2024 Open Enrollment Period: October 9 - 27, 2023
Medical Plan
Percentages in the accompanying chart represent the percentages of allowed benefit covered by the GW plan as well as the LTD recipient responsibility.
Medical Plan
Note: The GW LTD PPO medical plan offerings use the UHC Choice Plus network.
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GW LTD PPO |
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| MFA Provider† | In-Network | Out-Of-Network | |
| Deductible | |||
| Individual |
$750 |
$2,000 | |
| Family | $1,500 | $4,000 | |
| Out-of-Pocket-Maximum (OOPM) | |||
| Individual | $3,000 | $6,000 | |
| Family | $6,000 | $12,000 | |
| Coinsurance | |||
| GW - 90% Participant - 10% |
GW - 80% Participant - 20% |
GW - 60% Participant - 40% |
|
| Lifetime Maximum | |||
| Unlimited | Unlimited | ||
| Office Visit | |||
| Primary Care Physician (PCP) | $10 copay | $30 copay | After deductible: GW - 60% participant - 40% |
| Specialist | $25 copay | $50 copay | After deductible: GW - 60% Participant - 40% |
| Virtual Visits and Telemental Health Visits* | |||
| 100% covered In-Network Only by the GW PPO and GW HSP through 12/31/24 | |||
| Imaging and Labs†† LabCorp and Quest Diagnostics will continue to be GW's preferred vendors for lab work. | |||
| Preferred | Non-Preferred | ||
| Diagnostic Test (x-ray, blood work) |
After deductible: GW - 80% Participant - 20% |
After deductible: GW - 60% Participant - 40% |
|
|
Imaging |
After deductible: GW - 80% Participant - 20% |
After deductible: GW - 60% Participant - 40% |
|
*Virtual visits are those provided by a UHC Designated Virtual Visit Providers (i.e. Optum Virtual Care, Teladoc, Doctor on Demand, Amwell, Walmart Virtual Care.) Telemental Health Visits are provided by UHC In-Network Behavioral Health Providers. Note: Telehealth Visits are provided via phone or video by an In-Network Medical Provider (Primary Care Providers and Medical Specialists) in UHC’s Choice Plus Network. Copay or deductible/coinsurance apply.
† The MFA tier applies to professional charges by MFA providers; MFA behavioral health providers continue to be out-of-network.
†† Preferred Network = in-network freestanding facilities and GW hospital
Non-Preferred Network = in-network hospitals (other than GW Hospital) or out-of-network freestanding facilities or hospitals (in- or out-of-network deductible applies as appropriate)
|
GW LTD PPO |
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| In-Network | Out-Of-Network | |
| Hospital Care | ||
| Inpatient |
After deductible: |
After deductible: GW - 60% Participant - 40% |
| Outpatient | After deductible: GW - 80% Participant - 20% |
After deductible: GW - 60% Participant - 40% |
| Urgent Care | $30 copay | After deductible: GW - 60% Participant - 40% |
| Emergency Room | After deductible: GW - 80% Participant - 20% |
After deductible: GW - 80% Participant - 20% |
| Preventive | ||
| Mammography* | 100% for one preventive mammogram per year, age 40 and over | |
| Pap Test* | GW covers 100% if part of wellness exam | After deductible: GW - 60% Participant - 40% |
| Prostate Exam* | GW covers 100% if part of wellness exam | After deductible: GW - 60% Participant - 40% |
| Well Child and Well Adult Exams* | GW covers 100% | After deductible: GW - 60% Participant - 40% |
| Applied Behavior Analysis (ABA) | ||
| Covered | Covered | |
| Chiropractic Care | ||
| $50 copay per office visit, up to 60 visits per year (combined in- and out-of-network) | After deductible: GW - 60% Participant - 40% up to 60 visits per year (combined in-and out-of-network) |
|
| Acupuncture | ||
| $50 copay per office visit, up to 20 visits per year (combined in- and out-of-network) | After deductible: GW - 60% Participant - 40% up to 20 visits per year (combined in-and out-of-network) |
|
| Fertility Benefits** | ||
| Up to $30,000 lifetime medical benefit and up to a $8,000 pharmacy benefit | Not Covered | |
| Hearing Aids*** | ||
| After deductible: GW - 80% Participant - 20% |
After deductible: GW - 60% Participant - 40% |
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* Preventive care guidelines are based on recommendations of the U.S. Preventive Services Task Force and other health organizations. Visit uhcpreventivecare.com for additional details on ALL preventive care guidelines based on your age and sex.
** Artificial insemination, in vitro fertilization, and other procedures are covered. Please contact UHC for details.
*** Up to a single purchase (including repair/replacement) per hearing impaired ear every 36 months.
|
GW LTD PPO |
||
| In-Network | Out-Of-Network | |
| Cochlear Implants | ||
| Covered | Not Covered | |
| Bariatric Surgery**** | ||
| Up to $60,000 lifetime limit | Not Covered | |
| Vision | ||
|
Routine eye exams are covered once every 24 months with applicable copy. Discounts on hardware frames/contacts are available at participating eye centers. You are subject to the annual deductible and coinsurance if you go out-of-network in the GW LTD PPO. |
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| Prescription Out-of-Pocket Maximum | ||
| Individual | $3,600 | $7,200 |
| Family | $7,200 | $14,400 |
| Retail Prescription Drugs | ||
| Generic | 10% Coinsurance (Minimum $15, Maximum $30) 30-supply |
|
| Brand Formulary | 20% Coinsurance (Minimum $30, Maximum $50) 30-supply |
|
| Brand Non-Formulary | 25% Coinsurance (Minimum $60, Maximum $100) 30-supply |
|
| Specialty | 30% Coinsurance for PrudentRx eligible specialty prescriptions filled at CVS Specialty*, $0 when enrolled in PrudentRx. | |
| *Your plan includes the PrudentRx program for specialty medications. This program is designed to lower your out of pocket costs by assisting you with enrollment in drug manufacturers discount copay cards/assistance programs. When enrolled in PrudentRx, your out of pocket cost will be $0 for medications included on the PrudentRx exclusive specialty drug list. If you opt out, you will be responsible for the 30% coinsurance (only the amount you pay out of pocket will apply toward your deductible/out of pocket maximums for essential health benefit medications.) | ||
| Mail-Order Prescription Drugs | ||
| Generic Vacation Exception Additional 30-day supply one time per year |
10% Coinsurance (Minimum $37.50, Maximum $75) 90-supply |
|
| Brand Formulary Vacation Exception Additional 30-day supply one time per year |
20% Coinsurance (Minimum $75, Maximum $125) 90-supply |
|
| Brand Non-Formulary | 25% Coinsurance (Minimum $150, Maximum $250) 90-supply |
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**** Notification is required six months prior to surgery. Please contact UHC for plan details.
Review 2024 contribution rates for medical coverage.