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.

Note: The GW LTD PPO medical plan offerings use the UHC Choice Plus network.

	GW LTD PPO
	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*
		$10 copay
Telehealth Visits**
	$10 copay	$30 copay	After deductible: GW - 60% Employee: 40%
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 (CT/PET scans, MRIs)		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. Teladoc, Doctor on Demand, Amwell.)

**Telehealth Visits include medical and behavioral health care and are provided via phone or video by Primary Care Providers and Medical or Behavioral Health specialists. 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
	In-Network	Out-Of-Network
Hospital Care
Inpatient	After deductible: GW - 80% Participant - 20%	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
	Covered through Progyny	Not Covered
Breast Reduction Surgery**
	Covered	Covered
Hearing Aids***
	After deductible: GW - 80% Participant - 20%	After deductible: GW - 60% Participant - 40%

* 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.

**Covered when considered medically necessary - Please see GW PPO SPD for criteria. Note: Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each covered Health Service category in this Benefit Summary. For example, for services provided in the Physician’s Office, a Copayment will apply to the office visit. All other services would be deductible and then co-insurance.

*** 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
Up to one routine exam covered every 24 months Note: Materials are NOT covered	$30 copay	After deductible: GW - 60% Participant - 40%
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 under Brand Non-Formulary	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

**** Notification is required six months prior to surgery. Please contact UHC for plan details.

Medical Plan Programs

Real Appeal: Real Appeal is a weight-loss support program offered under the GW LTD PPO plan. (You must be a plan participant to join Real Appeal.) Real Appeal supports plan participants with a body mass index (BMI)* of 23 or more at no cost. The program uses live online coaching and highly interactive weekly internet videos to drive small behavior changes week by week.
If you are currently enrolled in the GW LTD PPO plan, you may enroll at any time after meeting BMI eligibility requirements.
Visit gwu.realappeal.com for more information.

*BMI eligibility requirements must be met to enroll.

Freestanding Imaging and Labs Preferred Network: A freestanding network facility performs outpatient services and submits claims separately from any hospital affiliation, and may be a lower cost option for certain medical services. For LTD recipients and their dependents enrolled in the GW LTD PPO, GW continues to offer a preferred network,* including a lower coinsurance, for usage of freestanding facilities in lieu of hospitals for lab tests, radiology services, major diagnostics and other services. LabCorp and Quest Diagnostics will continue to be GW’s preferred vendors for lab work.

*In-network freestanding facilities and GW Hospital.

Health Advocate: For hassle-free assistance with resolving healthcare and insurance issues, look no further than GW’s Health Advocate program, which will continue to be a special benefit offering available to all LTD recipients. Example services include resolving medical bill errors, estimating costs for medical procedures, locating eldercare and caregiver support resources, clarifying insurance plans and more.

Health Advocate: (866) 695-8622 | healthadvocate.com/gwu.

UHC Virtual Visits: Virtual Visits will remain a health plan feature for 2025, allowing UHC members to connect with a doctor via mobile device or computer—24/7, no appointment needed. Get timely care, including diagnosis and prescription, and pay less out-of-pocket. To access a UnitedHealthcare Virtual Visit provider, log on to www.myuhc.com or download the UHC App. Find instructions on how to access the additional virtual visit providers in the FAQ section on myuhc.com under related links for additional information.
Telemental Health: Telemental Health is available through your UHC medical benefit. The service uses secure, video-calling technology to provide real-time access to a behavioral health professional, and features a network of over 3,000 providers in all 50 states. Learn more or schedule a visit at myuhc.com.