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how
cost-sharing works. Also, read Section 9 for information about how we pay if you have other
coverage, or if you are age 65 or over.

• When multiple or bilateral surgical procedures add complexity to an operative session, the Plan

allowance for the second or less expensive procedure is one-half of what the Plan allowance would
have been if that procedure had been performed independently.

-  When a surgery requires two primary surgeons (co-surgeons), the Plan allowance for each

surgeon will not exceed 62.5% of our allowance. This allowance will be further reduced by half
for secondary procedures.

-  Multiple or bilateral surgical procedures performed through the same incision are "incidental" to
the primary surgery. That is, the procedure would not add time or complexity to patient care. We
do not pay extra for incidental procedures.

• If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is

primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our
PSHB members. This plan enhances your PSHB 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 a $100 monthly Part B reimbursement. The
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.
(See Section 9 for additional details.)

What is an accidental injury?

An accidental injury is a bodily injury sustained solely through violent, external, and accidental means, such as broken bones,
animal bites, and poisonings.

What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or
could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies
because, if not treated promptly, they might become more serious; examples include deep cuts, broken bones and mental
health related care. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes,
poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are
medical emergencies – what they all have in common is the need for quick action. If you are unsure of the severity of a
condition in terms of this benefit, the Plan recommends that you first call UnitedHealthcare's 24-hour NurseLine
at 866-569-2064, or your physician.

2025 APWU Health Plan

62

High Option Section 5(d)

Benefits Description

You pay
After the calendar year deductible…

Note: The calendar year deductible applies to almost all benefits in this Section.
We say "(No deductible)" when it does not apply.

Accidental injury

High Option

If you receive care for your accidental injury within 72 hours, we cover:

PPO: Nothing (No deductible)

High Option

Non-PPO: Nothing (No deductible)

•  Physician services and supplies

•  Related outpatient hospital services

•  Air ambulance to nearest facility where necessary treatment is
available is covered if no emergency ground transportation is
available or suitable and the patient's condition warrants immediate
evacuation.  Air ambulance will not be covered if transport is beyond
the nearest available suitable facility, but is requested by patient or
physician for continuity of care or other reasons

Note: See Section 5(c) for hospital benefits if you are admitted.
Services received after 72 hours are considered the same as any other
illness and regular Plan benefits will apply.

If you receive care for your accidental injury within 72 hours, we cover:

PPO: Nothing

•  Professional Ambulance Services

Medical emergency

Outpatient facility charges including medical or surgical services and
supplies in an Urgent Care Center

Note:  High technology radiology/imaging services including CT/CAT
Scan, MRI, MRA, Nuclear Cardiology and PET are subject to
coinsurance and deductible (outpatient requires precertification except
for Nuclear Cardiology), (see Section 5(a)).

Outpatient medical or surgical services and supplies, other than an
Urgent Care Center

Ambulance

Non-PPO: Only the difference between our
allowance and the billed amount (No
deductible)

High Option

PPO: $30 copayment (No deductible)

Non-PPO: 40% of the Plan allowance

Note:  For Non-PPO benefits, members may be
billed the difference between the Plan
allowance and the billed amount.

PPO: 15% of the Plan allowance

Non-PPO: 15% of the Plan allowance

High Option

Professional ambulance services within 24 hours of a medical
emergency

PPO: 15% of the Plan allowance (No
deductible)

Note: See Section 5(c) for non-emergency service.

Air ambulance

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.

Not covered:

•  Non-emergent Air ambulance

•  Emergent transport beyond the nearest suitable facility

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount (No deductible)
High Option

PPO: 15% of the Plan allowance (No
deductible)

Non-PPO: 15% of the Plan allowance (No
deductible)

All charges

Air ambulance - continued on next page

2025 APWU Health Plan

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High Option Section 5(d)

Benefits Description

Air ambulance (cont.)

You pay
After the calendar year deductible…
High Option

•  Air ambulance requested by patient or physician which are beyond the

All charges

nearest facility for continuity of care or other reasons

High Option

2025 APWU Health Plan

64

High Option Section 5(d)

High Option

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

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

• The calendar year deductible is: PPO - $450 per person ($800 per Self Plus One enrollment, or $800

per Self and Family enrollment); Non-PPO - $1,000 per person ($2,000 per Self Plus One
enrollment, or $2,000 per Self and Family enrollment). The calendar year deductible applies to
almost all benefits in this Section. We added “(No deductible)” to show when the calendar year
deductible does not apply.

• The calendar year deductible or, for facility care, the inpatient deductible applies to almost all
benefits in this Section. We added "(No deductible)" to show when a deductible does not apply.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how
cost-sharing works. Also, read Section 9 for information about how we pay if you have other
coverage, or if you are age 65 or over.

• YOU MUST GET PREAUTHORIZATION FOR HOSPITAL STAYS; FAILURE TO DO SO

WILL RESULT IN A MINIMUM $500 PENALTY.  Please refer to the precertification
information shown in Section 3 to be sure which services require precertification.

• To obtain preauthorization of an admission for mental conditions or substance use disorder

treatment, call UnitedHealthcare at 866-569-2064.

• We will provide medical review criteria or reasons for treatment plan denials to enrollees, members

or providers upon request or otherwise required.

• OPM will base its review of disputes about treatment plans on the treatment plan's clinical

appropriateness. OPM will generally not order us to pay or provide one clinically appropriate
treatment plan in favor of another.

• We do not make available provider directories for mental health or substance use disorder treatment
providers. To find a mental health or substance use disorder treatment provider, call APWU Health
Plan at 800-222-2798 or visit our website at www.apwuhp.com.

• Schools or other educational institutions are not covered.

• If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is

primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our
PSHB members. This plan enhances your PSHB 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 a $100 monthly Part B reimbursement. The
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.
(See Section 9 for additional details.)

2025 APWU Health Plan

65

High Option Section 5(e)

High Option

Benefits Description

You pay
After the calendar year deductible…

Note: The calendar year deductible applies to almost all benefits in this Section.
We say “(No deductible)” when it does not apply.

Professional services

High Option

We cover professional services by licensed professional mental health
and substance use disorder treatment practitioners when acting within
the scope of their license, such as psychiatrists, psychologists, clinical
social workers, licensed professional counselors, or marriage and family
therapists.

Your cost-sharing responsibilities are no greater
than for other illnesses or conditions.

In a physician's office *

PPO:  $25 copayment (No deductible)

Non-PPO:  40% of the Plan allowance and any
difference between our allowance and the
billed charges

PPO:  15% of the Plan allowance

Non-PPO:  40% of the Plan allowance and any
difference between our allowance and the
billed charges

•  Treatment and counseling (including individual or group therapy

visits)

•  Diagnosis and treatment to address gender dysphoria (in-network

only), (see Section 5(b) and 5(c) for exclusions)

•  Diagnosis and treatment of substance use disorders (outpatient)

•  Diagnosis and treatment of psychiatric conditions, mental illness, or

mental disorders.  Services include:

-   Diagnostic evaluation

-   Crisis intervention and stabilization for acute episodes

-   Medication evaluation and management (pharmacotherapy)

•  Professional charges for intensive outpatient treatment in a provider's
office or other professional setting (preauthorization required by
UnitedHealthcare)

* Professional services of a physician via Telehealth/Telemedicine are
covered the same as in a physician's office.

Professional and other services for the diagnosis and treatment of
psychiatric conditions, mental illness or mental disorders:

•  Psychological and neuropsychological testing necessary to determine

the appropriate psychiatric treatment

•  Diagnosis and treatment of substance use disorders, including

detoxification, treatment and counseling (inpatient)

•  Repetitive Transcranial Magnetic Stimulation, TMS, for the treatment

of depressive disorders which have not been responsive to other
interventions such as psychotherapy and antidepressant medications
(preauthorization required by UnitedHealthcare)

•  Electroconvulsive therapy

Note: Applied Behavioral Analysis (ABA) therapy benefit is listed in
Section 5(a), Medical Services and Supplies Provided by Physicians and
Other Healthcare Professionals.

2025 APWU Health Plan

66

High Option Section 5(e)

High Option

Benefits Description

TeleHealth services

You pay
After the calendar year deductible…
High Option

Virtual visits through Teladoc for non-emergency visits.

Teladoc:

Covered services include consultation, diagnosis and prescriptions
(when appropriate) through the web or your mobile device.

Note: Telehealth services are available in most states, but some states do
not allow telehealth or prescriptions per state regulations.

Please visit www.teladoc.com, or call 800-835-2362 to start your virtual
visit.

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

Nothing (no deductible) for first 2 visits

$10 copayment (no deductible) after first 2
visits

Diagnostics

High Option

•  Outpatient diagnostic tests provided and billed by a licensed mental

PPO:  15% of the Plan allowance

health and substance use disorder treatment practitioner

•  Outpatient diagnostic tests provided and billed by a laboratory,

hospital or other covered facility

Non-PPO:  40% of the Plan allowance and any
difference between our allowance and the
billed charges

Inpatient hospital or other covered facility

High Option

Inpatient services provided and billed by a hospital, Residential
Treatment Center (RTC), or other covered facility (preauthorization
required by UnitedHealthcare)

•  Room and board, such as semiprivate or intensive accommodations,
general nursing care, meals and special diets, and other hospital
services

•  Inpatient diagnostic tests provided and billed by a hospital,

Residential Treatment Center (RTC), or other covered facility

PPO:  15% of the Plan allowance (No
deductible)

Non-PPO:  After $300 per admission, 40% of
our allowance and any difference between our
allowance and the billed charges (No
deductible)

Not covered:

All charges

•  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 covered
facility

•  Services such as partial hospitalization or full-day hospitalization

(preauthorization required by UnitedHealthcare)

•  Facility-based intensive outpatient treatment (preauthorization

required by UnitedHealthcare)

PPO:  15% of the Plan allowance

Non-PPO:  40% of the Plan allowance and any
difference between our allowance and the
billed charges

Outpatient hospital or other covered facility - continued on next page

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Benefits Description

Outpatient hospital or other covered facility (cont.)

High Option

You pay
After the calendar year deductible…
High Option

Not covered:

All charges

•  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

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High Option

Section 5(f). Prescription drug benefits

Important things to keep in mind about these benefits:

• We cover prescribed drugs and medications, as described in the chart below.

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

• Your prescribers must obtain prior approval/authorizations for certain prescription drugs and
supplies before coverage applies. Prior approval/authorizations must be renewed periodically.

• Federal law prevents the pharmacy from accepting unused medications.

• The calendar year deductible does not apply to prescription drug benefits.

• The non-network benefits are the standard benefits of this Plan. Network benefits apply only when
you use a network provider. When no network provider is available, non-network benefits apply.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how
cost-sharing works. Also read Section 9, for information about how we pay if you have other
coverage, or if you are age 65 or over.

• Prior authorization is required for certain drugs and must be renewed periodically. This review uses
Plan rules based on FDA-approved prescribing and safety information, clinical guidelines and uses
that are considered reasonable, safe and effective. See the coverage authorization information shown
in Section 3, Other services and Section 5(f), Prescription Drug Utilization Management, for more
information about this program.

• If you enroll in APWU Health Plan's High Option and have Medicare Parts A and B and it is

primary, we offer a UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan to our
PSHB members. This plan enhances your PSHB 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 a $100 monthly Part B reimbursement. The
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan is subject to Medicare rules.
See Section 9 for additional details.

There are important features you should be aware of.  These include:

• Who can write your prescription.  A licensed physician or dentist, and in states allowing it, licensed/certified providers

with prescriptive authority prescribing within their scope of practice must prescribe your medication.

• Where can you obtain them.  You can fill the prescription at an Express Scripts network pharmacy, a non-network

pharmacy, or by mail.  We pay our highest level of benefits for mail order and you should use the mail order program to
obtain your maintenance medications.

• You may only obtain a 30-day supply and one refill of maintenance prescriptions at a network pharmacy participating with
Express Scripts. After two courtesy 30-day fills at regular network retail, you will pay the non-network pharmacy benefit
level.

• You may purchase maintenance prescription medications (non-specialty drugs that you take regularly for ongoing

conditions, for a 90-day supply) from a participating Smart90® Retail Network pharmacy or Express Scripts mail order.

• To find a Smart90® Retail Network pharmacy that participates in filling 90-day supplies, log in or register at

www.express-scripts.com/rx, select "Manage Prescriptions," and look for a link directing you to the Participating
Smart90® Retail Network pharmacies, or call 866-890-1419. The pharmacy can tell you how to transfer your non-
specialty maintenance medication prescription or start a new one. If you continue to use a non-participating
Smart90® pharmacy, you will pay the non-network pharmacy benefit level.

• Your copayment for your 90-day supply will be the same whether you fill your prescription through Express Scripts Mail

order or at a participating Smart90® Retail Network pharmacy.

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High Option Section 5(f)

High Option

• We have a managed formulary. Our formulary is the National Preferred Formulary through Express Scripts. A formulary
is a list of medications we have selected based on their clinical effectiveness and lower cost. By asking your doctor to
prescribe formulary medications, you can help reduce your costs while maintaining high-quality care. There are safe,
proven medication alternatives in each therapy class that are covered on the formulary. Some drugs will be excluded from
the formulary and coverage, see www.apwuhp.com/high_option_pharmacy_program.php for a list of excluded
medications.  This list is not all inclusive and there may be changes to the list during the year.  A formulary exception
process is available to prescribers if they feel the formulary alternatives are not appropriate. Prescribers may request a
clinical exception by calling 800-753-2851. During the year, the Plan's formulary may change.

• Member cost-share for prescription drugs is determined by the tier to which a drug has been assigned. To determine the

tier assignments for formulary drugs, our Pharmacy Benefit Managers (PBM) work with their Pharmacy and Therapeutic
Committee, a group of physicians and pharmacists who are not employees or agents of, nor have financial interest in the
Plan. The Committee’s recommendations, together with our PBM's evaluation of the relative cost of the drugs, determine
the placement of formulary drugs on a specific tier. Using lower cost preferred drugs will provide you with a high quality,
cost-effective prescription drug benefit. You can view a list on our website at
www.apwuhp.com/high_option_pharmacy_program.php.

• Our payment levels are generally categorized as:

-  Tier 1 Includes generic drugs

-  Tier 2 Includes preferred brand name drugs

-  Tier 3 Includes non-preferred brand name drugs

-  Tier 4 Includes generic specialty drugs

-  Tier 5 Includes preferred brand name specialty drugs

-  Tier 6 Includes non-preferred brand name specialty

Brand/Generic Drugs

• Why use generic drugs? A generic drug is a chemical equivalent of a corresponding name brand drug. The US Food and
Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality
and strength as brand name drugs. Generic drugs are generally less expensive than brand drugs, therefore, you may reduce
your out-of-pocket-expenses by choosing to use a generic drug.

• A generic equivalent will be dispensed if it is available, unless your prescriber specifically requires a brand name drug. If
you receive a brand name drug when a FDA approved generic drug is available, and your prescriber has not received a
preauthorization, you have to pay the difference in cost between the name brand drug and the generic, in addition to your
coinsurance. However, if your doctor obtains preauthorization because it is medically necessary that a brand name drug be
dispensed, you will not be required to pay this cost difference. Your doctor may seek preauthorization by calling
800-753-2851.

• The Plan may have certain coverage limitations to ensure clinical appropriateness. For example, prescription drugs used

for cosmetic purposes may not be covered, a medication might be limited to a certain amount (such as the number of pills
or total dosage) within a specific time period, or require authorization to confirm clinical use based on FDA labeling. In
these cases, you or your prescriber can begin the coverage review process by calling Express Scripts Customer Service at
800-841-2734.

These are the dispensing limitations:

• The Express Scripts Retail Network – you may obtain up to a 30-day supply plus one 30-day refill for each prescription
purchased from an Express Scripts network pharmacy. After one 30-day refill, you must obtain a new prescription and
either purchase your non-specialty maintenance prescription medications (drugs you take regularly for ongoing conditions)
at either a participating Smart90 Retail Network pharmacy or the Express Scripts mail order. If you do not, we will pay the
non-network pharmacy benefit level. To receive maximum savings you must present your card at the time of each
purchase, and your enrollment information must be current and correct. In most cases, you simply present the card together
with the prescription to the pharmacist. Refills cannot be obtained until 75% of the drug has been used.

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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.

Benefits Description

You pay
After the calendar year deductible…

The calendar year deductible applies to almost all benefits in this Section.
We say "(No deductible)" when it does not apply.

Covered medications and supplies

High Option

•  Network Retail: $10 Tier 1. 25% Tier 2 up
to a maximum of $200 coinsurance per
prescription for a 30-day supply. 45% Tier 3
up to a maximum of $300 coinsurance per
prescription for a 30-day supply

•  Non-network Retail: 50% of cost for a 30-

day supply

•  Network Mail Order: $20 Tier 1. 25% Tier
2 up to a maximum of $300 coinsurance per
prescription for a 90-day supply. 45% Tier 3
up to a maximum of $500 coinsurance per
prescription for a 90-day supply

Each new enrollee will receive a description of our prescription drug
program, a prescription drug/Plan identification card, a mail order form/
patient profile and a pre-addressed reply envelope.

You may purchase the following medications and supplies prescribed
from either a pharmacy or by mail:

•  Drugs and medications, for use at home that are obtainable only upon

a doctor’s prescription and listed in official formularies

•  Drugs and medications (including those administered during a non-

covered admission or in a non-covered facility) that by Federal law of
the United States require a prescription for their purchase, except
those listed as not covered

•  Insulin, Insulin Pump supplies and test strips for known diabetics

•  Disposable needles and syringes for the administration of covered

medications

•  Approved drugs for organic impotence such as Viagra and Levitra are

subject to prior authorization, (see Section 3, Other services and
Section 5(f), Prescription Drug Utilization Management)

•  Drugs that could be used for cosmetic purposes such as Retin A or

Botox (requires prior authorization, see Section 3, Other services and
Section 5(f), Prescription Drug Utilization Management)

•  Drugs to treat gender dysphoria. See Section 5(b), Reconstructive

Surgery, for gender affirming care.

•  FDA-approved drugs for weight management (requires prior

authorization, see Prescription Drug Utilization Management).

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High Option Section 5(f)

Covered medications and supplies - continued on next page

Benefits Description

Covered medications and supplies (cont.)

•  Medications prescribed to treat obesity.

High Option

You pay
After the calendar year deductible…
High Option

•  Network Retail: $10 Tier 1. 25% Tier 2 up
to a maximum of $200 coinsurance per
prescription for a 30-day supply. 45% Tier 3
up to a maximum of $300 coinsurance per
prescription for a 30-day supply

•  Non-network Retail: 50% of cost for a 30-

day supply

•  Network Mail Order: $20 Tier 1. 25% Tier
2 up to a maximum of $300 coinsurance per
prescription for a 90-day supply. 45% Tier 3
up to a maximum of $500 coinsurance per
prescription for a 90-day supply

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-

For a list of Insulins and non-Insulin Diabetes drugs with fixed copays,
go to www.apwuhp.com/members/high-option/pharmacy/

day supply

Note: Standard Plan coinsurance applies to all other covered diabetic
medications and supplies.

Note: Standard dispensing limitations apply (see Section 5(f), Brand/
Generic Drugs).

Diabetic medications and supplies

•  Network Mail Order: $0

•  Oral Generic medications for the specific purpose of lowering blood

sugar

•  Formulary blood glucose test strips and lancets

Specialty Prescription Drugs

•  Specialty drugs must be obtained through Accredo Specialty

Pharmacy. This benefit pertains to specialty drugs administered either
at home or in an outpatient setting.

Note: See Prescription Drug Utilization Management for definition.

Note: If your specialty medication is available through Accredo
Specialty Pharmacy and you do not obtain your medication through
Accredo Specialty Pharmacy, you will be responsible for the full cost of
your medication.

•  Network Retail: 25% Tier 4 with up to a

maximum of $300 per prescription for a 30-
day supply. 25% Tier 5 up to a maximum of
$600 coinsurance per prescription for a 30-
day supply. 45% Tier 6 up to a maximum of
$1,000 coinsurance per prescription for a 30-
day supply

•  Non-network Retail: 50% of cost for a 30-

day supply

•  Network Mail Order: 25% Tier 4 with up

to a maximum of $150 per prescription for a
90-day supply. 25% Tier 5 up to a maximum
of $300 coinsurance per prescription for a
90-day supply. 45% Tier 6 up to a maximum
of $500 coinsurance per prescription for a
90-day supply

Contraceptive drugs and devices as listed on the Health Resources and
Services Administration site www.hrsa.gov/womens-guidelines.

•  Network Retail: $0

•  Network Mail order: $0

Covered medications and supplies - continued on next page

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High Option Section 5(f)

High Option

You pay
After the calendar year deductible…
High Option

•  Network Retail: $0

•  Network Mail order: $0

Network Retail: Nothing

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

Network Mail Order: Nothing

All charges

Benefits Description

Covered medications and supplies (cont.)

Contraceptive coverage is available at no cost to PSHB members. The
contraceptive benefit includes at least one option in each of the HRSA-
supported categories 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.

Over-the-counter and prescription drugs approved by the FDA to prevent
unintended pregnancies.

•  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. Express Scripts
responds to contraception exception requests within 24 hours of
receipt of sufficient information to make a coverage determination.

•  Reimbursement for covered over-the-counter contraceptives can be

submitted in accordance with Section 7.

