Plan Features and Glossary

Benefits have a language all their own. Understanding how your insurance plans work is crucial to making the most out of your coverage. Become familiar with these commonly-used benefits terms to help you compare and choose plans.

Total Out-of-Pocket Costs

Here’s a simple equation that shows how much you’ll pay out-of-pocket for your health insurance each year.

Premiums + Deductible + Copays & Coinsurance (up to the Out-of-Pocket Maximum) = Total Employee Costs

Once you meet your plan's Out-of-Pocket Maximum, the plan pays 100% of your covered medical expenses for the balance of the year.

Premiums: The amount you pay for your health insurance every month.
Deductible: The amount you pay out-of-pocket for healthcare before plan starts to pay. (Please note, the deductible may not be applicable to all services.) Separate in-and-out of network deductibles apply.
Copays: A set amount (for example, $30) you pay for a covered healthcare service.
Coinsurance: The percentage you pay for the cost of covered healthcare services, after you meet your deductible.
Out-of-Pocket Maximum: This is a “cap” on your costs for the year; it is the most you’ll pay for healthcare services. Once you reach your out-of-pocket maximum, the plan pays 100 percent of your covered medical expenses for the balance of the year. Separate in- and out-of-network out-of-pocket maximums do apply.

Deductibles

Not all deductibles are created equal. Here are a few common types:

Network Deductibles: The GW LTD PPO has separate annual deductibles for when you get in-network care versus out-of-network care. These amounts are usually different for individuals and families.
Family Deductibles: With the GW LTD PPO, you’ll need to meet the deductible for each covered family member up to the family cap.

For example, under the GW LTD PPO, each person will need to meet the in-network individual deductible of $750 (capped at $1,500 per family). Once an individual meets the $750 deductible, coinsurance begins for that person.When you cover your family, review your family deductible closely.

Glossary of Terms

Covered Services: Those services deemed by your plan to be medically necessary for the care and treatment of an injury or illness.

Formulary: Sometimes referred to as a preferred drug list, a list of prescription medications that are covered by a pharmacy plan. Drugs not on a formulary may not be available, may carry a higher cost-share amount or may be accessible only with prior authorization.

Generic: An FDA-approved drug, composed of virtually the same chemical formula as a brand-name drug. Ask for generics! Generic medications contain the same active ingredients as brand-name drugs, but cost less. Talk to your doctor about switching to generics and making sure your medications are on your plan’s formulary.

Specialty Drugs: Low-volume, high-cost medication prescribed for chronic and complex illnesses such as multiple sclerosis, hepatitis C and hemophilia, as well as some common diseases such as rheumatoid arthritis. Specialty drugs often require special storage and handling and are not readily available at the typical local retail pharmacy.

Network: A group of doctors, labs, hospitals and other providers that your plan contracts with at a set payment rate.

Preventive Care: Preventive care services include those that help you manage your health, such as routine physical exams, screenings and lab tests. These services are covered at 100 percent by the GW health plans, with no out-of-pocket costs (such as deductibles or copays) if the services are received in-network. Be sure your provider codes the services as “preventive.”

Preferred Provider Organization (PPO): A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals and providers outside of the network for an additional cost.