How to Utilize Your Care

How Prescription Coinsurance Works

Coinsurance is your share of the costs of a covered healthcare service, calculated as a percent (for example, 20 percent) of the total cost for the service or prescription drug. GW pays the remainder of the cost.

There is financial protection built into the prescription drug benefit in that you will never pay more than the "maximum," outlined in the tables below. Once you reach the out-of-pocket maximum (OOPM), GW will pay 100 percent of prescription drug costs thereafter.

George is enrolled in the GW PPO. He isn’t feeling well so he goes to his Primary Care Physician. He has bronchitis and his physician recommends a prescription antibiotic as treatment. George asks his physician if he can prescribe a generic antibiotic.

Generic Coinsurance	10%
Maximum	$30
Cost of Drug	$160
George Pays	$16
GW Pays	$144

Martha is enrolled in the GW PPO and does not feel well. Martha goes to her Primary Care Physician and has bronchitis. Her physician writes her a prescription for a preferred brand antibiotic with a similar chemical formula to the antibiotic George received. She gets to the pharmacy and finds out the total antibiotic cost is $400.

Preferred Brand Coinsurance	20%
Maximum	$50
Cost of Drug	$400
Martha Pays	$50
GW Pays	$350

For those on the GW HSP:

You must pay all prescription drug costs until you meet your annual deductible. After you meet your annual deductible, you will be responsible for 20 percent coinsurance until you reach the out-of-pocket maximum.
Please note: Under the GW HSP, your pharmacy deductible is combined with your medical deductible.

Preventive medications are covered at 100 percent under the GW HSP. Coinsurance and deductible do not apply.

Maintenance Choice provisions apply. After three 30-day retail fills, in order to have continue receiving your preventive prescription at no cost, you will need to fill a 90-day prescription via CVS Retail or CVS Mail Order OR contact CVS Caremark to opt-out of the maintenance choice program.

Remember: You can use your HSA to pay for eligible out-of-pocket costs, including your deductible and prescription coinsurance.

Save Money by Using Freestanding Facilities

Prices vary significantly for imaging and lab work – even if you go in-network.

Not only do prices vary, but you will pay a lower coinsurance when you use a freestanding network facility instead of a hospital for healthcare services or treatments that do not require an overnight hospital stay. A freestanding facility performs outpatient services and submits claims separately from any hospital affiliation. GW offers a preferred network* for labs, X-ray and major diagnostics. When you go to a preferred network freestanding facility for these services, you will pay 20 percent coinsurance under the GW PPO or GW HSP plans. If you go to a facility that is not in the preferred network, you will pay 40 percent coinsurance under the GW PPO or GW HSP plans. LabCorp and Quest Diagnostics will continue to be GW's preferred vendors for lab work.

When you do need outpatient lab tests and imaging, refer to the checklist below of what to ask.

For instructions on how to compare costs and locate a preferred provider for networks and labs view UHC's flier for freestanding facilities.

*In-network freestanding facilities and GW Hospital

When using outpatient lab tests and imaging, ask:

Do you know the cost of the tests you are ordering?
Is the provider or laboratory in my network?
Since my share of the cost is less for services performed at a freestanding facility that is not connected to a hospital, can the test or service be performed at a freestanding facility?
Can you recommend a freestanding facility in the UnitedHealthcare network?

Average costs of imaging and diagnostic services for the GW PPO

Selected Imaging, X-Ray, Major Diagnostic Service	In-Network Freestanding Facility Total Cost / Member Cost (20% Coinsurance)*	Hospital Total Average Cost / Member Cost (40% Coinsurance)*
MRI Scan with and without Dye - Abdomen	Total - $617 Member - $123	Total - $1,556 Member - $622
Ultrasound – Abdomen	Total - $114 Member - $23	Total - $445 Member - $178
General Blood Health Panel Test	Total - $24 Member - $5	Total - $92 Member - $37
PET Scan with CT Scan	Total - $1,800 Member - $360	Total - $3,984 Member - $1,594