Note: If you have concerns about the Health Plan’s compliance with the
ACA/HRSA requirements or have difficulty accessing contraceptive
coverage or other reproductive healthcare, contact
contraception@opm.gov. See OPM’s web page about contraception.

Note: For additional Family Planning benefits see Section 5(a)

Note: Over-the-counter and appropriate prescription drugs approved by
the FDA to treat tobacco dependence are covered under the Tobacco
Cessation Educational Classes and Programs in Section 5(a)

Opioid rescue agents such as naloxone are covered under this Plan with
no cost-sharing when obtained from an in-network pharmacy in any
over-the-counter or prescription form available such as nasal sprays and
intramuscular injections.

For more information consult the FDA guidance at
www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-
life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go
to https://www.findtreatment.samhsa.gov/

Not covered:

•  Drugs and supplies for cosmetic purposes

•  Drugs to enhance athletic performance

•  Vitamins, nutrients and food supplements not listed as a covered

benefit even if a doctor prescribes or administers them

•  Medical supplies such as dressings and antiseptics

•  Nonprescription medications/over-the-counter drugs, except as stated

below:

2025 APWU Health Plan

Covered medications and supplies - continued on next page
High Option Section 5(f)

73

Benefits Description

Covered medications and supplies (cont.)

-   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.

Preventive care medications

The following are covered:

•  Medications to promote better health as recommended by ACA.

•  Preventive Medications with USPSTF A and

B recommendations. 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

You pay
After the calendar year deductible…
High Option

All charges

High Option

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

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

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High Option Section 5(f)

High Option

Prescription Drug Utilization Management

• The information below describes a feature of your prescription drug plan known as utilization management. Utilization

management programs help to ensure you are taking safe and effective medications at a reasonable cost.

• Some medications require a prior authorization and are not covered unless you receive approval through a coverage review
(prior authorization). Examples of drug categories that require a coverage review include but are not limited to, growth
hormones, Botox, Interferons, rheumatoid arthritis agents, Retin A, drugs for organic impotence/sexual disorders, FDA
approved drugs for weight management, gender dysphoria and gender transition, blood disorders treatment, pain treatment,
cardiovascular disease, respiratory disease treatment, skin conditions, ophthalmic conditions, neuromuscular, mental/
neurological, renal disease, anti infectives, gastrointestinal and endocrine. This review uses Plan rules based on FDA-
approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and
effective. There are other medications that may be covered with limits (for example, only for a certain amount or for
certain uses) unless you receive approval through a review. During this review, Express Scripts asks your doctor for more
information than what is on the prescription before the medication may be covered under your plan. If coverage is
approved, you simply pay your normal copayment for the medication. If coverage is not approved, you will be responsible
for the full cost of the medication.

• In our ongoing effort to provide a robust yet cost-effective prescription drug benefit, APWU Health Plan participates in
programs to encourage the prescribing and use of generics and lower-cost alternative brands when appropriate.  In most
cases, you save money when the preferred generic or formulary brand is dispensed. Step therapy helps to ensure that your
prescriber considers cost-effective alternatives before prescribing more expensive medications. If you have received one or
more of the less costly alternatives in the past, you will be able to get your medicine at the pharmacy without any delay.
Currently the Plan offers step therapy programs on specialty cholesterol, hypnotic, osteoporosis, migraine, glaucoma,
hypoglycemic, Non Steroidal Anti-Inflammatory (NSAID's), COX-2 Inhibitors, nasal steroids, Proton Pump Inhibitors
(PPI's), oral Tetracyclines, topical acne, topical Corticosteroids, topical Immunomodulator medications, allergies,
respiratory conditions, stimulants, bone conditions, genitourinary conditions, diabetes, endocrine disorders, blood
disorders, cardiovascular disease, inflammatory conditions, depression, metabolic disorders, pain, gastrointestinal
disorders, mental/neurological, electrolyte imbalance, BPH, hypertension, and vitamin deficiency. In situations where your
prescribed drug is targeted and there is no history of a first line agent, a new prescription for a first line agent will need to
be obtained or a coverage review will be necessary for coverage of your medication.  If the coverage review is approved,
the member is responsible for the normal coinsurance found in Section (f), Covered medications and supplies. If the
coverage review is denied, the member is responsible for the full cost of the drug.  If the member does not first obtain the
coverage review (prior authorization) approval, they will pay the full cost of the drug. Coverage reviews can be initiated
by the member, pharmacist, or doctor by calling Express Scripts at 800-841-2734.

• The APWU Health Plan prescription benefit plan will no longer cover prescriptions for certain compound medications.

The U.S. Food and Drug Administration (FDA) defines a compound medication as one that requires a licensed pharmacist
to combine, mix or alter the ingredients of a medication when filling a prescription. The FDA does not verify the quality,
safety and/or effectiveness of compound medications, therefore the Plan will no longer cover certain compounded
prescriptions unless FDA approved. To avoid paying the full cost of these medications, you should ask your doctor for a
new prescription for a manufactured FDA-approved drug before your next fill.

• The Plan will participate in other approved managed care programs to ensure patient safety and appropriate therapy in

accordance with the Plan rules based on FDA guidelines referenced above.

• To find out more about your prescription drug plan, please visit Express Scripts online at www.express-scripts.com or call

Express Scripts Member Services at 800-841-2734.

• “Specialty Drugs” are injectable, infused, oral or inhaled drugs defined as having one or more of several key

characteristics: (1) requires frequent dosing adjustments and intensive clinical monitoring to decrease potential for drug
toxicity and increase probability for beneficial treatment outcomes; (2) need for intensive patient training and compliance
assistance to facilitate therapeutic goals; (3) limited or exclusive product availability and distribution; (4) specialized
product handling and/or administration requirements.

Some examples of the disease categories currently in Express Scripts specialty pharmacy programs include cancer, cystic
fibrosis, Gaucher disease, growth hormone deficiency, hemophilia, immune deficiency, hepatitis C, infertility, multiple
sclerosis and rheumatoid arthritis.

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High Option Section 5(f)

High Option

In addition, a follow-on-biologic or generic product will be considered a Specialty Drug if the innovator drug is a Specialty
Drug.

Many of the Specialty Drugs covered by the Plan fall under the Prescription Drug Utilization Management program
mentioned. Many of the Specialty medications must be obtained through Accredo. You can send your prescription through
your normal mail service process or have your physician fax your prescription to Accredo.

You or your prescriber must contact Accredo at 844-581-4862 to determine if a specialty medication that you are receiving
from the physician's office or outpatient setting must be obtained through Accredo Specialty Pharmacy.  Contact Accredo to
speak to a representative to inquire how your medication can be obtained through Accredo and possibly administered at
home using Accredo nursing services.  If your specialty medication is available through Accredo Specialty Pharmacy and
you do not obtain your medication through Accredo Specialty Pharmacy, you will be responsible for the full cost of the
medication.

• For Medicare Part B insurance coverage. If Medicare Part B is primary, ask about your options for submitting claims
for Medicare-covered medications and supplies, whether you use a Medicare-approved supplier or Express Scripts by
Mail.  Prescriptions typically covered by Medicare Part B include diabetes supplies (test strips and meters), specific
medications used to aid tissue acceptance (such as with organ transplants), certain oral medications used to treat cancer,
and ostomy supplies.

• When you do have to file a claim. Use a Prescription Drug Claim Form to claim benefits for prescription drugs

and supplies purchased from a non-network pharmacy. You may obtain forms by calling 800-222-2798 or from our
website at www.apwuhp.com. Your claim must include receipts that show the prescription number, the National Drug
Code (NDC) number, name of the drug, prescriber's name, date of purchase and charge for the drug. Mail the claim form
and receipt(s) to:

APWU Health Plan
P.O. Box 8660, Elkridge, MD 21075

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High Option

Section 5(f)(a). PDP EGWP Prescription Drug Benefits

Important things you should keep in mind about these benefits:

• These prescription drug benefits are for members enrolled in our Medicare Part D Prescription Drug

Plan (PDP) Employer Group Waiver Plan (EGWP).

• Express Scripts Medicare (PDP) is the administrator for this plan.

• If you are a Postal Service annuitant and their covered Medicare-eligible family member, you will
be automatically group enrolled in our PDP EGWP. Contact Express Scripts Medicare Customer
Service at 844-818-8790 for additional information.

Note: Notify us as soon as possible if you or your eligible family member is already enrolled in a
Medicare Part D Plan. Enrollment in our PDP EGWP will cancel your enrollment in another Medicare
Part D plan.

There are advantages to being enrolled in our PDP EGWP:

• In our PDP EGWP, your cost-share for covered drugs, medications, and supplies will be equal to or
better than the cost-share for those enrolled in our standard non-PDP EGWP Prescription Drug
Program.

• In our PDP EGWP, you have a pharmacy network that may include pharmacies that are out-of-

network or excluded for those enrolled in our standard non-PDP EGWP Prescription Drug Program.

• There is custom coverage which includes coverage for some non-Medicare Part D prescription

drugs. Please contact customer service for additional information.

• Prescriptions purchased at out-of-network pharmacies are only covered in emergency situations.

Out-of-Network Coverage:

You must use Express Scripts Medicare network pharmacies to fill your prescriptions. Covered
Medicare Part D drugs are available at out-of-network pharmacies only in special circumstances, such
as illness while traveling outside of the plan’s service area where there is no network pharmacy. You
generally have to pay the full cost for drugs received at an out-of-network pharmacy at the time you
fill your prescription. You can ask us to reimburse you for our share of the cost. Contact
Express Scripts Medicare Customer Service at 844-818-8790 for additional information.

We cover drugs, medications, and supplies as described below and on the following pages.

• Please remember that all benefits are subject to the definitions, limitations and exclusions in this

brochure and are payable only when we determine they are medically necessary.

• Your prescribers must obtain prior approval/authorizations for certain prescription drugs. Prior

approval/authorizations must be renewed periodically.

• Federal law prevents the pharmacy from accepting unused drugs, medications, and supplies.

• The Medicare Part D calendar year deductible is: $0 per person. This deductible applies to almost all
benefits in this Section. We added “(No deductible)” to show when the calendar year deductible
does not apply.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how
cost-sharing works. Also, read Section 9 for information about how we pay if you have other
coverage.

Warning:  If you opt out of or disenroll from our PDP EGWP, you will not have any PSHB
Program prescription drug coverage. However, you can enroll in our High Option MAPD during
Open Season or for a qualifying life event (QLE) and receive PSHB Program Prescription Drug
Coverage. Call APWU Health Plan at 800-222-2798 for more information.

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High Option

Note: If you choose to opt out of or disenroll from our PDP EGWP, your premium will not be
reduced, and you may have to wait to re-enroll during Open Season or for a QLE. If you do not
maintain creditable coverage, re-enrollment in our PDP EGWP may be subject to a late
enrollment penalty. Call APWU Health Plan at 800-222-2798 for more information.

Each new enrollee will receive a description of our PDP EGWP Summary of Benefits, a combined
prescription drug/Plan identification card, a mail order form/patient profile and a pre-addressed reply
envelope.

There are important features you should be aware of. These include:

• Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/certified providers
with prescriptive authority prescribing within their scope of practice must prescribe your medication. Your prescribers
must have Medicare-approved prescriptive authority.

• Where you can obtain prescription drugs. You may fill prescriptions at any network pharmacy. For assistance locating a

PDP EGWP network pharmacy, visit our website at www.apwuhp.com or call Express Scripts Medicare (PDP) at
844-818-8790.

• We have a managed formulary. Your provider may prescribe drugs that are subject to additional review to determine
they are medically necessary. You may view our formulary on our website at www.apwuhp.com or call Express Scripts
Medicare (PDP) at 844-818-8790.

• These are the dispensing limitations:

-  The Express Scripts Retail Network – you may obtain up to a 90-day supply from participating retail pharmacy.

-  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
some medications may not be available in a 90-day supply from Express Scripts by Mail even though the prescription is
for 90 days.

-  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.

-  Refills cannot be obtained until 70% of the drug has been used.

• We may require Utilization Management strategies:

-  Step Therapy  – A utilization tool that requires you to first try another drug to treat your medical condition, before

coverage of the drug your physician may have initially prescribed is approved.

-  Prior Authorization – A type of plan restriction requiring approval in advance to get certain drugs. Express Scripts may

ask your physician for more information than what is on the prescription before the medication is approved for
coverage.

-  Quantity Limits – A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization

reasons. Limits may be on the amount of the drug covered per prescription or for a defined period of time.

• You may request a Formulary Exception. Call Express Scripts Medicare (PDP) at 844-818-8790.

• A generic equivalent will be dispensed if it is available unless your physician specifically requires a brand name drug.
If you receive a brand name drug when an FDA approved generic drug is available, and your physician has not specified
Dispense as Written for the brand name drug, you have to pay the difference in cost between the brand name drug and the
generic.

• Why use generic drugs. A generic drug is a prescription drug that has the same active ingredients as the brand-name drug.
Generally, generics work just as well as the brand-name drugs and usually cost less. There are generic drug substitutes
available for many brand-name drugs.

• When you do have to file a claim. You may request Express Scripts to pay you back by sending the request in writing. If
you send a request in writing, send your receipt documenting the payment you have made. It’s a good idea to make a copy
of your receipts for your records. You must submit your claim to Express Scripts within 36 months of the date you
received the service, item or drug. To make sure you are giving Express Scripts all the information needed to make a
decision, you can fill out our claim form to make your request for payment.

-  You don’t have to use the form, but it will help us process the information faster.

2025 APWU Health Plan

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High Option Section 5(f)(a)

High Option

-  Either download a copy of the form from our website, express-scripts.com, or call Customer Service and ask for a

“Direct Claim”

-  Mail your request for payment, together with any bills or paid receipts, to us at this address: Express Scripts, Attn:

Medicare Part D, Box 14718, Lexington, KY 40512-4718

-  You also have the option of faxing your claim form and receipts to 1-608-741-5483. Please be sure to contact Express
Scripts Customer Service if you have any questions. If you don’t know what you should have paid, we can help. You
can also call if you want to give us more information about a request for payment you have already sent to us.

• If we deny your claim and you want to appeal, you, your representative, or your prescriber must request an appeal

following the process described in Section 8(a). Medicare PDP EGWP Disputed Claims Process. The PDP EGWP appeals
process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next
level. At each level, you'll get instructions in the decision letter on how to move to the next level of appeal.

PDP EGWP Catastrophic Maximum

You will have a separate $2,000 out-of-pocket maximum for your prescription costs. Once you reach this maximum, you will
no longer pay a cost share for covered drugs. Your portion of this $2,000 will also apply to the Plan’s out-of-pocket
maximum. See Section 4 for details on the out-of-pocket maximum.

Benefits Description

You pay
After the calendar year deductible…

The calendar year deductible applies to almost all benefits in this Section.
We say "(No deductible)" when it does not apply.

Covered medications and supplies

High Option

You may purchase the following medications and supplies prescribed by
a physician from either a pharmacy or by mail:

•  Drugs and medications (including those administered during a non-

covered admission or in a non-covered facility) that by Federal law of
the United States require a physician’s prescription for their purchase,
except those listed as Not covered.

•  Insulin

•  Diabetic supplies limited to:

-   Disposable needles and syringes for the administration of covered

medications

•  Drugs to treat gender dysphoria. The Plan covers medications used for

gender affirming care, including anti-androgens, estrogens, and
testosterone.

•  Medications prescribed to treat obesity. See Section 5(h), Wellness

and Other Special Features

•  Medical Foods (medical foods are excluded from coverage, see

Section 5(a), Treatment Therapies)

•  Sexual dysfunction drugs. Select erectile dysfunction and sexual

desire disorder drugs are covered under the plan with quantity limits
in place. Please contact customer service for more information.

•  Select fertility drugs are covered under the plan. Please contact

customer service for more information.

Diabetes medications and supplies

•  Certain Insulins and non-Insulin Diabetes drugs to treat diabetes

Retail:

•  Up to 30-day supply: Tier 1 - $10. Tier 2 -
25% of Plan allowance up to a maximum of
$200 per prescription for a 30-day supply.
Tier 3 - 25% of Plan allowance up to a
maximum of $300 per prescription for a 30-
day supply. Tier 4 - 25% of Plan allowance
up to a maximum of $300 per prescription
for a 30-day supply.

•  Up to 90-day supply: Tier 1 - $20. Tier 2 -
25% of Plan allowance up to a maximum of
$300 per prescription for a 90-day supply.
Tier 3 - 25% of Plan allowance up to a
maximum of $500 per prescription for a 90-
day supply. Tier 4 - 25% of Plan allowance
up to a maximum of $300 per prescription
for a 90-day supply.

Mail Order:

•  Up to a 90-day supply: Tier 1 - $20. Tier 2 -
25% of Plan allowance up to a maximum of
$300 per prescription. Tier 3 - 25% of Plan
allowance up to a maximum of $500 per
prescription. Tier 4 - 25% up to a maximum
of $150 per prescription.

Network Retail: $25 copay for a 30-day
supply

•  For a list of Insulins and non-Insulin Diabetes drugs with fixed

copays, go to https://apwuhp.com/members/high-option/pharmacy/

Network Mail Order: $75 copay for a 90-day
supply

•  All other insulin:

2025 APWU Health Plan

Covered medications and supplies - continued on next page
High Option Section 5(f)(a)

79

High Option

Benefits Description

Covered medications and supplies (cont.)

You pay
After the calendar year deductible…
High Option

-   You pay: $35 for a 30-day supply and $105 for a 90-day supply

-   You won’t pay more than $35 for a one-month supply of each

Network Retail: $25 copay for a 30-day
supply

insulin product covered by our plan.

Note: Standard Plan coinsurance applies to all other covered diabetic
medications and supplies.

Note: Standard dispensing limitations apply (see Section 5(f), Brand/
Generic Drugs).

Network Mail Order: $75 copay for a 90-day
supply

Diabetic medications and supplies

Network Mail Order: $0

•  Oral Generic medications for the specific purpose of lowering blood

sugar

•  Formulary blood glucose test strips and lancets

Contraceptive drugs and devices as listed in the Health Resources and
Services Administration site https://www.hrsa.gov/womens-guidelines.

Nothing

Contraceptive coverage is available at no cost to PSHB members. The
contraceptive benefit includes at least one option in each of the HRSA-
supported categories 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.

•  Over-the-counter and prescription drugs approved by the FDA to

prevent unintended pregnancies.

•  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. Express Scripts
responds to contraception exception requests within 24 hours of
receipt of sufficient information to make a coverage determination.

•  Reimbursement for covered over-the-counter contraceptives can be

submitted in accordance with Section 7.

Note: If you have concerns about the Health Plan’s compliance with the
ACA/HRSA requirements or have difficulty accessing contraceptive
coverage or other reproductive healthcare, contact
contraception@opm.gov. See OPM’s web page about contraception.

Note: For additional Family Planning benefits see Section 5(a)

Note: Over-the-counter and appropriate prescription drugs approved by
the FDA to treat tobacco dependence are covered under the Tobacco
Cessation Educational Classes and Programs in Section 5(a).

Covered medications and supplies - continued on next page

2025 APWU Health Plan

80

High Option Section 5(f)(a)

Benefits Description

Covered medications and supplies (cont.)

Not covered

•  Drugs and supplies for cosmetic purposes

•  Drugs to enhance athletic performance

•  Drugs obtained at a non-Plan pharmacy; except for out-of-area

emergencies

•  Nonprescription medications medicines

Preventive medications

The following are covered:

•  Preventive Medications with USPSTF A and B recommendations.

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

You pay
After the calendar year deductible…
High Option

All charges

High Option

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

Opioid rescue agents such as naloxone are covered under this Plan with
no cost sharing when obtained from a network pharmacy in any over-
the-counter or prescription form available such as nasal sprays and
intramuscular injections.

Nothing

For more information consult the FDA guidance at
www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-
life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to
https://www.findtreatment.samhsa.gov/.

Not covered:

•  Drugs and supplies for cosmetic purposes

•  Nonprescription medications

All charges

2025 APWU Health Plan

81

High Option Section 5(f)(a)

High Option

Section 5(g). Dental Benefits

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

• If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental

Plan, your PSHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan
is secondary to your PSHB Plan. See Section 9, Coordinating Benefits with Medicare and Other
Coverage.

• The calendar year deductible is: PPO - $450 per person ($800 per Self Plus One enrollment, or $800

per Self and Family enrollment); Non-PPO - $1,000 per person ($2,000 per Self Plus One
enrollment, or $2,000 per Self and Family enrollment). The calendar year deductible applies to
almost all benefits in this Section. We added “(No deductible)” to show when the calendar year
deductible does not apply.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how
cost-sharing works. Also read Section 9, for information about how we pay if you have other
coverage, or if you are age 65 or over.

Note: We cover hospitalization and anesthesia for dental procedures only when a non-dental physical
impairment exists which makes hospitalization necessary to safeguard the health of the patient. We do
not cover the dental procedure, (see Section 5(c), Inpatient hospital benefits).

Accidental injury benefit

Accidental injury benefit

We cover restorative services and supplies necessary to repair (but not
replace) sound natural teeth. The need for these services must result
from an accidental injury (a blow or fall) and must be performed within
two years of the accident (see also Section 5(d), Accidental injury).

Dental benefits service

•  Office visits (routine limited to 2 visits per year)

•  Restorative care (fillings)

•  X-rays of all types (limited to 2 per year)

•  Prophylaxis (cleanings), (limited to 2 per year)

•  Simple extractions

Note: Office visits include examinations and fluoride treatment.

