How your APWU Consumer Driven HP works with Medicare

How your APWU Consumer Driven Option works with Medicare

In general, if you or your spouse are working and are covered by an APWU Health Plan, APWU Health Plan is your primary health plan and Medicare is secondary.

If both you and your spouse are retired, Medicare is your primary coverage and APWU Health Plan is secondary.

When you are part of Medicare and the APWU Health Plan, your provider will submit the claim to Medicare. After Medicare pays, they will submit the paperwork directly to the APWU Health Plan. As a member, there is no need for you to complete any paperwork.

Your Consumer Driven Option and Medicare Part A

Hospital services

In general, members with Medicare Part A as their primary insurance do not need to pre-certify hospital stays with the Health Plan. See the Health Plan Brochure for rules about pre-certification.

Worldwide coverage

Medicare generally does not pay for hospital or medical services outside of the United States. But APWU Health Plan’s Consumer Driven Option coverage travels with you around the world. When you have services outside the U.S., you will probably have to pay the bill at the time of service, then submit a bill directly for reimbursement.

Your Consumer Driven Option Plan and Medicare Part B

When an APWU Consumer Driven Option member is enrolled in Medicare Part B, Medicare pays first and the Plan is billed the remaining cost. With the Consumer Driven Option, the deductibles and coinsurance are not waived. The Health Plan suggests that members explore this option and consider it. It will reduce your total out-of-pocket expense, but is not mandatory.

 Medicare participating doctors and suppliers

Medicare will pay the provider directly and usually pays for covered services at 80% after satisfaction of Medicare Part B’s annual deductible. With the Consumer Driven Option, if the benefit dollars are available in the Personal Care Account, the Medicare deductible and coinsurance will be paid.

If the provider accepts Medicare’s assignment, the provider will reduce his or her charge to no more than the Medicare allowance. You pay nothing for the covered charges up to our allowance.

Your Consumer Driven Option Plan and Medicare Part C

Medicare C – or Medicare Advantage Plans – are private health plans that are Medicare approved. As a member of the APWU Consumer Driven Option, there is no need to take Medicare Part C.

Your Consumer Driven Option Plan and Medicare Part D

This is Medicare’s prescription drug program. Prescription coverage is an integral part of your total health benefits package with APWU Health Plan. As a member of the APWU Consumer Driven Option Plan, the prescription drug benefit you receive can exceed that of Medicare Part D. There is no need to take part in Medicare D.

The amount that APWU Health Plan covers and/or its share of the cost of prescription drugs is the same or more than that of the standard Medicare Part D prescription drug benefits. There is an additional premium for Medicare Part D.

  • Prescription drugs are covered at 100% through your Personal Care Account (PCA) as long as you use a network pharmacy.
  • If the PCA is exhausted and your deductible met, Traditional Health Coverage begins.
  • There is no prescription drug deductible. Members pay 25% of the charge for either Network Retail (minimum $10), with a maximum of $200 per prescription; or mail order drugs (minimum $15), and a maximum of $600 per prescription.
  • There is no prescription drug benefit if you use out-of-network pharmacies.

For more information on prescription coverage with the Consumer Driven Option, call 1-800-309-5528.