Medical Plan

Percentages in the accompanying chart represent the percentages of allowed benefit covered by the plan (GW) as well as the retiree responsibility.

The GW Retiree HSP medical plan offerings use the UHC Choice Plus network.

	GW RETIREE HEALTH SAVINGS PLAN (HSP)
	MFA Provider *	In-Network	Out-Of-Network
Deductible
Individual		$2,000	$3,000
Family		$4,000^†	$6,000†
Out-of-Pocket-Maximum (OOPM)^††
Individual		$4,000	$6,000
Family		$8000	$12,000
Coinsurance
	GW - 90% Retiree - 10%	GW - 80% Retiree - 20%	GW - 60% Retiree - 40%
Lifetime Maximum
		Unlimited
Office Visit
Primary Care Physician (PCP)	After deductible: GW - 90% Retiree - 10%	After deductible: GW - 80% Retiree - 20%	After deductible: GW - 60% Retiree - 40%
Specialist	After deductible: GW - 90% Retiree - 10%	After deductible: GW - 80% Retiree - 20%	After deductible: GW - 60% Retiree - 40%
Virtual Visits**
		After deductible: GW - 80%, Employee - 20%
Telehealth Visits***
	After deductible: GW - 90% Retiree - 10%	After deductible: GW - 80%, Employee - 20%	After deductible: GW - 80%, Employee - 20%
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% Retiree - 20%	After deductible: GW - 60% Retiree - 40%
Imaging (CT/PET scans, MRIs)		After deductible: GW - 80% Retiree - 20%	After deductible: GW - 60% Retiree - 40%

*The MFA tier applies to professional charges by MFA providers; MFA behavioral health providers continue to be out-of-network.
**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.

† For family coverage, no one in the family is eligible for the coinsurance benefit until the family coverage deductible is met.

†† Under Healthcare Reform all plans must have an out-of-pocket maximum. In addition deductibles, copays and coinsurance must apply to the OOPM. (Only allowed charges will count towards the OOPM for out-of-network benefits.)

††† 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 RETIREE HEALTH SAVINGS PLAN (HSP)
	In-Network	Out-Of-Network
Hospital Care
Inpatient	After deductible: GW - 80% Retiree - 20%	After deductible: GW - 60% Retiree - 40%
Outpatient	After deductible: GW - 80% Retiree - 20%	After deductible: GW - 60% Retiree - 40%
Urgent Care	After deductible: GW - 80% Retiree - 20%	After deductible: GW - 60% Retiree - 40%
Emergency Room	After deductible: GW - 80% Retiree - 20%	After deductible: GW - 80% Retiree - 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% Retiree - 40%
Prostate Exam*	GW covers 100% if part of wellness exam	After deductible: GW - 60% Retiree - 40%
Well Child and Well Adult Exams*	GW covers 100%	After deductible: GW - 60% Retiree - 40%
Applied Behavior Analysis (ABA)
	Covered	Covered
Chiropractic Care
	After deductible: GW - 80% Retiree - 20% up to 60 visits per year (combined in-and out-of-network)	After deductible: GW - 60% Retiree - 40% up to 60 visits per year (combined in-and out-of-network)
Acupuncture
	After deductible: GW - 80% Retiree - 20% up to 20 visits per year (combined in-and out-of-network)	After deductible: GW - 60% Retiree - 40% up to 20 visits per year (combined in-and out-of-network)

* Preventive care guidelines are based on recommendations of the U.S. Preventive Services Task Force and other health organizations. Visit myuhc.com for additional details on ALL preventive care guidelines based on your age and sex.

	GW RETIREE HEALTH SAVINGS PLAN (HSP)
	In-Network	Out-Of-Network
Vision
Up to one routine exam every 24 months Note: Materials are NOT covered	After deductible: GW - 80% Retiree - 20%	After deductible: GW - 60% Retiree - 40%
Durable Medical Equipment (DME)
	After deductible: GW - 80% Retiree - 20%	After deductible: GW - 60% Retiree - 40%
Prescription Drug Deductible
Included in overall plan deductible ($2,000 individual/$4,000 family)
Prescription Out-of-Pocket Maximum
Individual	Combined with medical
Family	Combined with medical
Preventive Drugs
	Covered at 100%
Retail Prescription Drugs
Generic	After deductible: GW - 80% Retiree - 20%	After deductible: GW - 60% Retiree - 40%
Brand Formulary	After deductible: GW - 80% Retiree - 20%	After deductible: GW - 60% Retiree - 40%
Brand Non-Formulary	After deductible: GW - 80% Retiree - 20%	After deductible: GW - 60% Retiree - 40%
Specialty under Brand Non-Formulary	After deductible: 30% for PrudentRx eligible specialty prescriptions filled at CVS Specialty, $0*** when enrolled in PrudentRx
Mail-Order Prescription Drugs**
Generic Vacation Exception Additional 30-day supply one time per year	After deductible: GW - 80% Retiree - 20%	After deductible: GW - 60% Retiree - 40%
Brand Formulary Vacation Exception Additional 30-day supply one time per year	After deductible: GW - 80% Retiree - 20%	After deductible: GW - 60% Retiree - 40%
Brand Non-Formulary	After deductible: GW - 80% Retiree - 20%	After deductible: GW - 60% Retiree - 40%

**Mandatory Maintenance Choice with Opt-Out provisions apply. Please see page 22 for more information
*** HSP participants must meet their combined medical/prescription deductible before the out-of-pocket cost will be $0.

Medical Plan Programs

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 GW retirees enrolled in a medical plan through bswift or Via Benefits. Example services include resolving medical bill errors, estimating costs for medical procedures, locating eldercare and caregiver support resources, clarifying insurance plans and more.

Call Health Advocate at (866) 695-8622 or visit healthadvocate.com/gwu.

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 GW retirees and their dependents enrolled in the GW Retiree HSP, GW will continue 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

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.
Real Appeal: The weight-loss support program, Real Appeal, will continue to be offered through the GW Retiree HSP. (You must be a plan participant to join Real Appeal.) Real Appeal is designed to support members who have 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 over the course of an entire year.

If you are currently enrolled in a UnitedHealthcare medical plan through GW, 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.