Note: Restorative care does not include crowns or in-lay/on-lay
restoration.

Note: General anesthetics not covered unless due to an underlying
medical condition.

You pay
High Option

Within 72 hours of accident:

PPO: Nothing (No deductible)

Non-PPO: Only the difference between our
allowance and the billed amount (No
deductible)

More than 72 hours after accident:

PPO: 15% of the Plan allowance

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount

High Option

30% of the Plan allowance and any difference
between our allowance and the billed amount
(No deductible)

Note: No in-network dental providers; choose
any provider.

2025 APWU Health Plan

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High Option Section 5(g)

Section 5(h). Wellness and Other Special Features

High Option

Special Feature

Flexible benefits option

Description

Under the flexible benefits option, we determine the most effective way to provide
services.

•  We may identify medically appropriate alternatives to regular contract benefits as a

less costly alternative. If we identify a less costly alternative, we will ask you to sign
an alternative benefits agreement that will include all of the following terms in
addition to other terms as necessary. Until you sign and return the agreement, regular
contract benefits will continue.

•  Alternative benefits will be made available for a limited time period and are subject to

our ongoing review. You must cooperate with the review process.

•  By approving an alternative benefit, we do not guarantee you will get it in the future.

•  The decision to offer an alternative benefit is solely ours, and except as expressly
provided in the agreement, we may withdraw it at any time and resume regular
contract benefits.

•  If you sign the agreement, we will provide the agreed-upon alternative benefits for the
stated time period (unless circumstances change). You may request an extension of the
time period, but regular contract benefits will resume if we do not approve your
request.

•  Our decision to offer or withdraw alternative benefits is not subject to OPM review
under the disputed claims process.  However, if at the time we make a decision
regarding alternative benefits, we also decide that regular contract benefits are not
payable, then you may dispute our regular contract benefits under the OPM disputed
claims process (see Section 8, The Disputed Claims Process).

24-hour NurseLine

We offer a 24-hour nurse advisory service for your use. This program is strictly voluntary
and confidential. You may call toll-free at 866-569-2064 and reach registered nurses to
discuss an existing medical concern or to receive information about numerous healthcare
issues.

High Risk Maternity

Members can enroll in our maternity support program and Maven (virtual program) which
provide support in every stage of pregnancy, including self measured blood pressure
monitoring and support.

Services for deaf and
hearing impaired

We offer a toll-free TDD line for customer service. The number is 800-622-2511. TDD
equipment is required.

Disease Management
Program

A voluntary program that provides a variety of services to help you manage a chronic
condition with outpatient treatment and avoid unnecessary emergency care or inpatient
admissions. As an example, members with cardiac conditions can participate in this
program. We use medical and/or pharmacy claims data as well as interactions with you
and your physician(s). If you have a chronic condition and would like additional
information, call UnitedHealthcare at 866-569-2064.

Review and Reward
Program

If you send us a corrected hospital billing, we will credit 20% of any hospital charge over
$20 for covered services and supplies that were not actually provided to a covered person.
The maximum amount payable under this program is $100 per person per calendar year.

Weight Management

$0 copay for in-network office visits to a registered Dietician/Nutritionist

Special Programs

Online programs and services provide extra support and savings, visit www.apwuhp.
com or call 866-569-2064 for more information.

•  Pregnancy Support Program - Enroll in this program and you take the first step

toward giving your baby a healthy start in life.

2025 APWU Health Plan

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High Option Section 5(h)

High Option

•  Maven - Mothers-to-be receive online support through every stage of pregnancy and

delivery.

•  Cancer Support Program - Enroll in the program and receive enhanced benefits at

Cancer Centers of Excellence.

•  Kidney Resources Program - For those diagnosed with end-stage renal disease or
those who are currently receiving dialysis treatment, this program will help you.
•  One Pass Select TM – visit www.WeRally.com or call 877-515-9364 to sign up for
One Pass, a gym membership discount program offering access to national gym
memberships, online fitness classes and Grocery Delivery service.

•  UnitedHealthcare Hearing- Call 855-523-9355 or visit www.UHCHearing.com for

hearing aids, care options and dedicated support.

•  Alternative medicine - find discounts for acupuncture, chiropractor, and massage.

Online tools and
resources

Online tools are available at www.myAPWUHP.com:

•  www.myAPWUHP.com - online information for member services and claims to view

claims and find year-to-date information with claim details

Health Risk Assessment
(HRA)

A Health Risk Assessment (HRA) is available at Welcome to Rally! (www.werally.
com) and via your Member Portal at www.myAPWUHP.com. The HRA is an online
program that analyzes your health related responses and gives you a personalized plan to
achieve specific health goals. Your HRA profile provides information to put you on a path
to good physical and mental health.

Consumer choice
information

Access to our website (www.apwuhp.com) is provided to support your important health
and wellness decisions, including:

•  Online Preferred 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

2025 APWU Health Plan

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High Option Section 5(h)

Consumer Driven Option Benefits Table of Contents

See page 173 for a benefits summary of the Consumer Driven Option.
Consumer Driven Health Plan Overview ....................................................................................................................................87
Section 5. In-Network Preventive Care ......................................................................................................................................88
Preventive care, adult ........................................................................................................................................................88
Preventive care, children ...................................................................................................................................................90
Section 5. Personal Care Account (PCA) ....................................................................................................................................92
Personal Care Account (PCA) ...........................................................................................................................................92
Section 5. Traditional Health Coverage Overview .....................................................................................................................95
Deductible before Traditional Health Coverage begins ....................................................................................................95
Section 5(a). Medical Services and SuppliesProvided by Physicians and Other Healthcare Professionals ...............................97
Diagnostic and treatment services .....................................................................................................................................97
TeleHealth services ...........................................................................................................................................................98
Lab, X-ray and other diagnostic tests ................................................................................................................................98
Maternity care ...................................................................................................................................................................98
Family planning ..............................................................................................................................................................100
Infertility services ...........................................................................................................................................................101
Allergy care .....................................................................................................................................................................101
Treatment therapies .........................................................................................................................................................102
Physical and occupational therapies ...............................................................................................................................102
Applied behavioral analysis (ABA) ................................................................................................................................103
Speech therapy ................................................................................................................................................................103
Hearing services (testing, treatment, and supplies) .........................................................................................................103
Vision services (testing, treatment, and supplies) ...........................................................................................................103
Foot care ..........................................................................................................................................................................104
Orthopedic and prosthetic devices ..................................................................................................................................104
Durable medical equipment (DME) ................................................................................................................................105
Home health services ......................................................................................................................................................106
Chiropractic .....................................................................................................................................................................106
Alternative treatments .....................................................................................................................................................106
Educational classes and programs ...................................................................................................................................107
Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals ........................108
Surgical Procedures .........................................................................................................................................................108
Reconstructive Surgery ...................................................................................................................................................110
Oral and Maxillofacial Surgery .......................................................................................................................................111
Organ/Tissue Transplants ................................................................................................................................................112
Anesthesia .......................................................................................................................................................................115
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services .....................................................116
Inpatient hospital .............................................................................................................................................................116
Cancer Centers of Excellence .........................................................................................................................................117
Outpatient hospital or ambulatory surgical center ..........................................................................................................118
Extended care benefits/Skilled nursing care facility benefits .........................................................................................118
Hospice care ....................................................................................................................................................................119
End of life care ................................................................................................................................................................119
Ambulance ......................................................................................................................................................................119
Section 5(d). Emergency Services-Accidents ...........................................................................................................................120
Accidental injury .............................................................................................................................................................121

2025 APWU Health Plan

85

CDHP Section 5

Medical emergency .........................................................................................................................................................121
Ambulance ......................................................................................................................................................................121
Air ambulance .................................................................................................................................................................121
Section 5(e). Mental Health and Substance Use Disorder Benefits ..........................................................................................122
Professional services .......................................................................................................................................................122
TeleHealth services .........................................................................................................................................................123
Diagnostics ......................................................................................................................................................................123
Inpatient hospital or other covered facility .....................................................................................................................124
Outpatient hospital or other covered facility ...................................................................................................................124
Section 5(f). Prescription Drug Benefits ...................................................................................................................................125
Covered medications and supplies ..................................................................................................................................126
Preventive medications ...................................................................................................................................................128
Section 5(f)(a). PDP EGWP Prescription Drug Benefits ..........................................................................................................131
Section 5(g). Dental Benefits ....................................................................................................................................................137
Dental benefits ................................................................................................................................................................137
Section 5(h). Wellness and Other Special Features ...................................................................................................................138
Flexible benefits option ...................................................................................................................................................138
Section 5(i). Health Education Resources and Account Management Tools ............................................................................139
Special Features ..............................................................................................................................................................139
Summary of Benefits for the Consumer Driven Option Plan - 2025 ........................................................................................173

2025 APWU Health Plan

86

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
Preventive Care benefit that includes a broad range of preventive services, preventive tests and screenings, counseling
services, and contraceptives, including prescription drug contraceptives.

Personal Care Account (PCA)

The Plan also provides a Personal Care Account (PCA) for each enrollment. Each year, the Plan provides $1,200 for a Self
Only enrollment or $2,400 for a Self Plus One or Self and Family enrollment. The PCA covers 100% for your covered
medical expenses, which include dental and vision care.  If you have an unused PCA balance at the end of the year, you can
rollover that balance so you can use it in the future. The Personal Care Account is described in Section 5, Personal Care
Account (PCA).

Note that the in-network Preventive Care benefits paid under Section 5 do NOT count against your Personal Care Account
(PCA).

Traditional Health Coverage

After you have used up your Personal Care Account (PCA) and paid your Net Deductible, the Plan starts paying benefits
under the Traditional Health Coverage described in Section 5, Traditional Health Coverage. The Plan generally pays 85% of
the cost for in-network care and 50% of the Plan allowance for out-of-network care.

Covered services include:

• Medical services and supplies, Section 5(a)

• Surgical and anesthesia services, Section 5(b)

• Hospital services, other facilities and ambulance, Section 5(c)

• Emergency services/Accidents, Section 5(d)

• Mental health and substance use disorder treatment benefits, Section 5(e)

• Prescription drug benefits, Section 5(f)

Health Education Resources and Account Management Tools

Section 5(i) describes the health tools and resources available to you under the Consumer Driven Option to help you improve
the quality of your healthcare and manage your expenses. You can receive a $25 wellness incentive when you complete an
annual physical, mammogram or cervical screening with a clinical professional each year.

2025 APWU Health Plan

87

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.

• Preventive care performed using out-of-network providers are paid using your PCA while funds are

available. Once your PCA is exhausted, member pays all charges.

• For preventive care not listed in this Section or for preventive care from a non-network provider,

please see CDHP Section 5, Personal Care Account (PCA).

• For all other covered expenses, please see CDHP Section 5, Personal Care Account

(PCA) and Traditional Health Coverage.

• Note that the in-network Preventive Care paid under this Section does NOT count against or use up

your Personal Care Account (PCA).

• Please remember that all benefits are subject to the definitions, limitations and exclusions in this

brochure and are payable only when we determine they are medically necessary.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how
cost-sharing works.  Also read Section 9 for information about how we pay if you have other
coverage, or if you are age 65 or over.

• Receive $25 each when you complete an annual physical, mammogram or cervical screening with a

clinical professional each year, see Section 5(i) for details.

Benefit Description

You pay

Note: There is no calendar year deductible for in-network preventive care under the Consumer Driven Option.

Preventive care, adult

Consumer Driven Option

Routine physical every calendar year.

In-network: Nothing

The following preventive services are covered at the time interval
recommended at each of the links below:

Out-of-network: All charges after PCA is
exhausted

•  Receive $25 each when you complete an annual

physical, mammogram or cervical screening with a clinical
professional each year (see Section 5(i) for details)

•  U.S. Preventive Services Task Force (USPSTF) A and B

recommended screenings such as cancer, osteoporosis, depression,
diabetes, high blood pressure, total blood cholesterol, HIV, and
colorectal cancer.  Preventive medications with a USPSTF
recommendation of A or B are covered without cost-share when
prescribed by a healthcare professional and filled by a network
pharmacy.  For a complete list of screenings go to the website
at: www.uspreventiveservicestaskforce.org/uspstf/recommendation-
topics/uspstf-a-and-b-recommendations

•  Individual counseling on prevention and reducing health risks

•  Well woman care 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 Well
Women preventive care services go to the Health and Human Services
(HHS) website at www.hrsa.gov/womens-guidelines.

•  Routine Prostate Specific Antigen (PSA) test, one annually for men

age 40 and older

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88

CDHP Section 5 In-Network Preventive Care

Preventive care, adult - continued on next page

CDHP

You pay
Consumer Driven Option

In-network: Nothing

Out-of-network: All charges after PCA is
exhausted

Benefit Description

Preventive care, adult (cont.)

•  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

•  Adult Immunizations endorsed by the Centers for Disease Control and

Prevention (CDC): based on the Advisory Committee on
Immunization Practices (ACIP) schedule. For a complete list of
endorsed immunizations go to the Centers for Disease Control (CDC)
website at https://www.cdc.gov/vaccines/schedules/

•  To build your personalized list of preventive services go to

https://health.gov/myhealthfinder

Note: Any procedure, injection, diagnostic service, laboratory, or x-ray
service done in conjunction with a routine examination and is not
included in the preventive recommended listing of services will be
subject to the applicable member copayments, coinsurance, and
deductible.

•  Routine mammogram - covered for women, including 3D

In-network: Nothing

Out-of-network: All charges after PCA is
exhausted

In-network: Nothing

Out-of-network: All charges after PCA is
exhausted

mammograms covered for women age 35 and older; as follows:

-   From age 35 through 39, one during this five year period

-   From age 40, one every calendar year

•  To build your personalized list of preventive services go to

https://health.gov/myhealthfinder

Obesity counseling, screening and referral for those persons at or above
the USPSTF obesity prevention risk factor level, to intensive nutrition
and behavioral weight-loss therapy, counseling, or family-centered
programs under the USPSTF A and B recommendations are covered as
part of prevention and treatment of obesity as follows:

•  Intensive nutrition and behavioral weight-loss counseling therapy:

-   Unlimited preventive medical nutrition therapy (assessment and

intervention)

-   Unlimited preventive medical counseling for the purpose of

promoting health and preventing illness

-   Unlimited visits to a registered dieticians/nutritionist

•  Family-centered programs when medically identified to support
obesity prevention and management by an in-network provider:

-   Unlimited preventive medical counseling group (including family

counseling)

•  When anti-obesity medication is prescribed as indicated by the FDA
obesity medication treatment guidelines. See Sections 5(f) or 5(f)(a)
for cost share requirements for anti-obesity medications.

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CDHP Section 5 In-Network Preventive Care

Preventive care, adult - continued on next page

CDHP

Preventive care, adult (cont.)

Benefit Description

You pay
Consumer Driven Option

•  When Bariatric or Metabolic surgical treatment or intervention is

In-network: Nothing

indicated for severe obesity. See Section 5(b) for surgery requirements
and cost share. For coverage policy, visit www.apwuhp.com and click
on Member Resources.

Out-of-network: All charges after PCA is
exhausted

Obesity screening and referral, for those persons below the USPSTF
obesity prevention risk factor level, see Section 5(h) for Weight
Management and Special Programs.

Not covered:

All charges

•  Adult immunizations not endorsed by the Centers for Disease Control

and Prevention (CDC): based on the Advisory Committee on
Immunization Practices (ACIP) schedule.

•  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.

Preventive care, children

Consumer Driven Option

•  Well-child visits examinations, and other preventive services as

In-network: Nothing

Out-of-network: All charges after PCA is
exhausted

described in the Bright Future Guidelines provided by the American
Academy of Pediatrics. For a complete list of the American Academy
of Pediatrics Bright Futures Guidelines go to www.brightfutures.aap.
org

•  Children’s immunizations endorsed by the Centers for Disease

Control (CDC) including DTaP/Tdap, Polio, Measles, Mumps, and
Rubella (MMR), and Varicella. For a complete list of immunizations
go to the Centers for Disease Control (CDC) website at
https://www.cdc.gov/vaccines/schedules/index.html

You may also find a complete list of U.S. Preventive Services Task
Force (USPSTF) A and B recommendations online at
www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/
uspstf-a-and-b-recommendations

•  Examinations, limited to:

In-network: Nothing

Out-of-network: All charges after PCA is
exhausted

-   Examinations for amblyopia and strabismus - limited to one

screening examination (ages 3 through 5)

-   Examinations done on the day of immunizations (ages 3 through

21)

-   One Screening Examination of Premature Infants for Retinopathy

of Prematurity or infants with low birth weight or gestational age of
32 weeks or less

•  To build your personalized list of preventive services go to

https://health.gov/myhealthfinder

Note: In-network facility and lab services directly related to covered, in-
network preventive care will also be covered at 100%.

Preventive care, children - continued on next page

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CDHP Section 5 In-Network Preventive Care

CDHP

You pay
Consumer Driven Option

In-network: Nothing

Out-of-network: All charges after PCA is
exhausted

In-network: Nothing

Out-of-network: All charges after PCA is
exhausted

Preventive care, children (cont.)

Benefit Description

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray
service done in conjunction with a routine examination and is not
included in the preventive recommended listing of services will be
subject to the applicable member copayments, coinsurance, and
deductible.

Obesity counseling, screening and referral for those persons at or above
the USPSTF obesity prevention risk factor level, to intensive nutrition
and behavioral weight-loss therapy, counseling, or family-centered
programs under the USPSTF A and B recommendations are covered as
part of prevention and treatment of obesity as follows:

•  Intensive nutrition and behavioral weight-loss counseling therapy:

-   Unlimited preventive medical nutrition therapy (assessment and

intervention)

-   Unlimited preventive medical counseling for the purpose of

promoting health and preventing illness

-   Unlimited visits to a registered dieticians/nutritionist

•  Family-centered programs when medically identified to support
obesity prevention and management by an in-network provider:

-   Unlimited preventive medical counseling group (including family

counseling)

•  When anti-obesity medication is prescribed as indicated by the FDA
obesity medication treatment guidelines. See Section 5(f) for cost
share requirements for anti-obesity medications.

•  When Bariatric or Metabolic surgical treatment or intervention is

indicated for severe obesity. See Section 5(b) for surgery requirements
and cost share. For coverage policy, visit www.apwuhp.com and click
on Member Resources.

Obesity screening and referral, for those persons below the USPSTF
obesity prevention risk factor level, see Section 5(h) for Weight
Management and Special Programs.

Not covered:

All charges

•  Adult immunizations not endorsed by the Centers for Disease Control

(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

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CDHP Section 5 In-Network Preventive Care

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.

• Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable

only when we determine they are medically necessary.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also

read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.

• YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A
MINIMUM $500 PENALTY. Please refer to the precertification information shown in Section 3 to confirm which
services require precertification.

• Members can turn off the PCA for medical claims only via www.myuhc.com. Medical claims must then be submitted

manually to UnitedHealthcare. Pharmacy claims will continue to pay from the PCA.

Benefits Description

You pay

There is no calendar year deductible for in-network preventive care under the Consumer Driven Option
Consumer Driven Option

Personal Care Account (PCA)

A Personal Care Account (PCA) is provided by the Plan for each
enrollment. Each year the Plan adds to your account:

•  $1,200 per year for a Self Only enrollment or

•  $2,400 per year for a Self Plus One or Self and Family enrollment

The Personal Care Account covers eligible expenses at 100%. For
example, if you are ill and go to a network doctor, the doctor will submit
your claim and the provider's contracted rate for the visit will be
deducted automatically from your PCA; you pay nothing.

In-network and Out-of-network: Nothing up to
$1,200 for a Self Only enrollment or $2,400 for
a Self Plus One or Self and Family enrollment

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Section 5. Personal Care Account (PCA)

Personal Care Account (PCA) - continued on next page

Personal Care Account (PCA) (cont.)

Benefits Description

You pay
Consumer Driven Option

     Balance in PCA for Self Only                        $1,200
     Less provider contracted rate for visit               -$60
     Remaining Balance in PCA                           $1,140

In-network and Out-of-network: Nothing up to
$1,200 for a Self Only enrollment or $2,400 for
a Self Plus One or Self and Family enrollment

CDHP

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

-   Medicare Part B premium reimbursement – Retirees that participate
with Medicare Part B may request reimbursement for their Part B
premiums, if PCA funds are available. For reimbursement,
members should visit www.MYUHC.com to download a Health
Reimbursement Account (HRA) form or to sign in to upload your
documents for reimbursement.

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

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93

Section 5. Personal Care Account (PCA)

CDHP

You pay
Consumer Driven Option

All charges

Personal Care Account (PCA) (cont.)

Benefits Description

Not covered:

•  Orthodontia

•  Dental treatment for cosmetic purposes including teeth whitening

•  Out-of-network preventive care services not included under CDHP

Section 5

•  Services or supplies shown as not covered under Traditional Health
Coverage (see CDHP Section 5) and not included under Extra PCA
Expenses above

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.

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Section 5. Personal Care Account (PCA)

CDHP

Section 5. Traditional Health Coverage Overview

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable

only when we determine they are medically necessary.

• In-network Preventive Care is covered at 100% under CDHP Section 5 and does not count against your Personal

Care Account.

• Your Personal Care Account must be used first for eligible healthcare expenses.

• If your Personal Care Account has been exhausted, you must pay your Net Deductible before your Traditional Health

Coverage may begin. Your Deductible applies to all benefits in this section.

• The Consumer Driven Option provides coverage for both in-network and out-of-network providers. The out-of-network
benefits are the standard benefits under the Traditional Health Coverage. In-network benefits apply only when you use a
provider from the large, national network. When a network provider is not available, out-of-network benefits apply.

• If you join at any time during the year other than Open Season, your Deductible for your first year will be prorated at a rate
of: in-network $83.33 per month for Self Only, $166.67 per month for Self Plus One or Self and Family; or out-of-network
$125.00 per month for Self Only or $250.00 per month for Self Plus One or Self and Family for each full month of
coverage remaining in that calendar year.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also,

read Section 9 for information about how we pay if you have other coverage, or if you are age 65 or over.

• YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A
MINIMUM $500 PENALTY. Please refer to the precertification information shown in Section 3 to confirm which
services require precertification.

Deductible before Traditional Health Coverage begins

Benefit Description

You Pay
Consumer Driven Option

In-network:  $1,000 per Self Only enrollment,
$2,000 for Self Plus One enrollment or $2,000
per Self and Family enrollment

Out-of-network:  $1,500 per Self Only
enrollment, $3,000 for Self Plus One and
$3,000 for Self and Family enrollment

If your Personal Care Account has been exhausted, you are responsible
to pay your Deductible before your Traditional Health Coverage begins.

Traditional Health Coverage benefits begin for in-network after covered
eligible expenses (deductible) total $2,200 for Self Only, $4,400 for Self
Plus One or $4,400 for Self and Family (the combination of eligible
expenses paid out of your PCA and your Net Deductible) each calendar
year.  For out-of-network, covered benefits begin after covered eligible
expenses total $2,700 for Self Only, $5,400 for Self Plus One and $5,400
for Self and Family.

Note:  You must use any available PCA benefits, including any amounts
rolled over from previous years, before Traditional Health Coverage
begins.

In year one, therefore, the Net Deductible is $1,000 for Self Only,
$2,000 for Self Plus One and $2,000 for Self and Family enrollment.

Type of Plan

Deductible before Traditional Health Coverage begins - continued on next page

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Section 5. Traditional Health Coverage Overview

CDHP

You Pay
Consumer Driven Option

In-network:  $1,000 per Self Only enrollment,
$2,000 for Self Plus One enrollment or $2,000
per Self and Family enrollment

Out-of-network:  $1,500 per Self Only
enrollment, $3,000 for Self Plus One and
$3,000 for Self and Family enrollment

Benefit Description

Deductible before Traditional Health Coverage begins
(cont.)

In-Network Deductible
Self Only: $2,200 Deductible ($1,200 PCA + $1,000 Net Deductible)
Self Plus One:  $4,400 Deductible ($2,400 PCA + $2,000 Net
Deductible)
Self and Family: $4,400 Deductible ($2,400 PCA + $2,000 Net
Deductible

Out-of-Network Deductible
Self Only: $2,700 Deductible ($1,200 PCA + $1,500 Net Deductible)
Self Plus One:  $5,400 Deductible ($2,400 PCA + $3,000 Net
Deductible)
Self and Family: $5,400 Deductible ($2,400 PCA + $3,000 Net
Deductible)

Basic PCA Expenses paid by PCA
Self Only: $1,200
Self Plus One: $2,400
Self and Family: $2,400

Deductible paid by you
Self Only: In-network $1,000; Out-of-network $1,500
Self Plus One: In-network $2,000; Out-of-network $3,000
Self and Family: In-network $2,000; Out-of-network $3,000

Traditional Health Coverage starts after
Self Only: In-network $2,200; Out-of-network $2,700
Self Plus One: In-network $4,400; Out-of-network $5,400
Self and Family: In-network $4,400; Out-of-network $5,400

Any PCA dollars that you rollover at the end of the year will reduce your
Deductible next year.  In future years, the amount of your Deductible
may be lower if you rollover PCA dollars at the end of the year.  For
example, if you rollover $300 at the end of the year:

PCA for year 2 Rollover from year 1
Self Only:  $1,200 + $300 $1,500
Self Plus One: $2,400+ $300 $2,700
Self Self and Family:  $2,400+ $300 $2,700

Net Deductible paid by you
Self Only: In-network + $700 Out-of-network + $1,200
Self Plus One: In-network + $700 Out-of-network + $2,700
In-network + $700 Out-of-network + $2,700

Traditional Health Coverage starts when eligible expenses total
Self Only:  In-network $2,200 Out-of-network  $2,700
Self Plus One:  In-network $4,400 Out-of-network  $5,400
Self and Family:  In-network $4,400 Out-of-network $5,400

If you decide to use your PCA for Extra PCA Expenses for other than
covered dental and/or vision services, you may increase your
Deductible.  For example, if you have out-of-network preventive care
for $150 and later an accident that leads to a hospital stay, you will have
to pay your Deductible plus "make up" the $150 dollars you spent on
Extra PCA Expenses.

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Section 5. Traditional Health Coverage Overview

CDHP

Section 5(a). Medical Services and Supplies
Provided by Physicians and Other Healthcare Professionals

Important things to keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations and exclusions in this

brochure and are payable only when we determine they are medically necessary.

• In-network Preventive Care is covered at 100% under CDHP Section 5 and does not count against

your Personal Care Account.

• Your Personal Care Account must be used first for eligible healthcare expenses.

• If your Personal Care Account has been exhausted, you must pay your Net Deductible before your
Traditional Health Coverage may begin. Your Deductible applies to all benefits in this section.

• The Consumer Driven Option provides coverage for both in-network and out-of-network providers.
The out-of-network benefits are the standard benefits under the Traditional Health Coverage. In-
network benefits apply only when you use a provider from the large, national network. When a
network provider is not available, out-of-network benefits apply.

• If you join at any time during the year other than Open Season, your Deductible for your first year

will be prorated at a rate of:  In-network $83.33 per month for Self Only, $166.67 per month for Self
Plus One or Self and Family; or out-of-network $125.00 per month for Self Only or $250.00 per
month for Self Plus One or Self and Family, for each full month of coverage remaining in that
calendar year.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how

cost-sharing works.  Also read Section 9 for information about how we pay if you have
other coverage, or if you are age 65 or over.

• YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO

WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification
information shown in Section 3 to confirm which services require precertification.

• 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

Diagnostic and treatment services

Professional services of physicians

•  In physician's office *

•  Medical consultations in the office

•  At home

•  In an urgent care center

•  During a hospital stay

•  In a skilled nursing facility

•  Second surgical opinion

Consumer Driven Option

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
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.

•  At a Cancer Center of Excellence

In-network Cancer Center of Excellence
(COE):  10% of the Plan allowance

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CDHP Section 5(a)

Diagnostic and treatment services - continued on next page

CDHP

 Benefit Description

You pay

Diagnostic and treatment services (cont.)

Consumer Driven Option

Note: To receive the higher level of benefits for cancer related treatment,
you are required to visit a designated Cancer Center of Excellence
facility.

In-network Cancer Center of Excellence
(COE):  10% of the Plan allowance

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:

•  Blood tests

•  Urinalysis

•  Non-routine mammogram, including 3D mammogram

•  Pathology

•  X-ray

•  Non-routine Pap test

•  CT/CAT Scans/MRI/MRA/NC/PET

•  Ultrasound

•  Electrocardiogram and EEG

In-network:  15% of the Plan allowance

Out-of-network:  50% of the Plan allowance
and any difference between our allowance and
the billed amount

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.

Not covered:

All charges

•  Professional fees for automated lab tests

•  Genetic screening (see Definitions, Section 10)

•  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

•  Prenatal and postpartum care

•  Delivery

•  Initial examination of a newborn child covered under a Self Plus One

or Self and Family enrollment

•  Breastfeeding and lactation support, supplies and counseling for each

birth

•  Screening and counseling for prenatal and postpartum depression

Out-of-network:  50% of the Plan allowance
and any difference between our allowance and
the billed amount

Note:  For inpatient hospital care related to
maternity, we pay for covered services in full
when you use preferred providers.

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Maternity care - continued on next page
CDHP Section 5(a)

 Benefit Description

You pay

Maternity care (cont.)

Consumer Driven Option

 Note - Here are some things to keep in mind:

In-network:  Nothing

CDHP

Out-of-network:  50% of the Plan allowance
and any difference between our allowance and
the billed amount

Note:  For inpatient hospital care related to
maternity, we pay for covered services in full
when you use preferred providers.

Note:  In-network facility and lab services
directly related to covered, in-network
maternity care will also be covered at 100%.

•  You do not need to precertify your vaginal or cesarean delivery; see
Section 3 for other circumstances, such as extended stays for you or
your baby.

•  As part of your coverage you have access to in-network certified
nurse midwives, home nurse visits and board-certified lactation
specialists during the prenatal and post-partum period.

•  Doula virtual coverage through Maven (a free wellness program). See

Section 5(i).

•  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 will cover other
care of an infant who requires non-routine treatment only if we cover
the infant under a Self Plus One or Self and Family enrollment.

•  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 are covered under Section 5(b).

Note: When a newborn requires definitive treatment during or after the
mother's hospital stay, the newborn is considered a patient in their own
right. If the newborn is eligible for coverage, regular medical or surgical
benefits apply rather than maternity benefits.  In addition, circumcision
is covered at the same rate as for regular medical or surgical benefits.

Note: Maternity care expenses incurred by a Plan member serving as a
surrogate mother are covered by the Plan subject to reimbursement from
the other party to the surrogacy contract or agreement. The involved
Plan member must execute our Reimbursement Agreement completed
by APWU Health Plan against any payment they may receive under the
surrogacy contract or agreement. Expenses of the newborn child are not
covered under this or any other benefit in a surrogate mother situation.

•  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
circumcision of a covered newborn.

Out-of-network:  50% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered:

All charges

•  Amniocentesis if for diagnosing multiple births

•  Genetic screening (see Definitions, Section 10)

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CDHP Section 5(a)

 Benefit Description

You pay

Family planning

Consumer Driven Option

Contraceptive counseling on an annual basis

In-network: Nothing

CDHP

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

In-network: Nothing

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Note: If you have concerns about the Health Plan’s compliance with the
ACA/HRSA requirements or have difficulty accessing contraceptive
coverage or other reproductive healthcare, you can
contact contraception@opm.gov. See OPM’s web page about
contraception.

A range of voluntary family planning services, without cost-sharing, that
includes at least one form of contraception in each of the categories on
the HRSA list. This list includes:

•  Voluntary female sterilization

•  Surgically implanted contraceptives

•  Injectable contraceptive drugs (such as Depo Provera)

•  Intrauterine devices (IUDs)

•  Diaphragms

Note: See additional Family Planning and Prescription drug coverage
Section 5(f)

Note: Your plan offers some type of voluntary female sterilization
surgery coverage at no cost to members. The contraceptive benefit
includes at least one option in each of the HRSA-supported categories of
contraception (as well as the screening, education, counseling, and
follow-up care). Any type of voluntary female sterilization surgery that
is not already available without cost sharing can be accessed through the
contraceptive exceptions process described below.

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. Urgent requests are reviewed
within 24 hours.

•  Voluntary male sterilization

In-network: 15% of the Plan allowance

Not covered:

•  Reversal of voluntary surgical sterilization

•  Genetic testing and counseling

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

All charges

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CDHP Section 5(a)

 Benefit Description

You pay

CDHP

Consumer Driven Option

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance

Infertility services

Diagnosis and treatment of infertility specific to, except as shown in Not
covered, see Section 10, Definitions

•  Artificial insemination (AI):

-   Intravaginal insemination (IVI),

-   Intracervical insemination (ICI)

-   Intrauterine insemination (IUI)

•  Infertility medications, including IVF related drugs. See Section 5

(f), Prescription drug benefits.

For coverage policy, visit www.apwuhp.com and click on Member
Resources.

•  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
of disease and gender reassignment.

Out-of-network: 50% of the Plan allowance

Note: Fertility preservation procedures require prior approval (see
Section 3, Other services).

Limited benefits: $12,000 lifetime maximum.

Not covered:

All charges

•  Infertility services after voluntary sterilization

•  Assisted reproductive technology (ART) procedures, such as:

-   In vitro fertilization (IVF) (excluding IVF drugs)

-   Embryo transfer and gamete intra-fallopian transfer (GIFT) and

zygote intra-fallopian transfer (ZIFT)

•  Services and supplies related to ART procedures

•  Cost of donor sperm

•  Cost of donor egg

Allergy care

Consumer Driven Option

•  Testing and treatment, including materials (such as allergy serum)

In-network:  15% of the Plan allowance

•  Allergy injections

Not covered:

•  Provocative food testing

•  Sublingual allergy desensitization

Out-of-network:  50% of the Plan allowance
and any difference between our allowance and
the billed amount

All charges

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CDHP Section 5(a)

 Benefit Description

You pay

Treatment therapies

Consumer Driven Option

•  Chemotherapy and radiation therapy

In-network: 15% of the Plan allowance

CDHP

Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed in Section 5
(b), Organ/tissue transplants.

•  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).

•  Respiratory and inhalation therapies

•  Cardiac rehabilitation following qualifying event/condition

•  Medical food formulas ordered by a healthcare provider that are
medically necessary to treat specific nutritional risks, including
Phenylketonuria (PKU) and other inborn errors of metabolism (IEM).

Limited benefits: We pay a maximum of $2,500 for each calendar year

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

In-network:  15% of the Plan allowance and all
charges after we pay $2,500 in a calendar year

Out-of-network:  50% of the Plan allowance
and all charges after we pay $2,500 in a
calendar year

Not covered:

All charges

•  Medical foods for conditions other than permanent inborn errors of

metabolism.

Physical and occupational therapies

Physical therapy and occupational therapy provided by a licensed
registered therapist or physician up to a combined 60 visits per calendar
year

We cover rehabilitative and habilitative therapies; a physician should:

•  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.

Note:  We also have the right to deny any type of therapy, service or
supply for the treatment of a condition which ceases to be therapeutic
treatment and is instead administered to maintain a level of functioning
or to prevent a medical problem from occurring or recurring.

Consumer Driven Option

In-network:  15% of the Plan allowance

Out-of-network:  50% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered:

•  Maintenance therapies

•  Exercise programs

All charges

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CDHP Section 5(a)

 Benefit Description

You pay

CDHP

Applied behavioral analysis (ABA)

Outpatient Applied Behavioral Analysis (ABA) services, for the
treatment of Autism Spectrum Disorder. Services must be provided
under the supervision of a Board Certified Behavior Analyst who is
contracted with UnitedHealthcare Behavioral Health, or agrees to
participate with UnitedHealthcare Behavioral Health's care management
activities. Preauthorization required by UnitedHealthcare
Behavioral Health.

Note: UnitedHealthcare Behavioral Health's review of ABA services is
based on an intensive care management model that monitors treatment
plans, objectives, and progress milestones.

We have the right to deny services for treatment when outcomes do not
meet the defined treatment plan objectives and milestones.

Speech therapy

Speech therapy where medically necessary and provided by a licensed
therapist

Note:  Speech therapy is combined with 60 visits per calendar year for
the services of physical and/or occupational therapy (see above).

Note:   We also have the right to deny any type of therapy, service or
supply for the treatment of a condition which ceases to be therapeutic
treatment and is instead administered to maintain a level of functioning
or to prevent a medical problem from occurring or recurring.
Hearing services (testing, treatment, and supplies)

Consumer Driven Option

In-network:  15% of the Plan allowance

Out-of-network:  All charges

Consumer Driven Option

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

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

Note: For routine hearing screening performed during a child's
preventive care visit see Section 5, Preventive care, children.

•  External hearing aids

•  Implanted hearing-related devices, such as bone anchored hearing

aids (BAHA) and cochlear implants for bilateral hearing los

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Note:  For benefits for the devices see Section
5(a), Orthopedic and prosthetic devices.

Not covered:

All charges

•  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 to
correct an impairment caused by accident or illness. Services are limited
to the testing, evaluation and fitting of the first contact lenses required to
correct an impairment caused by accident or illness.

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Note: See Preventive care, children, for eye exams for children.

Not covered:

All charges

•  Eyeglasses or contact lenses and examinations for them except under

PCA

•  Eye exercises and visual training

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CDHP Section 5(a)

103

CDHP

 Benefit Description

You pay

Vision services (testing, treatment, and supplies) (cont.)

Consumer Driven Option

•  Radial keratotomy and other refractive surgery

All charges

•  Refraction

Foot care

Routine foot care when you are under active treatment for a metabolic or
peripheral vascular disease, such as diabetes

Note:  See Orthopedic and prosthetic devices for information on
podiatric shoe inserts.

Consumer Driven Option

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered:

All charges

•  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

•  Artificial limbs and eyes

•  Prosthetic sleeve or sock

•  Externally worn breast prostheses and surgical bras, including

necessary replacements following a mastectomy

•  Leg, arm, neck, joint and back braces

•  Implanted hearing-related devices, such as bone anchored hearing
aids (BAHA) and cochlear implants for bilateral hearing loss

•  Internal prosthetic devices, 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

•  Covered every 3 years limited to $1,500

Note:  Excluding batteries, benefits for hearing aid dispensing fees,
accessories, supplies, and repair service are included in the benefit limit
described above.

Consumer Driven Option

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

PPO: All charges in excess of $1,500, up to the
PPO allowance  (No deductible)

Non-PPO: All charges in excess of $1,500 (No
deductible)

Not covered:

All charges

•  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

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CDHP

 Benefit Description

You pay

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

treating your illness or injury)

2. Are medically necessary

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the 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

We cover rental or purchase, of durable medical equipment, at our
option, including repair and adjustment. Covered items include but are
not limited to:

•  Oxygen

•  Dialysis equipment

•  Hospital beds

•  Wheelchairs (standard and electric)

•  Ostomy supplies (including supplies purchased at a pharmacy)

•  Crutches

•  Walkers

Note: Preauthorization of durable medical equipment is required,
(see Other services, Section 3).

Note: We will pay only for the cost of the standard item. Coverage for
specialty equipment, such as all-terrain wheelchairs, is limited to the
cost of the standard equipment.

Note:  We limit the Plan allowance for DME rental benefit to an amount
no greater than what we would have considered if the equipment had
been purchased.

Not covered :

•  Whirlpool equipment

•  Sun and heat lamps

•  Light boxes

•  Heating pads

•  Exercise devices

•  Stair glides

•  Elevators

•  Air Purifiers

•  Computer “story boards,” “light talkers,” or other communication aids

for communication-impaired individuals

All charges

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CDHP Section 5(a)

CDHP

 Benefit Description

You pay

Home health services

Services for skilled nursing care up to 50 visits per calendar year, not to
exceed two hours per day; and

•  a registered nurse (R.N.), licensed practical nurse (L.P.N.) or licensed

vocational nurse (L.V.N.) provides the services;

•  the attending physician orders the care;

•  the physician identifies the specific professional skills required by the

patient and the medical necessity for skilled services; and

•  the physician indicates the length of time the services are needed

Consumer Driven Option

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance; all
charges in excess of two hours, and any
difference between our allowance and the
billed amount

Note: Skilled nursing care must be preauthorized. Call UnitedHealthcare
at 800-718-1299.

Not covered:

All charges

•  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

In-network: 15% of the Plan allowance

year

•  Electrical stimulation and ultrasound therapy provided by a licensed

chiropractor

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Note:  X-ray covered under Section 5(a), Lab, X-ray and other
diagnostic tests.

Not covered:

•  Massage therapy

•  Maintenance therapy

Alternative treatments

All charges

Consumer Driven Option

•  Acupuncture - by a doctor of medicine or osteopathy, or licensed or

In-network: 15% of the Plan allowance

certified acupuncture practitioner

•  Dry Needling – by a licensed or certified practitioner

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered:

All charges

•  Services of any provider not listed as covered (see Covered

providers, Section 3)

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CDHP Section 5(a)

CDHP

 Benefit Description

You pay

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;

•  Group therapy sessions or;

•  Educational sessions with a physician

Out-of-network:  50% of the Plan allowance
and any difference between our allowance and
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
approved by the FDA to treat tobacco dependence. For a listing of
medications go to our website at:
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.

Diabetes self-management training services, up to 10 hours initial
training the first year and 2 hours subsequent training annually

In-network:  Nothing

Out-of-network:  All charges

In-network:  15% of the Plan allowance

Out-of-network:  50% of the Plan allowance
and any difference between our allowance and
the billed amount

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CDHP Section 5(a)

CDHP

Section 5(b). Surgical and Anesthesia Services
Provided by Physicians and Other Healthcare Professionals

Important things to keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations and exclusions in this

brochure and are payable only when we determine they are medically necessary.

• In-network Preventive Care is covered at 100% under CDHP Section 5 and does not count against

your Personal Care Account.

• Your Personal Care Account must be used first for eligible healthcare expenses.

• If your Personal Care Account has been exhausted, you must pay your Net Deductible before your
Traditional Health Coverage may begin. Your Deductible applies to all benefits in this section.

• The Consumer Driven Option provides coverage for both in-network and out-of-network providers.
The out-of-network benefits are the standard benefits under the Traditional Health Coverage. In-
network benefits apply only when you use a provider from the large, national network. When a
network provider is not available, out-of-network benefits apply.

• If you join at any time during the year other than Open Season, your Deductible for your first year

will be prorated at a rate of:  In-network $83.33 per month for Self Only, $166.67 per month for Self
Plus One or Self and Family; or out-of-network $125.00 per month for Self Only or $250.00 per
month for Self Plus One or Self and Family, for each full month of coverage remaining in that
calendar year.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how
cost-sharing works. Also, read Section 9 for information about how we pay if you have other
coverage, or if you are age 65 or over.

• YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO

WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification
information shown in Section 3, to confirm which services require precertification.

Benefits Description

You pay

Surgical Procedures

Consumer Driven Option

A comprehensive range of services, such as:

In-network:  15% of the Plan allowance

Out-of-network:  50% of the Plan allowance
and any difference between our allowance and
the billed amount

•  Operative procedures

•  Treatment of fractures, including casting

•  Normal pre- and post-operative care by the surgeon

•  Correction of amblyopia and strabismus

•  Endoscopy procedures

•  Biopsy procedures

•  Removal of tumors and cysts

•  Correction of congenital anomalies (see Section 5(b), Reconstructive

surgery)

•  Surgical treatment of severe obesity (bariatric surgery) (requires

preauthorization, see Section 3, Other services). For coverage policy,
visit www.apwuhp.com and click on Member Resources.

•  Insertion of internal prosthetic devices (see Section 5(a), Orthopedic

and prosthetic devices, for device coverage information)

•  Treatment of burns

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CDHP Section 5(b)

Surgical Procedures - continued on next page

CDHP

Benefits Description

You pay

Surgical Procedures (cont.)

Consumer Driven Option

•  Assistant surgeons - We cover up to 20% of our allowance for the

In-network:  15% of the Plan allowance

surgeon’s charge

Note: For female surgical family planning procedures see Family
Planning Section 5(a).

Note: For male surgical family planning procedures see Family Planning
Section 5(a).

Out-of-network:  50% of the Plan allowance
and any difference between our allowance and
the billed amount

When multiple or bilateral surgical procedures performed during the
same operative session add time or complexity to patient care, our
benefits are:

In-network: 15% of the Plan allowance for the
primary procedure and 15% of one-half of the
Plan allowance for the secondary procedure(s)

Out-of-network: 50% of the Plan allowance for
the primary procedure and 50% of one-half of
the Plan allowance for the secondary procedure
(s); and any difference between our payment
and the billed amount

•  For the primary procedure:

-   In-network: 85% of the Plan allowance or

-   Out-of-network: 50% of the Plan allowance

•  For the secondary procedure(s):

-   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.

Not covered:

All charges

•  Cosmetic surgery and other related expenses if not preauthorized

•  Reversal of voluntary sterilization

•  Services of a standby surgeon, except during angioplasty or other high
risk procedures when we determine standbys are medically necessary

•  Radial keratotomy and other refractive surgery

•  Routine treatment of conditions of the foot (see Foot care, Section 5

(a))

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CDHP Section 5(b)

CDHP

Benefits Description

You pay

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:

-   The condition produced a major effect on the member’s appearance

and

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the 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 breast

-   Treatment of any physical complications, such as lymphedema

-   Breast prostheses; and surgical bras and replacements (see Section

5(a), Prosthetic devices, for coverage)

Note: We pay for internal breast prostheses as hospital benefits.

Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.

•  Surgical treatment for gender affirmation

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

•  Gender affirming surgery benefits are only available for the diagnosis

of gender dysphoria

Requirements:

•  Prior approval is required.

•  Must be at least 18 years of age at time prior approval is requested

and treatment plan is submitted.

•  Must have diagnosis of gender dysphoria by a qualified healthcare

professional.

•  Persistent, well-documented gender dysphoria.

•  Member’s gender dysphoria is not a symptom of another mental

disorder or chromosomal abnormality.

•  Continuous hormone therapy as appropriate.

•  Two clinical assessments from qualified healthcare professionals are
required for genital and gonadal surgeries, all other surgeries require
one assessment.

•  If medical or mental health concerns are present, they are being

optimally managed and are reasonably well-controlled.

For coverage policy, visit www.apwuhp.com and click on Member
Resources.

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Reconstructive Surgery - continued on next page

CDHP

Benefits Description

You pay

Reconstructive Surgery (cont.)

Consumer Driven Option

Not covered:

All charges

•  Cosmetic services that are not medically necessary

•  Travel and lodging

Oral and Maxillofacial Surgery

Consumer Driven Option

Oral surgical procedures, limited to:

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

•  Reduction of fractures of the jaw or facial bones

•  Surgical correction of cleft lip, cleft palate or severe functional

malocclusion

•  Removal of stones from salivary ducts

•  Excision of leukoplakia or malignancies

•  Excision of cysts and incision of abscesses when done as independent

procedures

•  Other surgical procedures that do not involve the teeth or their

supporting structures

•  Extraction of impacted (unerupted) teeth

•  Alveoplasty, partial ostectomy and radical resection of mandible with

bone graft unrelated to tooth structure

•  Excision of bony cysts of the jaw unrelated to tooth structure

•  Excision of tori, tumors, and premalignant lesions, and biopsy of hard

and soft oral tissues

•  Reduction of dislocations and excision, manipulation, arthrocentesis,

aspiration or injection of temporomandibular joints

•  Removal of foreign body, skin, subcutaneous alveolar tissue, reaction-
producing foreign bodies in the musculoskeletal system and salivary
stones

•  Incision/excision of salivary glands and ducts

•  Repair of traumatic wounds

•  Sinusotomy, including repair of oroantral and oromaxillary fistula

and/or root recovery

•  Surgical treatment of trigeminal neuralgia

•  Frenectomy or frenotomy, skin graft or vestibuloplasty-stomatoplasty

unrelated to periodontal disease

•  Incision and drainage of cellulitis unrelated to tooth structure

Note: Call UnitedHealthcare at 800-718-1299 to determine if a
procedure is covered.

Not covered:

•  Oral implants and transplants

All charges

•  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

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Oral and Maxillofacial Surgery - continued on next page

Benefits Description

You pay

Oral and Maxillofacial Surgery (cont.)

Consumer Driven Option

•  Treatment of periodontal disease and gingival tissues, and abscesses

All charges

CDHP

Consumer Driven Option

In-network Transplant Center of Excellence
(COE): 10% of the Plan allowance

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount and any amount over
$100,000

•  Charges related to orthodontic treatment

Organ/Tissue Transplants

These solid organ transplants are subject to medical necessity and
experimental/investigational review by the Plan. Refer to Other
services, Section 3, for prior authorization procedures.

Solid organ transplants are limited to:

•  Autologous pancreas islet cell transplant (as an adjunct to total or near

total pancreatectomy) only for patients with chronic pancreatitis

•  Cornea

•  Heart

•  Heart/lung

•  Intestinal transplants

-   Isolated small intestine

-   Small intestine with the liver

-   Small intestine with multiple organs, such as the liver, stomach, and

pancreas

•  Kidney

•  Kidney-pancreas

•  Liver

•  Lung single/bilateral/lobar

•  Pancreas

These tandem blood or marrow stem cell transplants for covered
transplants are subject to medical necessity review by the Plan. Refer to
Section 3, Other services, for prior authorization procedures.

•  Autologous tandem transplants for

-   AL Amyloidosis

-   Multiple myeloma (de novo and treated)

-   Recurrent germ cell tumors (including testicular cancer)

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below:

•  Allogeneic transplants for

-   Acute lymphocytic or non-lymphocytic (i.e., myelogenous)

leukemia

-   Acute myeloid leukemia

-   Advanced Hodgkin's lymphoma with recurrence (relapsed)

-   Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)

-   Advanced Myeloproliferative Disorders (MPDs)

In-network Transplant Center of Excellence
(COE): 10% of the Plan allowance

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount and any amount over
$100,000

In-network Transplant Center of Excellence
(COE): 10% of the Plan allowance

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount and any amount over
$100,000

-   Advanced neuroblastoma

-   Amyloidosis

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Organ/Tissue Transplants - continued on next page
CDHP Section 5(b)

Benefits Description

You pay

Organ/Tissue Transplants (cont.)

Consumer Driven Option

-   Beta Thalassemia Major

-   Chronic inflammatory demyelination polyneuropathy (CIDP)

In-network Transplant Center of Excellence
(COE): 10% of the Plan allowance

-   Chronic lymphocytic leukemia/small lymphocytic lymphoma

In-network: 15% of the Plan allowance

CDHP

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount and any amount over
$100,000

(CLL/SLL)

-   Early stage (indolent or non-advanced) small cell lymphocytic

lymphoma

-   Hemoglobinopathy

-   Infantile malignant osteopetrosis

-   Kostmann's syndrome

-   Leukocyte adhesion deficiencies

-   Marrow failure and related disorders (i.e., Fanconi's Paroxysmal

Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)

-   Mucolipidosis (e.g., Gaucher's disease, metachromatic

leukodystrophy, adrenoleukodystrophy)

-   Mucopolysaccharidosis (e.g., Hunter's syndrome, Hurler's

syndrome, Sanfillippo's syndrome, Maroteaux-Lamy syndrome
variants)

-   Multiple Myeloma

-   Myelodysplasia/Myelodysplastic Syndromes

-   Myeloproliferative disorders

-   Paroxysmal Nocturnal Hemoglobinuria

-   Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-

Aldrich syndrome)

-   Severe combined immunodeficiency

-   Severe or very severe aplastic anemia

-   Sickle cell anemia (pediatric only)

-   X-linked lymphoproliferative syndrome

•  Autologous transplants for

-   Acute lymphocytic or non-lymphocytic (i.e., myelogenous)

leukemia

-   Advanced childhood kidney cancers

-   Advanced Hodgkin's lymphoma with recurrence (relapsed)

-   Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)

-   Amyloidosis

-   Aggressive non-Hodgkin's lymphomas

-   Breast cancer

-   Childhood rhabdomyosarcoma

-   Ependymoblastoma

-   Epithelial ovarian cancer

-   Ewing's sarcoma

-   Mantle cell (non-Hodgkin's lymphoma)

-   Medulloblastoma

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Organ/Tissue Transplants - continued on next page
CDHP Section 5(b)

CDHP

Benefits Description

You pay

Organ/Tissue Transplants (cont.)

Consumer Driven Option

-   Multiple myeloma

-   Neuroblastoma

-   Pineoblastoma

-   Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell

tumors

-   Waldenstrom's macroglobulinemia

In-network Transplant Center of Excellence
(COE): 10% of the Plan allowance

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount and any amount over
$100,000

Mini-transplants (non-myeloablative, reduced intensity conditioning or
RIC) are subject to medical necessity review by the Plan.

In-network Transplant Center of Excellence
(COE): 10% of the Plan allowance

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount and any amount over
$100,000

In-network Transplant Center of Excellence
(COE): 10% of the Plan allowance

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount and any amount over
$100,000

These blood or marrow stem cell transplants are covered only in a
National Cancer Institute or National Institutes of Health approved
clinical trial or a Plan-designated Center of Excellence.

If you are a participant in a clinical trial, the Plan will provide benefits
for related routine care that is medically necessary (such as doctor visits,
lab tests, X-rays and scans, and hospitalization related to treating the
patient's condition) if it is not provided by the clinical trial. Section 9 has
additional information on costs related to clinical trials. We encourage
you to contact the Plan to discuss specific services if you participate in a
clinical trial.

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.

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
$100,000 for each listed transplant, including multiple organ transplants.

Note: We cover related medical and hospital expenses of the donor when
we cover the recipient.

Not covered:

All charges

•  Donor screening tests and donor search expenses, except as shown

above

•  Transplants not listed as covered

•  Implants of artificial organs

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CDHP Section 5(b)

Benefits Description

You pay

CDHP

Anesthesia

Professional services provided in –

•  Hospital (inpatient)

Professional services provided in –

•  Hospital outpatient department

•  Skilled nursing facility

•  Ambulatory surgical center

•  Office

Consumer Driven Option

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Note: If surgical services are rendered at an in-
network hospital or an in-network freestanding
ambulatory facility, we will pay the services of
out-of-network anesthesiologists at the in-
network rate, based on Plan allowance.

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CDHP Section 5(b)

CDHP

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

Important things to keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations and exclusions in this

brochure and are payable only when we determine they are medically necessary.

• In-network Preventive Care is covered at 100% under CDHP Section 5 and does not count against

your Personal Care Account.

• Your Personal Care Account must be used first for eligible healthcare expenses.

• If your Personal Care Account has been exhausted, you must pay your Net Deductible before your
Traditional Health Coverage may begin. Your Deductible applies to all benefits in this section.

• The Consumer Driven Option provides coverage for both in-network and out-of-network providers.
The out-of-network benefits are the standard benefits under the Traditional Health Coverage. In-
network benefits apply only when you use a provider from the large, national network. When a
network provider is not available, out-of-network benefits apply.

• If you join at any time during the year other than Open Season, your Deductible for your first year

will be prorated at a rate of:  In-network $83.33 per month for Self Only, $166.67 per month for Self
Plus One or Self and Family; or out-of-network $125.00 per month for Self Only or $250.00 per
month for Self Plus One or Self and Family, for each full month of coverage remaining in that
calendar year.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how

cost-sharing works.  Also read Section 9 for information about how we pay if you have
other coverage, or if you are age 65 or over.

• YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO

WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification
information shown in Section 3 to confirm which services require precertification.

• You must get prior approval for gender affirming surgery. See Section 3 for prior approval and

Section 5(b) for the surgical benefit.

• When you receive hospital observation services, we apply outpatient benefits to covered services up
to 48 hours. Inpatient benefits will apply only when your physician admits you to the hospital as
inpatient. Once you are formally admitted, your entire stay (including observation services) will be
processed and paid as inpatient benefits.

Benefits Description

Inpatient hospital

Room and board, such as:

•  Ward, semiprivate, or intensive care accommodations

•  General nursing care

•  Meals and special diets

Note: We only cover a private room when you must be isolated to
prevent contagion. Otherwise, we will pay the hospital’s average charge
for semiprivate accommodations. If the hospital only has private rooms,
we will 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.

You pay
Consumer Driven Option

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Note: For inpatient hospital care related to
maternity, we pay for covered services in full
when you use preferred providers, (see Section
5(a), Maternity care)

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CDHP Section 5(c)

Inpatient hospital - continued on next page

CDHP

Inpatient hospital (cont.)

Benefits Description

You pay
Consumer Driven Option

Other hospital services and supplies, such as:

In-network: 15% of the Plan allowance

•  Operating, recovery, maternity and other treatment rooms

•  Prescribed drugs and medications

•  Diagnostic laboratory tests and X-rays

•  Blood or blood plasma, if not donated or replaced

•  Dressings, splints, casts, and sterile tray services

•  Medical supplies and equipment, including oxygen

•  Anesthetics, including nurse anesthetist services

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Note: For inpatient hospital care related to
maternity, we pay for covered services in full
when you use preferred providers, (see Section
5(a), Maternity care).

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.

Not covered:

All charges

•  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)

•  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

•  Take-home items

Cancer Centers of Excellence

The Plan provides access to designated Cancer Centers of Excellence.
To locate a Cancer Center of Excellence, contact UnitedHealthcare at
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.

Consumer Driven Option

In-network Cancer Centers of Excellence
(COE): 10% of the Plan allowance

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CDHP Section 5(c)

Outpatient hospital or ambulatory surgical center

Benefits Description

You pay
Consumer Driven Option

•  Operating, recovery, and other treatment rooms

In-network: 15% of the Plan allowance

CDHP

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Note: For inpatient hospital care related to
maternity, we pay for covered services in full
when you use preferred providers (see Section
5(a), Maternity care).

•  Prescribed drugs and medications

•  Diagnostic laboratory tests, X-rays, and pathology services

•  Administration of blood, blood plasma, and other biologicals

•  Blood and blood plasma, if not donated or replaced

•  Pre-surgical testing

•  Dressings, casts, and sterile tray services

•  Medical supplies, including oxygen

•  Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental
procedures when necessitated by an underlying medical condition. We
do not cover the dental procedures.

Note: We cover outpatient services and supplies of a hospital or free-
standing ambulatory facility the day of a surgical procedure (including
change of cast), hemophilia treatment, hyperalimentation, rabies shots,
cast or suture removal, oral surgery, foot treatment, chemotherapy for
treatment of cancer, and radiation therapy.

Extended care benefits/Skilled nursing care facility
benefits

Consumer Driven Option

When APWU Health Plan is Primary

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

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.

Your skilled nursing care is supervised by a physician and provided by
an R.N., L.P.N., or L.V.N.

Note: Prior approval for these services is required.  Call
UnitedHealthcare at 800-718-1299,  (see Other services, Section 3).

When Medicare A or Other Insurance is Primary

Semiprivate room, board, services and supplies provided in a skilled
nursing care facility (SNF) for up to 30 days per person per calendar
year when you are admitted directly from a covered inpatient hospital
stay.

Note:  If Medicare pays the first 20 days in full, Plan benefits will begin
on the 21st day (when Medicare Part A copayments begin) and will end
on the 30th day.

Not covered:

All charges

•  Custodial care (see Section 10, Definitions)

•  All charges after 30 days per person per calendar year

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CDHP Section 5(c)

Hospice care

Benefits Description

Hospice is a coordinated program of home and inpatient supportive care
for the terminally ill patient and the patient’s family provided by a
medically supervised specialized team under the direction of a duly
licensed or certified Hospice Care Program.

•  We pay up to $15,000 lifetime maximum for combined outpatient and

inpatient services, which includes advance care planning

•  We pay a $200 bereavement benefit per family unit (no deductible or

coinsurance).

End of life care

End of life care

•  See Hospice care benefit which includes advance care planning,

above

Ambulance

Local professional ambulance service when medically appropriate
immediately before, during or after an inpatient admission

CDHP

You pay
Consumer Driven Option

Any amount over the annual maximums shown

Consumer Driven Option

Any amount over the annual maximums shown

Consumer Driven Option

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered:

All charges

•  Ambulance service used for routine transport

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CDHP

Section 5(d). Emergency Services-Accidents

Important things to keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations and exclusions in this

brochure and are payable only when we determine they are medically necessary.

• 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.

• 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.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how
cost-sharing works. Also, read Section 9 for information about how we pay if you have other
coverage, or if you are age 65 or over.

• When multiple or bilateral surgical procedures add complexity to an operative session, the Plan

allowance for the second or less expensive procedure is one-half of what the Plan allowance would
have been if that procedure had been performed independently.

-  When a surgery requires two primary surgeons (co-surgeons), the Plan allowance for each

surgeon will not exceed 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.

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.

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CDHP

Benefits Description

You pay

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

•  Related outpatient hospital services

Out-of-network: 15% of the Plan allowance

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.

Medical emergency

Consumer Driven Option

Outpatient facility charges in an Urgent Care Center

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance

Note:  For out-of-network benefits, members
may be billed the difference between the Plan
allowance and the billed amount.

In-network: 15% of the Plan allowance

Out-of-network: 15% of the Plan allowance
Consumer Driven Option

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Consumer Driven Option

In-network: 15% of the Plan allowance

Out-of-network: 15% of the Plan allowance

All charges

Outpatient medical or surgical services and supplies, other than  an
Urgent Care Center

Ambulance

Professional ambulance service within 24 hours of an accidental injury
or medical emergency

Note: See Hospital benefits, Section 5(c), for non-emergency service.

Air ambulance

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.

Not covered:

•  Non-emergent Air ambulance

•  Emergent transport beyond the nearest suitable facility

•  Air ambulance requested by patient or physician which are beyond the

nearest facility for continuity of care or other reasons

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CDHP

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

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.

• 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.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how

cost-sharing works.  Also read Section 9 for information about how we pay if you have
other coverage, or if you are age 65 or over.

• YOU MUST GET PREAUTHORIZATION FOR HOSPITAL STAYS; FAILURE TO DO SO

WILL RESULT IN A MINIMUM $500 PENALTY.  Please refer to the precertification
information shown in Section 3 to confirm which services require precertification.

• To obtain preauthorization of an admission for mental conditions or substance use disorder

treatment, call UnitedHealthcare 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. UnitedHealthcare 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

We cover professional services by licensed professional mental health
and substance use disorder treatment practitioners when acting within
the scope of their license, such as psychiatrists, psychologists, clinical
social workers, licensed professional counselors, or marriage and family
therapists.

Consumer Driven Option

Your cost-sharing responsibilities are no greater
than for other illnesses or conditions.

•  In a physician's office*

In-network: 15% of the Plan allowance

•  Professional charges for intensive outpatient treatment in a provider's

office or other professional setting

* Professional services of a physician via Telehealth/Telemedicine are
covered the same as in a physician’s office.

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Professional services - continued on next page

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CDHP Section (e)

Benefits Description

You pay

CDHP

Consumer Driven Option

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Professional services (cont.)

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)

•  Psychological and neuropsychological testing necessary to determine
the appropriate psychiatric treatment (preauthorization required by
UnitedHealthcare 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 UnitedHealthcare Behavioral Health
Solutions)

•  Electroconvulsive therapy (preauthorization required by

UnitedHealthcare Behavioral Health Solutions)

•  Professional charges for intensive outpatient treatment in a provider's
office or other professional setting (preauthorization required by
UnitedHealthcare 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 UnitedHealthcare Behavioral Health Solutions

In-network:  15% of the Plan allowance

for non-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,

hospital or other covered facility

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

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CDHP

Benefits Description

You pay

Inpatient hospital or other covered facility

Consumer Driven Option

Inpatient services provided and billed by a hospital, Residential
Treatment Center (RTC), or other covered facility (preauthorization
required by UnitedHealthcare Behavioral Health Solutions)

•  Room and board, such as semiprivate or intensive accommodations,
general nursing care, meals and special diets, and other hospital
services

•  Inpatient diagnostic tests provided and billed by a hospital,

Residential Treatment Center (RTC), or other covered facility

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered:

All charges

•  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
facility

•  Services such as partial hospitalization, or facility-based intensive

outpatient treatment (preauthorization required by UnitedHealthcare
Behavioral Health Solutions)

In-network: 15% of the Plan allowance

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Not covered:

All charges

•  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

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CDHP

Section 5(f). Prescription Drug Benefits

Important things to keep in mind about these benefits:

• We cover prescribed drugs and medications, as described in the chart below.

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

• Your prescribers must obtain prior approval/authorizations for certain prescription drugs and

supplies before coverage applies.  Prior approval/authorizations must be renewed periodically.

• Federal law prevents the pharmacy from accepting unused medications.

• 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.

• 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.

• 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 Section 5(f), Coverage
Authorization 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 physician or dentist, and in states allowing it, licensed/certified providers
with prescriptive authority prescribing within their scope of practice must prescribe your medication.

Where can you obtain them.  You can fill the prescription at an 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 have a managed 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

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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.

Benefits Description

You pay

Covered medications and supplies

Consumer Driven Option

•  Network Retail:

-   Tier 1 and Tier 2 - 25% of charge with a
minimum of $15 and a maximum per
prescription of $200 for a 30-day supply,
$400 for a 60-day supply, $600 for a 90-
day supply;

-   Tier 3 - 40% of charge with a minimum
$15 and a maximum per prescription of
$300 for a 30-day supply, $600 for a 60-
day supply, $900 for a 90-day supply

•  Network Home Delivery:

-   Tier 1 and Tier 2 - 25% of charge with a
minimum of $10 and a maximum per
prescription of $200 for a 30-day supply,
$400 for a 60-day supply, $600 for a 90-
day supply;

-   Tier 3 - 40% of charge with a minimum
$10 and a maximum per prescription of
$300 for a 30-day supply, $600 for a 60-
day supply, $900 for a 90-day supply

Each new enrollee will receive a combined prescription drug/Plan
identification card.

You may purchase the following medications and supplies prescribed by
a doctor from either a network pharmacy or by mail:

•  Drugs and medications, including those for Tobacco Cessation

programs, for use at home that are obtainable only upon a doctor’s
prescription

•  Drugs and medications (including those administered during a non-

covered admission or in a non-covered facility) that by Federal law of
the United States require a physician’s prescription for their purchase,
except those listed as not covered

•  Insulin and test strips for known diabetics

•  Disposable needles and syringes for the administration of covered

medications

•  Prior authorization/medical necessity review is required for certain

drugs and must be renewed periodically.  Prior authorization/medical
necessity review uses Plan rules based on FDA-approved prescribing
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 and
Section 5(f), Coverage Authorization for more information about this
program.

•  Drugs to treat gender dysphoria. See Section 5(b), Reconstructive

Surgery, for gender affirming care.

•  FDA approved drugs for weight management. Prior approval is

required, see Section 5(f), Coverage Authorization.

•  Medications prescribed to treat obesity.

Contraceptive drugs and devices as listed on the Health Resources and
Services Administration site https://www.hrsa.gov/womens-guidelines.

Network Retail: $0

Network Home Delivery: $0

Contraceptive coverage is available at no cost to PSHB members. The
contraceptive benefit includes at least one option in each of the HRSA-
supported categories 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 Optum Rx's Patient Protection and
Affordable Care Act (PPACA) Preventive Contraceptive Drug List for
contraception.  Find list at www.apwuhp.com.

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Benefits Description

You pay

Covered medications and supplies (cont.)

Consumer Driven Option

CDHP

Network Retail: $0

Network Home Delivery: $0

Network Retail:  Nothing

Network Home Delivery:  Nothing

All charges

•  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. Urgent requests
are reviewed within 24 hours.

•  Reimbursement for covered over-the-counter contraceptives can be
submitted by filling out an OptumRX direct member reimbursement
(DMR) form (prescription required) which can be found on
www.myuhc.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 or have difficulty accessing contraceptive
coverage or other reproductive healthcare, contact
contraception@opm.gov. See OPM’s web page about contraception.

Note: For additional Family Planning benefits see Section 5(a)

Note: Over-the-counter and appropriate prescription drugs approved by
the FDA to treat tobacco dependence are covered under the Tobacco
Cessation Educational Classes and Programs in Section 5(a)

Opioid rescue agents such as naloxone are covered under this Plan with
no cost-sharing when obtained from an in-network pharmacy in any
over-the-counter or prescription form available such as nasal sprays and
intramuscular injections.

For more information consult the FDA guidance at
https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-
save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go
to https://www.findtreatment.samhsa.gov/

Not covered:

•  Drugs and supplies for cosmetic purposes

•  Drugs to enhance athletic performance

•  Vitamins, nutrients and food supplements not listed as a covered

benefit even if a 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.

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Benefits Description

You pay

Covered medications and supplies (cont.)

Consumer Driven Option

Note: For prescription drugs approved by the FDA for contraception and
for devices for birth control see Family planning, Section 5(a).

All charges

Preventive medications

The following are covered:

•  Preventive Medications with USPSTF A and B recommendations.

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

Consumer Driven Option

•  Network Retail: Nothing when prescribed by

a healthcare professional and filled by a
network pharmacy.

•  Network Home Delivery: Nothing when

prescribed by a healthcare professional and
filled by a network pharmacy.

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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.

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• 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).

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Section 5(f)(a). PDP EGWP Prescription Drug Benefits

Important things you should keep in mind about these benefits:

• These prescription drug benefits are for members enrolled in our Medicare Part D Prescription Drug

Plan (PDP) Employer Group Waiver Plan (EGWP).

• UnitedHealthcare MedicareRx is the administrator for this plan.

• If you are a Postal Service annuitant and their covered Medicare-eligible family member, you will

be automatically group enrolled in our PDP EGWP. Contact UnitedHealthcare for additional
information at 888-201-4265.

Note: Notify us as soon as possible if you or your eligible family member is already enrolled in a
Medicare Part D Plan. Enrollment in our PDP EGWP will cancel your enrollment in another Medicare
Part D plan.

There are advantages to being enrolled in our PDP EGWP:

• In our PDP EGWP, your cost-share for covered drugs, medications, and supplies will be equal to or
better than the cost-share for those enrolled in our standard non-PDP EGWP Prescription Drug
Program.

• In our PDP EGWP, you have a pharmacy network that may include pharmacies that are out-of-

network or excluded for those enrolled in our standard non-PDP EGWP Prescription Drug Program.

• In our PDP EGWP, out-of-network pharmacies are not covered.

• There is custom coverage which includes coverage for some non-Medicare Part D prescription

drugs. Please contact customer service at 888-201-4265 for additional information.

We cover drugs, medications, and supplies as described below and on the following pages.

• Please remember that all benefits are subject to the definitions, limitations and exclusions in this

brochure and are payable only when we determine they are medically necessary.

• Your prescribers must obtain prior approval/authorizations for certain prescription drugs. Prior

approval/authorizations must be renewed periodically.

• Federal law prevents the pharmacy from accepting unused drugs, medications, and supplies.

• The Medicare Part D calendar year deductible is: $0 per person. This deductible applies to almost all
benefits in this Section. We added “(No deductible)” to show when the calendar year deductible
does not apply.

• Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how
cost-sharing works. Also, read Section 9 for information about how we pay if you have other
coverage.

Warning:If you opt out of or disenroll from our PDP EGWP, you will not have any PSHB
Program prescription drug coverage.  However, you can enroll in our High Option MAPD during
Open Season or for a qualifying life event (QLE) and receive PSHB Program Prescription Drug
Coverage. Call APWU Health Plan at 800-222-2798 for more information.

Note:  If you choose to opt out of or disenroll from our PDP EGWP, your premium will not be
reduced, and you may have to wait to re-enroll during Open Season or for a QLE.  If you do not
maintain creditable coverage, re-enrollment in our PDP EGWP may be subject to a late
enrollment penalty. Call APWU Health Plan at 800-222-2798 for more information.

Each new enrollee will receive a description of our PDP EGWP Summary of Benefits, a combined
prescription drug/Plan identification card, a mail order form/patient profile and a preaddressed reply
envelope.

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CDHP

There are important features you should be aware of.  These include:

• Who can write your prescription.  A licensed physician or dentist, and in states allowing it, licensed/certified providers
with prescriptive authority prescribing within their scope of practice must prescribe your medication. Your prescribers
must have Medicare-approved prescriptive authority.

• Where you can obtain prescription drugs. You may fill prescriptions at any network pharmacy. For assistance locating a

PDP EGWP network pharmacy, contact UnitedHealthcare MedicareRx Part D at 888-201-4265.

• We have a managed formulary. Your provider may prescribe drugs that are subject to additional review to determine

they are medically necessary. For information on our formulary, contact UnitedHealthcare MedicareRx Part D at
888-201-4265.

• These are the dispensing limitations:

-  Quantity limits - The plan will only cover a certain amount of this drug for 1 copay/coinsurance or over a certain

number of days. These limits can help ensure safe and effective use of the drug. If you are prescribed more than this
amount or your doctor or prescriber thinks the limit is not right for your situation, you or your doctor or prescriber can
ask the plan to cover the additional quantity.

-  Morphine Milligram Equivalent - Additional quantity limits may apply to all opioid drugs used to treat pain. This
additional limit is called a cumulative Morphine Milligram Equivalent (MME). It's designed to monitor safe dosing
levels of opioids for people who may be taking more than 1 opioid drug for pain management. If your doctor or
prescriber prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor or
prescriber can ask the plan to cover the additional quantity. 7-day limit
An opioid drug used to treat pain may be limited to a 7-day supply if you don't have a recent history of using opioids.
This limit helps minimize long-term opioid use. If you are new to the plan and have a recent history of using opioids,
the pharmacy may override the limit when appropriate.

-  Dispensing limit - Dispensing limits may apply to certain drugs limiting to a 1-month supply per prescription.

• We may require Utilization Management strategies:

-  Step Therapy  – There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may
be required to try 1 or more of these other drugs before the plan will cover your drug. If you have already tried other
drugs or your doctor or prescriber thinks they are not right for you, you or your doctor or prescriber can ask the plan to
cover this drug.

-  Prior Authorization – The plan requires you or your doctor or prescriber to get prior approval for certain drugs. This

means the plan needs more information from your doctor or prescriber to make sure the drug is being used and covered
correctly by Medicare for your medical condition. Certain drugs may be covered by either Medicare Part B (doctor and
outpatient health care) or Medicare Part D (prescription drugs) depending on how it is used. If you don’t get prior
approval, the plan may not cover the drug.

-  Quantity Limits – The plan will only cover a certain amount of this drug for 1 copay/coinsurance or over a certain
number of days. These limits can help ensure safe and effective use of the drug. If you are prescribed more than this
amount or your doctor or prescriber thinks the limit is not right for your situation, you or your doctor or prescriber can
ask the plan to cover the additional quantity.

• You may request a Formulary Exception.

-  How can I get an exception? Sometimes you may need to ask for drug coverage that’s not normally provided by your
plan. This is called asking for an exception. When you do, the plan will review your request and give you a coverage
decision known as a coverage determination.

-  Types of exceptions you can ask for:

 -  Drug List exception: Ask the plan to cover your drug even if it’s not on the Drug List. If approved, this drug will be
covered at a pre-determined cost-sharing level. You will not be able to ask us to provide the drug at a lower cost-
sharing level.

 -  Utilization exception: Ask the plan to revise the coverage rules or limits on your drug. For example, if your drug has

a quantity limit, you can ask the plan to change the limit and cover more.

 -  Tiering exception: Ask the plan to cover your drug on our list at a lower cost-sharing level if this drug is not on the
Specialty Tier. The plan may approve your request for an exception if the covered alternative drugs wouldn’t be as
effective in treating your condition or would cause adverse medical effects.

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-  Who can ask for an exception? You, your authorized representative, doctor or prescriber can ask for an exception by

calling Customer Service. Your doctor or prescriber must give us a supporting statement with the reason for the
exception.

-  How long does it take to get an exception? After we get the statement from your doctor or prescriber supporting your
request for an exception, we’ll give you a decision within 72 hours. You can ask for an expedited (fast) decision if you
or your doctor or prescriber believes that your health could be seriously harmed by waiting 72 hours. If your request for
an expedited review is approved, we’ll give you a decision within 24 hours after we get your doctor’s or prescriber's
supporting statement. Contact UnitedHealthcare MedicareRx Part D for more information at 888-201-4265.

• A generic equivalent will be dispensed if it is available unless your physician specifically requires a brand name drug.

• Why use generic drugs. Generic drugs have the same active ingredients as brand name drugs. They usually cost less than

brand name drugs and generally work just as well. They usually don't have well-known names. Generic drugs are
approved by the Food and Drug Administration (FDA). There are generic drugs available for many brand name drugs.
Depending on state laws, generic drugs usually can be substituted for brand name drugs at the pharmacy without a new
prescription. Our plan covers both brand name and generic drugs. Talk with your doctor or prescriber to see if any of the
brand name drugs you take have generic versions.

• When you do have to file a claim. You may have to file a claim if you had to pay prescription costs up front or if you
were overseas. Members can sign in or create an account to file a claim. Visit https://retiree.uhc.com/apwuhppartd

• If we deny your claim and you want to appeal, you, your representative, or your prescriber must request an appeal

following the process described in Section 8(a). Medicare PDP EGWP Disputed Claims Process. The PDP EGWP appeals
process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next
level. At each level, you'll get instructions in the decision letter on how to move to the next level of appeal.

PDP EGWP Catastrophic Maximum

You will have a separate $2,000 out-of-pocket maximum for your prescription costs. Once you reach this maximum, you will
no longer pay a cost share for covered drugs. Your portion of this $2,000 will also apply to the Plan’s out-of-pocket
maximum. See Section 4 for details on the out-of-pocket maximum.

Benefits Description

You pay

Covered medications and supplies

Consumer Driven Option

You may purchase the following medications and supplies prescribed by
a physician from either a pharmacy or by mail:

•  Drugs and medications (including those administered during a non-

covered admission or in a non-covered facility) that by Federal law of
the United States require a physician’s prescription for their purchase,
except those listed as Not covered.

•  Insulin

-   You won’t pay more than $35 for a one-month supply of each

insulin product covered by our plan.

•  Diabetic supplies limited to:

-   Disposable needles and syringes for the administration of covered

medications

•  Drugs to treat gender dysphoria. See Section 5(b), Reconstructive

Surgery, for gender affirming care.

•  Medications prescribed to treat obesity.

•  Medical Foods (medical foods are excluded from coverage, see

Section 5(a), Treatment Therapies).

•  Sexual dysfunction drugs. Select erectile dysfunction and sexual

desire disorder drugs are covered under the plan with quantity limits
in place. Please contact customer service for more information.

Part D Retail:

•  1 month supply: Tier 1 - 25% of Plan
allowance up to a maximum of $20 per
prescription. Tier 2 - 25% of Plan allowance
up to a maximum of $45 per prescription.
Tier 3 - 40% of Plan allowance up to a
maximum of $100 per prescription. Tier 4 -
40% of Plan allowance up to a maximum of
$100 per prescription.

•  2 month supply: Tier 1 - 25% of Plan
allowance up to a maximum of $40 per
prescription. Tier 2 - 25% of Plan allowance
up to a maximum of $90 per prescription.
Tier 3 - 40% of Plan allowance up to a
maximum of $200 per prescription. Tier 4 -
40% of Plan allowance up to a maximum of
$200 per prescription.

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133

Benefits Description

You pay

Covered medications and supplies (cont.)

Consumer Driven Option

•  Select fertility drugs are covered under the plan. Please contact

Part D Retail:

CDHP

customer service for more information.

•  1 month supply: Tier 1 - 25% of Plan
allowance up to a maximum of $20 per
prescription. Tier 2 - 25% of Plan allowance
up to a maximum of $45 per prescription.
Tier 3 - 40% of Plan allowance up to a
maximum of $100 per prescription. Tier 4 -
40% of Plan allowance up to a maximum of
$100 per prescription.

•  2 month supply: Tier 1 - 25% of Plan
allowance up to a maximum of $40 per
prescription. Tier 2 - 25% of Plan allowance
up to a maximum of $90 per prescription.
Tier 3 - 40% of Plan allowance up to a
maximum of $200 per prescription. Tier 4 -
40% of Plan allowance up to a maximum of
$200 per prescription.

•  3 month supply: Tier 1 - 25% of Plan
allowance up to a maximum of $60 per
prescription. Tier 2 - 25% of Plan allowance
up to a maximum of $135 per prescription.
Tier 3 - 40% of Plan allowance up to a
maximum of $300 per prescription. Tier 4 -
40% of Plan allowance up to a maximum of
$300 per prescription.

Part D Mail Order:

•  1 month supply: Tier 1 - 25% of Plan
allowance up to a maximum of $20 per
prescription. Tier 2 - 25% of Plan allowance
up to a maximum of $45 per prescription.
Tier 3 - 40% of Plan allowance up to a
maximum of $100 per prescription. Tier 4 -
40% of Plan allowance up to a maximum of
$100 per prescription.

•  2 month supply: Tier 1 - 25% of Plan
allowance up to a maximum of $40 per
prescription. Tier 2 - 25% of Plan allowance
up to a maximum of $90 per prescription.
Tier 3 - 40% of Plan allowance up to a
maximum of $200 per prescription. Tier 4 -
40% of Plan allowance up to a maximum of
$200 per prescription.

•  3 month supply: Tier 1 - 25% of Plan
allowance up to a maximum of $40 per
prescription. Tier 2 - 25% of Plan allowance
up to a maximum of $90 per prescription.
Tier 3 - 40% of Plan allowance up to a
maximum of $200 per prescription. Tier 4 -
40% of Plan allowance up to a maximum of
$200 per prescription.

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Benefits Description

You pay

Covered medications and supplies (cont.)

Consumer Driven Option

Contraceptive drugs and devices as listed in the Health Resources and
Services Administration site https://www.hrsa.gov/womens-guidelines.

Nothing

CDHP

Contraceptive coverage is available at no cost to PSHB members. The
contraceptive benefit includes at least one option in each of the HRSA-
supported categories 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.

•  Over-the-counter and prescription drugs approved by the FDA to

prevent unintended pregnancies.

•  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. Express Scripts
responds to contraception exception requests within 24 hours of
receipt of sufficient information to make a coverage determination.

•  Reimbursement for covered over-the-counter contraceptives can be

submitted in accordance with Section 7.

Note: If you have concerns about the Health Plan’s compliance with the
ACA/HRSA requirements or have difficulty accessing contraceptive
coverage or other reproductive healthcare, contact
contraception@opm.gov. See OPM’s web page about contraception.

Note: For additional Family Planning benefits see Section 5(a)

Over-the-counter and appropriate prescription drugs approved by the
FDA to treat tobacco dependence are covered under the Tobacco
Cessation Educational Classes and Programs in Section 5(a).

Not covered

•  Drugs and supplies for cosmetic purposes

•  Drugs to enhance athletic performance

•  Drugs obtained at a non-Plan pharmacy; except for out-of-area

emergencies

•  Non-prescription medications medicines

Preventive medication

The following are covered:

Preventive Medications with USPSTF A and B recommendations. 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

All charges

Consumer Driven Option

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

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Benefits Description

You pay

Preventive medication (cont.)

Consumer Driven Option

CDHP

Opioid rescue agents such as naloxone are covered under this Plan with
no cost sharing when obtained from a network pharmacy in any over-
the-counter or prescription form available such as nasal sprays and
intramuscular injections.

Nothing

For more information consult the FDA guidance at https://www.fda.gov/
consumers/consumer-updates/access-naloxone-can-save-life-during-
opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go
to https://www.findtreatment.samhsa.gov/.

Not covered:

•  Drugs and supplies for cosmetic purposes

•  Nonprescription medications

All charges

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CDHP

Section 5(g). Dental Benefits

Important things to keep in mind about these benefits:

• Refer to Personal Care Account (PCA).

Benefit

Dental benefits

No benefit

You Pay
Consumer Driven Option

See Section 5, Personal Care Account

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CDHP Section 5(g)

Section 5(h). Wellness and Other Special Features

CDHP

Special features

Flexible benefits option

Description

Under the flexible benefits option, we determine the most effective way to provide
services.

•  We may identify medically appropriate alternatives to regular contract benefits as a

less costly alternative. If we identify a less costly alternative, we will ask you to sign
an alternative benefits agreement that will include all of the following terms in
addition to other terms as necessary. Until you sign and return the agreement, regular
contract benefits will continue.

•  Alternative benefits will be made available for a limited time period and are subject to

our ongoing review. You must cooperate with the review process.

•  By approving an alternative benefit, we do not guarantee you will get it in the future.

•  The decision to offer an alternative benefit is solely ours, and except as expressly
provided in the agreement, we may withdraw it at any time and resume regular
contract benefits.

•  If you sign the agreement, we will provide the agreed-upon alternative benefits for the
stated time period (unless circumstances change). You may request an extension of the
time period, but regular contract benefits will resume if we do not approve your
request.

•  Our decision to offer or withdraw alternative benefits is not subject to OPM review
under the disputed claims process.  However, if at the time we make a decision
regarding alternative benefits, we also decide that regular contract benefits are not
payable, then you may dispute our regular contract benefits decision under the OPM
disputed claim process, see Section 8.

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CDHP

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

Special Features

Description

Online tools and resources

•  Your Personal Care Account balance and activity (also mailed quarterly)

•  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 UnitedHealthcare's mobile app for the same great features

Consumer choice information

Each member is provided access by Internet (www.myuhc.com) or telephone
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.

•  UnitedHealthcare Hearing - Call 855-523-9355 or visit

www.UHCHearing.com for hearing aids, care options and dedicated support.

•  Careington Dental - A dental discount plan that gives members access

to discounts ranging from 20-50% on procedures using a network provider. For
more information on the discounts and providers visit www.welcometouhc.com/
apwu.

•  One Pass Select TM – visit www.WeRally.com or call 877-515-9364 to sign up
for One Pass, a gym membership discount program offering access to national
gym memberships, online fitness classes and Grocery Delivery service.

Special Features - continued on next page

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Special Features (cont.)

Wellness Incentive

Health Risk Assessment

High Risk Maternity

CDHP

Description

Receive $25 for each of the following wellness visits - annual physical, mammogram
and cervical screening with a clinical professional each year.

When you complete these wellness visits, if you have Self Only coverage, we will
add $25 to your Personal Care Account (PCA) for each. 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 these wellness
visits. We will add these amounts in the calendar year in which the visits are
completed with a maximum of $75 per member.

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.

Members can enroll in our Maven (virtual maternity support program) which provide
support in every stage of pregnancy including, self measured blood pressure
monitoring and support.

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Non-PSHB Benefits Available to Plan Members

The benefits on this page are not part of the PSHB contract or premium, and you cannot file a PSHB disputed claim about
them. Fees you pay for these services do not count toward PSHB 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.

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. PSHB 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 PSHB premium and any charges for these
services do not count toward any PSHB deductibles, out-of-pocket maximum, copay, charges, etc. These benefits are not
subject to the PSHB 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 VBPlan@alliant.com.  Please specify that
you are an APWU Health Plan participant. This optional dental plan is an indemnity insurance plan underwritten by the
Metropolitan Life Insurance Company, New York, New York.

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 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).

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Non-PSHB 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 Sections

3 and 5(f)

• 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 PSHB 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 in Section 3.

• 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 Section 9, When you are 65 or over and do not have Medicare, doctor
charges exceeding the amount specified by the Department of Health and Human Services when benefits are payable
under Medicare limiting charge, see Section 9, 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.

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Section 6

• 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.

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Section 6

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.

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.
Submit claims to the address on the back of your APWU Health Plan ID card.

If you need assistance or when you must file a claim for reimbursement for services such
as dental, out-of-network providers, and overseas, please see below:

High Option (Medical and Behavioral Health)

For claims questions and assistance, call us at 800-222-2798, or visit our website at
www.apwuhp.com.

Mail claims to:

•  APWU Health Plan, P.O. Box 8660, Elkridge, MD 21075

High Option (Pharmacy)

Mail claims to:

•  Express Scripts, Attn: Commercial Claims, P.O. Box 14711, Lexington, KY

40512-4711

Consumer Driven Option (Medical, Behavioral Health and Pharmacy)

For claims questions and assistance, contact UnitedHealthcare at 800-718-1299 or visit
their website at www.myuhc.com.

Mail all claims to:

•  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.

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Section 7

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.

We will notify you of our decision within 30 days after we receive your post-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 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.

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.

Send us all the documents for your claim as soon as possible.  You must submit the 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.

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 8660, Elkridge, MD 21075.

•  Consumer Driven Option: UnitedHealthcare at the claims address shown on the back

of your UnitedHealthcare ID card.

Please reply promptly when we ask for additional information. We may delay processing
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.

You may designate an authorized representative to act on your behalf for filing a claim or
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.

How to claim benefits

Post-service claims
procedures

Records

Deadline for filing your
claim

Overseas claims

When we need more
information

Authorized
Representative

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Section 7

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.

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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. If you are a Postal Service
annuitant, or their covered Medicare-eligible family member, enrolled in our Medicare Part D Prescription Drug Plan (PDP)
Employer Group Waiver Plan (EGWP) and you disagree with our pre-service or post-service decision about your
prescription drug benefits, please, follow Medicare's appeals process outlined in Section 8a. Medicare PDP EGWP Disputed
Claims Process.

Please follow this Postal Service 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 8660, Elkridge, MD 21075 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

1

Ask us in writing to reconsider our initial decision. You must:

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 8660, Elkridge, MD 21075 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.

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Section 8

2

3

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:

1. Pay the claim or

2. Write to you and maintain our denial or.

3. 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.

You must write to OPM within:

•  90 days after the date of our letter upholding our initial 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, Postal
Service Insurance Operations, 1900 E Street, NW, Washington, DC 20415.

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.

4

OPM will review your disputed claim request and will use the information it collects from you and us to
decide whether our decision is correct. OPM will send you a final decision or notify you of the status of
OPM's review within 60 days. There are no other administrative appeals.

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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 OPM's PSIO at 202-936-0002 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.

Reminder: If you are a Postal Service annuitant, or their covered Medicare-eligible family member, enrolled in our Medicare
Part D PDP EGWP you may appeal an adverse pre-service or post-service determination through Medicare's appeals process.
See Section 8(a).

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Section 8(a). Medicare PDP EGWP Disputed Claims Process

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a
formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we followed all of the rules
properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we
have completed the review we give you our decision.

Consumer Driven

How to appeal a decision about your prescription coverage

Appeal Level 1 - You may ask us to review an unfavorable coverage decision we’ve issued to you, even if only part of our
decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan
"redetermination."

Appeal Level 2 – If we reviewed your appeal at “Appeal Level 1” and did not decide in your favor, you have the right to
appeal to the Independent Review Entity (IRE).

When we receive your request to review the adverse coverage determination, we give the request to people at our
organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.

To file an appeal:

• Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Provide your
name, your member identification number, your date of birth, and the drug you need. You may also request an appeal by
downloading and mailing in the Redetermination Request Form (pdf) or by secure email.

Send the letter or the Redetermination Request Form to the Medicare Part D Appeals and Grievance Department PO Box
6106, M/S CA 124-0197, Cypress CA 90630-9948. You may also fax your letter of appeal to the Medicare Part D Appeals
and Grievances Department at 1-866-308-6294. You must mail your letter within 60 days of the date the adverse
determination was issued, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day
deadline, you may still file your appeal if you provide a valid reason for missing the deadline.

• You can also submit an appeal online: Medicare Plan Appeals & Grievances Online Form.

• Note: if you are requesting an expedited (fast) appeal, you may also contact customer service

• The Medicare Part D Appeals and Grievance Department will look into your case and respond with a letter within 7
calendar days of receiving your request. You'll receive a letter with detailed information about the coverage denial.

• The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.

High Option

Grievance Contact Information

Use this contact information to file a grievance.

• Write: Express Scripts Medicare, Attn: Grievance Resolution Team, PO Box 3610, Dublin, OH 43016-0307

• Call: 1-844-818-8790 / 1-800-716-3231(TTY)

• Fax: 1-614-907-8547

• Hours: 24 hours a day / 7 days a week

Initial Coverage Reviews

Use this contact if you need an initial coverage decision for a medication that must be approved before the prescription can
be filled at a participating retail or home delivery pharmacy, or to remove or change a restriction on a specific medication.

• Write: Express Scripts, Attn: Medicare Reviews, PO Box 66571, St. Louis, MO 63166-6571

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• Call: 1-844-374-7377 / 1-800-716-3231(TTY)

• Fax: 1-877-251-5896

• Hours: 24 hours a day / 7 days a week

Appeals Contact Information

Use this contact information if you need to file an appeal because your coverage review was denied or because your request
to remove or change a restriction was denied.

• Write: Express Scripts, Attn: Medicare Appeals, PO Box 66588, St. Louis, MO 63166-6588

• Call: 1-844-374-7377 / 1-800-716-3231(TTY)

• Fax: 1-877-852-4070

• Hours: 24 hours a day / 7 days a week

Paper Claim Submission

Mail requests with receipts to obtain payment for medication already received to: Express Scripts, Attn: Medicare Part D, PO
Box 14718, Lexington, KY 40512-4718

To obtain a Direct Claim Form: download from our website, express-scripts.com, in the Medicare Resources Center found in
the Benefits menu, or call Customer Service.

The Direct Claim Form is not required, but it will help us proceed the information faster. It's a good idea to make a copy of
all your receipts for your records. You can fax us your request for payment 24 hours a day, 7 days a week to 1-608-741-5483.

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Section 9. Coordinating benefits with Medicare and other coverage

When you have other
health coverage

You must tell us if you or a covered family member has coverage under any other health
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 is the healthcare program for eligible dependents of military persons, and
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 PSHB coverage to enroll in TRICARE or CHAMPVA: If you are an
annuitant, you can suspend your PSHB coverage to enroll in one of these programs,
eliminating your PSHB premium. (OPM does not contribute to any applicable plan
premiums.) For information on suspending your PSHB enrollment, contact your
retirement or employing office. If you later want to re-enroll in the PSHB Program,
generally you may do so only at the next Open Season unless you involuntarily lose
coverage under TRICARE or CHAMPVA.

TRICARE and
CHAMPVA

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Workers’ Compensation

Every job-related injury or illness should be reported as soon as possible to your
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.

When other Government
agencies are responsible
for your care

When others are
responsible for injuries

Suspended PSHB coverage to enroll in Medicaid or a similar state-sponsored
program of medical assistance: If you are an annuitant, you can suspend your PSHB
coverage to enroll in one of these state programs, eliminating your PSHB premium. For
information on suspending your PSHB enrollment, contact your retirement or employing
office. If you later want to re-enroll in the PSHB Program, generally you may do so only
at the next Open Season unless you involuntarily lose coverage under the State program.

We do not cover services and supplies when a local, state, or federal government agency
directly or indirectly pays for them.

The terms “Reimbursement” and “Subrogation” are defined by the U.S. Office of
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.

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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 PSHB 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.

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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 subroinfo@odsalaw.com, 877-535-1075 or 202-898-1075

Consumer Driven Option: UnitedHealthcare, 800-718-1299

Some PSHB plans already cover some dental and vision services. When you are covered
by more than one vision/dental plan, coverage provided under your PSHB plan remains as
your primary coverage. FEDVIP coverage pays secondary to that coverage. When you
enroll in a dental and/or vision plan on www.benefeds.gov or by phone at
1-877-888-3337, (TTY 1-877-889-5680), you will be asked to provide information on
your PSHB plan so that your plans can coordinate benefits. Providing your PSHB
information may reduce your out-of-pocket cost.

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

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

Clinical trials

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•  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 “When do 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 Medicare
Plan (Part A or Part B)

Important Note: Subject to limited exceptions, Postal Service annuitants entitled to
Medicare Part A and their eligible family members who are entitled to Medicare Part A are
required to enroll in Medicare Part B to maintain eligibility for the PSHB Program in
retirement.

If you are required to enroll in Medicare Part B and fail to do so at your first opportunity,
you may be disenrolled (annuitants) and/or your family members removed from
coverage.

For more information on these requirements, please contact the PSHB Helpline at
1-844-451-1261.

The Original Medicare Plan (Original Medicare) is available everywhere in the United
States. It is the way everyone used to get Medicare benefits and is the way most people
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.

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Tell us about your
Medicare coverage

Private contract with
your physician

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.

Retirees that participate with Medicare Part B may request reimbursement for their Part B
premiums, if PCA funds are available (see Section 5, PCA).

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 this information.  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.

You must tell us if you or a covered family member has Medicare coverage, and let us
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.

If you are enrolled in Medicare Part B, a physician may ask you to sign a private contract
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.

If you are eligible for Medicare, you may choose to enroll and get your Medicare benefits
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: If you elect to enroll in our Medicare
Advantage plan you must also remain enrolled in our PSHB 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.

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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 $100 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. 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
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -
(UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): $0

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
UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan -
(UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network):
$100 per month

Benefit Description: Primary Care Provider
High Option You Pay without Medicare (In-Network): $25
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: Specialist
High Option You Pay without Medicare (In-Network): $25
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: Inpatient Hospital
High Option You Pay without Medicare (In-Network): 15%
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

Medicare Advantage
(Part C)

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Benefit Description: Outpatient Hospital
High Option You Pay without  Medicare (In-Network): 15%
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: 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 -
(UnitedHealthcare Medicare Advantage (PPO) for APWU Health Plan) (In-network): gym
memberships, dental, vision, eyewear allowance every 24 months (glasses and contacts),
podiatry, hearing aids and a 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
non-PSHB plan’s Medicare Advantage plan and also remain enrolled in our PSHB 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 PSHB coverage to enroll in a Medicare Advantage plan: If you are an
annuitant, you can suspend your PSHB coverage to enroll in a Medicare Advantage plan,
eliminating your PSHB premium.  (OPM does not contribute to your Medicare Advantage
plan premium.)  For information on suspending your PSHB enrollment, contact your
retirement or employing office.  If you later want to re-enroll in the PSHB 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.

If you elect to enroll in APWU Health Plan’s PSHB Medicare Advantage plan it will take
over as the primary and only payer so you will not need to coordinate benefits, however,
you must remain enrolled in the APWU Health Plan High Option if you elect the
Medicare Advantage plan. Do not suspend or cancel your coverage with OPM or you will
also be terminated from the Medicare Advantage plan.

When we are the primary payor, we process the claim first. If you (as an active employee
eligible for Medicare Part D or their covered Medicare Part D-eligible family member)
enroll in any open market Medicare Part D plan and we are the secondary payor, we will
review claims for your prescription drug costs that are not covered by that Medicare Part
D plan and consider them for payment under the PSHB plan.

Note: If you are a Postal Service annuitant or their covered Medicare-eligible family
member enrolled in our Medicare Part D PDP EGWP, this does not apply to you because
you may not be enrolled in more than one Medicare Part D plan at the same time. If you
opt out of or disenroll from our PDP EGWP you do not have our PSHB Program
prescription drug coverage and we are not a secondary payor for prescription drug
benefits.

Medicare Part D
Prescription Drug Plans

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Medicare Prescription
Drug Plan (PDP)
Employer Group Waiver
Plan (EGWP)

If you are enrolled in Medicare, and are not enrolled in a Medicare Advantage Plan (Part
C), you will be automatically enrolled in the Medicare Prescription Drug Plan (PDP)
Employer Group Waiver Plan (EGWP) for APWU Health Plan. Our PDP EGWP is a
prescription drug benefit for Postal Service annuitants and their covered Medicare-eligible
family members. This allows you to receive benefits that will never be less than the
standard prescription drug coverage that is available to members with non-PDP EGWP
prescription drug coverage. But more often you will receive benefits that are better than
members with standard non-PDP EGWP prescription drug coverage. Note:You have the
choice to opt out of or disenroll from our PDP EGWP at any time and may obtain
prescription drug coverage outside of the PSHB Program.

When you are enrolled in our Medicare PDP EGWP for your prescription drug benefits
you continue to have our medical coverage.

See our Health Plan specific details: for the High Option and Consumer Driven Plans
refer to Section 5(f)(a)

Members with higher incomes may have a separate premium payment for their Medicare
Part D Prescription Drug Plan (PDP) benefit. Please refer to the Part D-IRMAA section of
the Medicare website: https://www.medicare.gov/drug-coverage-part-d/costs-for-
medicare-drug-coverage/monthly-premium-for-drug-plans to see if you would be subject
to an additional premium.

For people with limited income and resources, Extra Help is a Medicare program to help
with Medicare prescription drug plan costs.  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 may
also contact APWU Health Plan at 800-222-2798.

The PDP EGWP opt out process:

If you were automatically group enrolled into our PDP EGWP and choose to opt out, you
may contact APWU Health Plan at 800-222-2798.

The PDP EGWP disenrollment process:

When you are enrolled in our PDP EGWP, you may choose to disenroll at any time. You
may contact APWU Health Plan at 800-222-2798 to opt out.

Warning:If you opt out of or disenroll from our PDP EGWP, you will not have any
PSHB Program prescription drug coverage. However, you can enroll in our High
Option MAPD during Open Season or for a QLE and receive PSHB Program Prescription
Drug Coverage. Contact APWU Health Plan at 800-222-2798 for more information.

Note: If you choose to opt out of or disenroll from our PDP EGWP, your premium
will not be reduced, and you may have to wait to re-enroll when and if you are
eligible.  If you do not maintain creditable coverage, re-enrollment in our PDP EGWP
may be subject to a late enrollment penalty. Contact APWU Health Plan at 800-222-2798
for more information.

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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.)

The primary payor for the
individual with Medicare is...

Medicare

This Plan

for Part B
services

for other

services

*

A.  When you - or your covered spouse - are age 65 or over and have Medicare and you...

Primary Payor Chart

1)  Have PSHB coverage on your own as an active employee

2)  Have PSHB coverage on your own as an annuitant or through your spouse who is an

annuitant

3)  Have PSHB through your spouse who is an active employee

4)  Are a reemployed annuitant with the Postal Service and your position is excluded from the
PSHB (your employing office will know if this is the case) and you are not covered under
PSHB through your spouse under #3 above

5)  Are a reemployed annuitant with the Postal Service and your position is not excluded from

the PSHB (your employing office will know if this is the case) and...
• You have PSHB coverage on your own or through your spouse who is also an active
employee
• You have PSHB coverage through your spouse who is an annuitant

6)  Are enrolled in Part B only, regardless of your employment status

7)  Are a Postal employee receiving Workers' Compensation

8)  Are a Postal 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 PSHB coverage on your own as an active employee or through a family member who is

an active employee

2)  Have PSHB coverage on your own as an annuitant or through a family member who is an

annuitant

*Workers' Compensation is primary for claims related to your condition under Workers' Compensation.

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

Under the FEHB law, which includes the PSHB Program, 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 PSHB 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 family member of an annuitant; and

• are not employed in a position that gives PSHB 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,
Then you are responsible for:
your deductibles, coinsurance, copayments, and any balance up to the Medicare approved amount.

If your physician:
Does not participate with Medicare,
Then you are responsible for:
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
Then you are responsible for:
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
Then you are responsible for:
your deductibles, coinsurance, copayments, and any balance your physician charges

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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
Original Medicare Plan
(Part A, Part B, or both)

We limit our payment to an amount that supplements the benefits that Medicare would
pay under Medicare Part A (Hospital insurance) and Medicare Part B (Medical insurance),
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.

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Section 10. High Option Health Plan Definitions

Accidental injury

An injury resulting from a violent external force.

Admission

Assignment

Calendar year

Clinical trials cost categories

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.

An authorization by you (the enrollee or covered family member) that is approved
by us (the Carrier), for us to issue payment of benefits directly to the provider.

•  We reserve the right to pay you directly for all covered services. Benefits

payable under the contract are not assignable by you to any person without
express written approval from us, and in the absence of such approval, any
assignment shall be void.· We reserve the right to pay you directly for all
covered services. Benefits payable under the contract are not assignable by you
to any person without express written approval from us, and in the absence of
such approval, any assignment shall be void.

•  Your specific written consent for a designated authorized representative to act
on your behalf to request reconsideration of a claim decision (or, for an urgent
care claim, for a representative to act on your behalf without designation) does
not constitute an Assignment.

•  OPM’s contract with us, based on federal statute and regulation, gives you a
right to seek judicial review of OPM's final action on the denial of a health
benefits claim but it does not provide you with authority to assign your right to
file such a lawsuit to any other person or entity. Any agreement you enter into
with another person or entity (such as a provider, or other individual or entity)
authorizing that person or entity to bring a lawsuit against OPM, whether or not
acting on your behalf, does not constitute an Assignment, is not a valid
authorization under this contract, and is void.

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.

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.

Coinsurance

See Section 4, Coinsurance.

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Copayment

Cost-sharing

See Section 4, Copayment.

See Section 4, Cost-sharing.

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, Deductible.

Experimental or investigational
services

Gender affirming services

A drug, device, or biological product is experimental or investigational if the drug,
device, or biological product cannot be lawfully marketed without approval of the
U.S. Food and Drug 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.

Healthcare that can include therapy to address feelings of gender dysphoria, as well
as medical treatments that help individuals achieve physical characteristics that
better align with their gender identity.

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Genetic screening

Genetic testing

Group health coverage

Habilitative services

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.

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.

Healthcare coverage that a member is eligible for because of employment by,
membership in, or 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.

Healthcare services that help a person keep, learn or improve skills and functioning
for daily 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 professional

A physician or other healthcare professional licensed, accredited, or certified to
perform specified health services consistent with state law.

Home healthcare agency

An agency which meets all of the following:

•  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

A coordinated program of home and inpatient palliative and supportive care for the
terminally ill patient and the patient's family provided by a medically supervised
specialized team under the direction of a duly licensed or certified Hospice Care
Program.

Infertility is defined as: The inability to conceive after 1 year of regular unprotected
sexual intercourse for an individual with female reproductive organs under 35 years
of age. The inability to conceive after 6 months for an individual with female
reproductive organs over age 35 years of age. The inability to conceive after 1 year
of artificial insemination (AI) for those under age 35 and 6 months for those over
age 35. The diagnosis of a disease or condition of the male or female reproductive
tract such that regular unprotected sex or artificial insemination would be
ineffective. The inability to carry a pregnancy to delivery.

Includes but is not limited to physical, occupational, or speech therapy where
continued therapy is not expected to result in significant restoration of a bodily
function but is utilized to maintain the current status.

Services, drugs, supplies or equipment provided by a hospital or covered provider
of healthcare 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

Hospice care program

Infertility

Maintenance therapy

Medical necessity

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Medicare Part A

Medicare Part B

Medicare Part C

Medicare Part D

Medicare Part D EGWP

Plan allowance

•  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.

Part A helps cover inpatient hospital stays, skilled nursing facility care, hospice
care, and some home healthcare.

Part B covers medically necessary services like doctors’ services and tests,
outpatient care, home health services, durable medical equipment, and other
medical services.

Part C is a Medicare Advantage plan that combines the coverage of Medicare Part A
and Part B.  Part C typically also covers additional benefits like, dental, vision, and
hearing services. Some Part C plans also include Medicare Part D coverage.

Medicare Part D plans provide coverage for prescription drugs. Private insurers
contract with CMS on an annual basis for the right to offer Part D plans. Part D can
be offered as a standalone Prescription Drug Plan (PDP) or as part of a Medicare
Advantage Prescription Drug Plan (MAPD).

A Medicare Part D Employer Group Waiver Plan (EGWP) is a type of Medicare
prescription drug plan that can be offered to employees and retirees of certain
companies, unions, or government agencies, which allows for flexibility and
enhanced coverage of traditional Medicare pharmacy benefits. Examples of
Medicare Part D EGWPs are Medicare Advantage Prescription Drug (MAPD) plan
EGWPs that include both health and drug benefits, as well as Prescription Drug
Plan (PDP) EGWPs, which only cover the prescription drug benefit.

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.

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Post-service claims

Pre-service claims

Rehabilitative care

Reimbursement

Residential Treatment Center

Subrogation

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.

Any claims that are not pre-service claims. 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.

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.

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.

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 Treatment Centers (RTCs) are accredited by a nationally recognized
organization 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.

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.

Surprise bill

An unexpected bill you receive for:

Urgent care claims

•  emergency care – when you have little or no say in the facility or provider from

whom you receive care, or for

•  non-emergency services furnished by nonparticipating providers with respect to

patient visits to participating healthcare facilities, or for

•  air ambulance services furnished by nonparticipating providers of air ambulance

services.

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.

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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.

Us and We refer to APWU Health Plan.

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.

Us/We

Virtual visits

You

You refers to the enrollee and each covered family member.

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Section 10. Consumer Driven Health Plan Definitions

Consumer Driven Option

Deductible

Personal Care Account

Rollover

A fee-for-service option under the PSHB 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.

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 Section 4.

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).

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.

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Summary of Benefits for the High Option Plan - 2025

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 PSHB Brochure. You can also obtain a copy of our Summary
of Benefits and 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 office

PPO: $25 copay per covered office visit (no
deductible); 15% of the Plan allowance

Non-PPO: 40% of our allowance plus amount
over allowance

Services provided by a hospital: Inpatient

PPO: 15% of the covered charges

Services provided by a hospital: Outpatient

Non-PPO: $300 admission and 40% of the
covered charges and any difference between
our allowance and the billed amount

PPO: 15% of the Plan allowance (calendar
year deductible applies)

Non-PPO: 40% of the Plan allowance and any
difference between our allowance and the
billed amount (calendar year deductible
applies)

Emergency benefits: Accidental injury

In-network: 15% of the Plan allowance

Emergency benefits: Medical emergency (other than an
Urgent Care)

Mental health and substance misuse disorder
treatment:

Out-of-network: 15% of the Plan allowance

In-network: 15% of the Plan allowance

Out-of-network: 15% of the Plan allowance

PPO:  $25 copayment (No deductible)

Non-PPO:  40% of the Plan allowance and
any difference between our allowance and the
billed charges

36

58

60

63

63

66

Prescription drugs: Retail pharmacy

•  Network Retail: $10 Tier 1. 25% Tier 2

71

up to a maximum of $200 coinsurance per
prescription for a 30-day supply. 45% Tier
3 up to a maximum of $300 coinsurance
per prescription for a 30-day supply

•  Non-network Retail: 50% of cost for a

30-day supply

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High Option Summary

High Option Benefits

Prescription drugs: Mail order

You pay

Page

•  Network Mail Order: $20 Tier 1. 25%

71

Specialty drugs

72

Tier 2 up to a maximum of $300
coinsurance per prescription for a 90-day
supply. 45% Tier 3 up to a maximum of
$500 coinsurance per prescription for a
90-day supply

•  Network Retail: 25% Tier 4 with up to a
maximum of $300 per prescription for a
30-day supply. 25% Tier 5 up to a
maximum of $600 coinsurance per
prescription for a 30-day supply. 45% Tier
6 up to a maximum of $1,000 coinsurance
per prescription for a 30-day supply

•  Non-network Retail: 50% of cost for a

30-day supply

•  Network Mail Order: 25% Tier 4 with up
to a maximum of $150 per prescription for
a 90-day supply. 25% Tier 5 up to a
maximum of $300 coinsurance per
prescription for a 90-day supply. 45% Tier
6 up to a maximum of $500 coinsurance
per prescription for a 90-day supply

Medicare PDP EGWP

Retail:

79

•  Up to 30-day supply: Tier 1 - $10. Tier

2 -25% of Plan allowance up to a
maximum of$200 per prescription for a
30-day supply. Tier 3 - 25% of Plan
allowance up to a maximum of $300 per
prescription for a 30-day supply. Tier 4 -
25% of Plan allowance up to a maximum
of $300 per prescription for a 30-day
supply.

•  Up to 90-day supply: Tier 1 - $20. Tier

2 -25% of Plan allowance up to a
maximum of$300 per prescription for a
90-day supply. Tier 3 - 25% of Plan
allowance up to a maximum of $500 per
prescription for a 90-day supply. Tier 4 -
25% of Plan allowance up to a maximum
of $300 per prescription for a 90-day
supply.

30% of the Plan allowance and any difference
between our allowance and the billed amount
(No deductible)

Dental care:

Special features:

See Section 5(h)

82

83

2025 APWU Health Plan

172

High Option Summary

Summary of Benefits for the Consumer Driven Option Plan - 2025

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 PSHB Brochure. You can also obtain a copy of our Summary
of Benefits and 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, $1,000 (PPO) or $1,500 (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

Personal Care Account (PCA)

A Personal Care Account (PCA) is provided
by the Plan for each enrollment. Each year the
Plan adds to your account:

•  $1,200 per year for a Self Only enrollment

or

•  $2,400 per year for a Self Plus One or Self

and Family enrollment

88

92

Medical services provided by physicians: Diagnostic
and treatment services provided in the office

In-network:  15% of the Plan allowance

97

Out-of-network:  50% of the Plan allowance
and any difference between our allowance and
the billed amount

Services provided by a hospital: Inpatient

In-network: 15% of the Plan allowance

116

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Services provided by a hospital: Outpatient

In-network: 15% of the Plan allowance

118

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

Emergency benefits: Accidental injury

In-network: 15% of the Plan allowance

118

Emergency benefits: Medical emergency (other than an
Urgent Care)

Out-of-network: 15% of the Plan allowance

In-network: 15% of the Plan allowance

118

Out-of-network: 15% of the Plan allowance

Mental health and substance use disorder treatment:

In-network: 15% of the Plan allowance

122

Out-of-network: 50% of the Plan allowance
and any difference between our allowance and
the billed amount

2025 APWU Health Plan

173

CDHP Summary

CDHP Benefits

Prescription drugs: Retail

You pay

•  Network Retail:

Page

126

-   Tier 1 and Tier 2 - 25% of charge with a
minimum of $15 and a maximum per
prescription of $200 for a 30-day
supply, $400 for a 60-day supply, $600
for a 90-day supply;

-   Tier 3 - 40% of charge with a minimum
$15 and a maximum per prescription of
$300 for a 30-day supply, $600 for a
60-day supply, $900 for a 90-day
supply

Prescription drugs: Mail Order

•  Network Home Delivery:

126

-   Tier 1 and Tier 2 - 25% of charge with a
minimum of $10 and a maximum per
prescription of $200 for a 30-day
supply, $400 for a 60-day supply, $600
for a 90-day supply;

-   Tier 3 - 40% of charge with a minimum
$10 and a maximum per prescription of
$300 for a 30-day supply, $600 for a
60-day supply, $900 for a 90-day
supply

Specialty drugs

•  Network Retail:

126

-   Tier 3 - 40% of charge with a minimum
$15 and a maximum per prescription of
$300 for a 30-day supply, $600 for a
60-day supply, $900 for a 90-day
supply

•  Network Home Delivery:

-   Tier 3 - 40% of charge with a minimum
$10 and a maximum per prescription of
$300 for a 30-day supply, $600 for a
60-day supply, $900 for a 90-day
supply

Medicare PDP EGWP

Part D Retail:

134

•  1 month supply: Tier 1 - 25% of Plan
allowance up to a maximum of $20 per
prescription. Tier 2 - 25% of Plan
allowance up to a maximum of $45 per
prescription. Tier 3 - 40% of Plan
allowance up to a maximum of $100 per
prescription. Tier 4 -40% of Plan
allowance up to a maximum of$100 per
prescription.

2025 APWU Health Plan

174

CDHP Summary

•  2 month supply: Tier 1 - 25% of Plan
allowance up to a maximum of $40 per
prescription. Tier 2 - 25% of Plan
allowance up to a maximum of $90 per
prescription. Tier 3 - 40% of Plan
allowance up to a maximum of $200 per
prescription. Tier 4 -40% of Plan
allowance up to a maximum of$200 per
prescription.

•  3 month supply: Tier 1 - 25% of Plan
allowance up to a maximum of $60 per
prescription. Tier 2 - 25% of Plan
allowance up to a maximum of $135 per
prescription. Tier 3 - 40% of Plan
allowance up to a maximum of $300 per
prescription. Tier 4 -40% of Plan
allowance up to a maximum of$300 per
prescription.

Dental services are reimbursable out of your
PCA.  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.

Dental care:

Special features:

See Section(5i)

137

139

2025 APWU Health Plan

175

CDHP Summary

Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

Index

Accidental injury

Claims ...12, 14-15, 23-25, 87, 92, 145-157,

CDHP ..........................................120-121
HO ..................................................62-64

Acupuncture

CDHP ............................................97-107
HO .......................................36-49, 83-84

Air Ambulance

CDHP ................19-21, 32, 120-121, 168
HO .........................19-21, 32, 62-64, 168

Allergy

CDHP ............................................97-107
HO ..................................................36-49

Alternative treatments

CDHP ............................................97-107
HO ..................................................36-49

Ambulance

CDHP ..............................29-32, 116-121
HO .....................29-32, 46-47, 58, 61, 63

Anesthesia

CDHP ........................29-31, 87, 115, 118
HO ................................29-31, 57, 60, 82

Applied Behavioral Health

CDHP ......................................19-21, 103
HO ......................................19-21, 45, 66

APWU Health Plan ...1, 4-5, 7-8, 13-15,

26-28, 141, 145, 147-148, 156-159, 169,
178
Mailing address ...............4, 145, 147-148
Phone number ..........4-5, 13-15, 141, 145
Balance Billing Protection .......................17
Biopsy

CDHP ...........................108-109, 111-112
HO .......................................50-51, 53-54

Blood and blood plasma

CDHP ..........................................116-118
HO ..................................................58-60

Breast reconstruction

CDHP ..........................................110-111
HO ..................................................52-53

Cancer Centers of Excellence

CDHP ...........29-31, 97-98, 117, 139-140
HO ................29-31, 97-98, 117, 139-140

Casts

CDHP ..........................................116-118
HO ..................................................58-60
Catastrophic protection .................29-31, 141
CHAMPVA ..............................................152
Chemotherapy/Radiation

CDHP ..............................19-21, 102, 118
HO ......................................19-21, 44, 60

Chiropractic

CDHP .................................................106
HO ..................................................35, 49

Cholesterol tests

CDHP ..............................88-90, 128-130
HO .......................................38-39, 74-76

159, 168

Clinical trials ...19-21, 54-56, 112-114,

155-156, 164-165

Coinsurance ...26-27, 29-31, 162-164,

167-168

Colorectal cancer screening

CDHP ..............................................88-90
HO ..................................................38-39

Congenital anomalies

CDHP ..............................19-21, 108-111
HO ..................................................50-53

Contraceptive devices and drugs

CDHP ...24, 87-90, 100, 126-128,
133-135
HO ...24, 35, 38-39, 42-43, 71-74, 79-81
Copayment ............................................26-27
Cost-sharing .........................................12, 26
Covered providers ........................17, 49, 106
Deductible

CDHP ....................17, 26-27, 29-31, 170
HO .......................................26-27, 29-31
Definitions ........................................164-170
Dental

CDHP ...92-94, 111-112, 118, 137,
139-141, 145, 170
HO ......................53-54, 60, 82, 145, 155

Diabetic supplies

CDHP ...79-81, 88-90, 98-99, 104, 107,
126-128, 133-135
HO ...38-39, 41-42, 46, 49, 71-74, 79-81

Diagnostic services

CDHP ...18-21, 88-91, 97-98, 106,
116-118, 122-124
HO ..........18, 36-41, 48-49, 58-60, 66-67

Dialysis

CDHP ..............18-21, 102, 105, 139-140
HO ...........................18, 44, 47-48, 83-84

Disease Management Program

HO ........................................................83

Disputed claims process ...24-25, 83, 138,

145, 147-151

Durable Medical Equipment (DME)

CDHP .................................................105
HO ..................................................47-48

Educational classes and programs

CDHP ...107, 126-128, 133-135, 139-140
HO ................49, 67, 71-74, 79-81, 83-84
Effective date of enrollment .................18-19
Emergency

CDHP ..........21, 23-24, 32, 120-121, 168
HO ..........................21, 24, 32, 35, 62-64

End of life care

CDHP ..........................................116-119
HO ........................................................61

Experimental or investigational

CDHP ......................19-21, 142-143, 165
HO ...19-21, 54-56, 112-114, 142-143,
165

Express Scripts Medicare .............77-78, 160
Eyeglasses

CDHP ..............................92-94, 103-104
HO ........................................................46

Family Planning

CDHP .................................................100
HO ..................................................42-43

Flexible benefits option

CDHP .................................................138
HO ........................................................83

Foot care

CDHP .................................................104
HO ........................................................46
Fraud .........................................................4-5
Gender affirming surgery

CDHP ................................17, 19-21, 165
HO .........................17, 19-21, 52-53, 165
General exclusions ................35, 87, 142-143
Hearing services

CDHP ..........................103-104, 139-141
HO .......................................45-47, 83-84

Home health services

CDHP ...................................................48
HO ........................................................48

Hospice

CDHP ..................19-21, 29-31, 119, 166
HO ....................................29-31, 61, 166

Hospital

CDHP ...7-8, 14-15, 18-19, 21-22, 24,
98-99, 116-118, 121, 124
HO ...7-8, 14-15, 18-19, 21-22, 24,
36-37, 41-42, 58-61, 63, 67-68, 98-99,
164

Immunizations

CDHP ..............................................87-91
HO ............................................35, 38-41

Infertility

CDHP .........................................101, 166
HO ..........................................43-44, 166

Insulin

CDHP ...............19-21, 126-128, 133-135
HO .......................................71-74, 79-81

Magnetic Resonance Imaging (MRI)

CDHP .............................................22, 98
HO ............................................22, 37, 63

Mail Order prescription drugs

CDHP ..........................................133-135
HO ........................69-74, 79-81, 125-126

Mammograms

CDHP ........................88-90, 98, 139-140
HO ..................................................37-39

Maternity

CDHP ....................................24, 139-140
HO .................................24, 41-42, 58-59
Medicaid ..................................................153
Medical emergency

CDHP ..........................................120-121
HO ..................................................62-64

2025 APWU Health Plan

176

Index

Medically necessary ...5-6, 17, 19, 21-22, 24,

Positron Emission Tomography (PET)

CDHP .............................................22, 98
HO ..................................................22, 37
Precertification ........................19, 21-22, 168
Preferred Provider Organizations (PPOs)

........................................................14-15

Prescription drugs

CDHP ...1, 107, 125-136, 150-151,
159-160
HO .......................1, 29-31, 35, 49, 69-81

Preventive care

Adult CDHP ...87-90, 126-128, 135-136
Adult HO .................35, 38-39, 71-74, 81
Children CDHP ...............................90-91
Children HO ...................................39-41
Prior approval ....................19-21, 24-25, 168
Prostate Cancer screening

CDHP ..............................................88-90
HO ..................................................38-39

Prosthetic devices

CDHP ..................................104, 108-109
HO ............................19-21, 46-47, 50-51
Rate information ....................................178
Review and reward program

HO ........................................................83

Room and board

CDHP ..................................116-118, 124
HO ............................................58-61, 67

Second surgical opinion

CDHP ..............................................97-98
HO ..................................................36-37

Skilled nursing

CDHP ...18-21, 97-98, 106, 118, 166,
168
HO ......18-21, 36-37, 48, 60-61, 166, 168
Subrogation ...............................153-155, 168
Substance use disorder

CDHP ...14-15, 18-21, 92-94, 122-124,
168
HO ..............14-15, 18-21, 35, 65-68, 168

166-167

Medicare ......1, 11, 19, 23, 142-143, 150-163
Mental health

CDHP ...14-15, 21, 122-124, 139-140,
168
HO ...14-15, 21, 29-31, 35, 65-68, 84,
168

Newborn care

CDHP ............................10-11, 24, 98-99
HO .................................10-11, 24, 41-42
No Surprises Act (NSA) .............................32
Non-PSHB benefits ..................................141
Nurse

CDHP ..............98-99, 106, 116-117, 166
HO ...........................41-42, 48, 58-59, 83

Nurse Help Line

HO ..................................................62, 83

Office visits

CDHP ................26, 97-98, 117, 122-123
HO .................................36-37, 66, 82-83

Organic Impotence

CDHP ..........................126-130, 142-143
HO .......................................19-21, 71-76

Orthopedic devices

CDHP ..........................103-104, 108-109
HO .......................................45-47, 50-51

Osteoporosis screening

CDHP ..............................................88-90
HO .......................................38-39, 74-76
Out-of-pocket expenses ................29-31, 170
Overseas claims .......................................145
Oxygen

CDHP ..................................105, 116-118
HO ............................19-21, 47-48, 58-60

Pap smear

CDHP ........................................88-90, 98
HO ..................................................37-39
PCA rollover ...........................87, 94-96, 170
Personal Care Account ...14-15, 26-27, 29,

87, 92-96, 137, 139-140, 170

Physical examinations

Adult CDHP ....................88-90, 139-140
Adult HO ..................................35, 38-39
Children CDHP ...............................39-41
Children HO ...................................39-41

Physician

CDHP ...14-15, 19, 21, 24, 27, 97-98,
106, 108-115, 121-123, 133-135, 157,
162-163, 166
HO ...14-15, 19, 21, 29, 36-37, 48, 50-57,
63, 66, 79-81, 166

Supplemental Discount Drug Program ...141
Surgery

CDHP ..............................19-21, 108-112
HO .......................................19-21, 50-54

Syringes

CDHP ..........................126-128, 133-135
HO .......................................71-74, 79-81

Telehealth

CDHP ...........................................98, 123
HO ..................................................37, 67
Temporary Continuation of Coverage (TCC)
..............................................................13
Therapy (Occupational, Physical & Speech)
CDHP ..........................................102-103
HO ........................................................45

Tobacco cessation

CDHP ..................107, 126-128, 133-135
HO ...........................35, 49, 71-74, 79-81

Transplants

CDHP ......................19-21, 102, 112-114
HO .................................19-21, 44, 54-56

Treatment therapies

CDHP
HO

TRICARE .........................................152-156
TTY ...................................1, 17-25, 152-163
UnitedHealthcare Hearing

CDHP ..........................................139-140
HO ..................................................83-84

Vision services

CDHP ..............92-94, 103-104, 155, 170
HO ..........................................46, 82, 155
Voluntary Benefits Dental Plan ................141
Weight management

CDHP ..............................88-91, 126-128
HO .................................38-41, 71-74, 83

Wheelchairs

CDHP .................................................105
HO .......................................19-21, 47-48
Workers' Compensation ...148-149, 153-155,

168

X-ray

CDHP ...18, 88-91, 98, 112-114, 116-118
HO ................18, 37-41, 54-56, 58-60, 82

2025 APWU Health Plan

177

Index

2025 Rate Information for the APWU Health Plan

To compare your PSHB health plan options please go to https://health-benefits.opm.gov/.

To review premium rates for all PSHB health plan options please go to www.opm.gov/healthcare-insurance/pshb/premiums/.

APWU rates apply to career Postal employees represented by APWU that have been enrolled in PSHB or FEHB for one year.

Premium Rates:

Type of
Enrollment

High Option
Self Only

High Option
Self Plus One

High Option
Self and Family

CDHP Option
Self Only

CDHP Option
Self Plus One

CDHP Option
Self and Family

Enrollment
Code

Biweekly Gov’t
Share

Biweekly Your
Share

Monthly Gov’t
Share

Monthly Your
Share

Biweekly
APWU
Your Share

23A

$286.09

$109.86

$619.86

$238.03

$109.86

23C

$618.40

$213.05

$1,339.87

$461.61

$213.05

23B

$672.95

$277.28

$1,458.06

$600.77

$277.28

23D

$241.87

$80.62

$524.05

$174.68

$16.12

23F

23E

$525.68

$175.23

$1,138.98

$379.66

$35.05

$573.47

$191.16

$1,242.53

$414.17

$38.23

2025 APWU Health Plan

178

