Summary Plan Description The George Washington University GW Health Savings Plan (HSP) Choice Plus Tiered Effective: January 1, 2021 Group Number: 730193 GW HEALTH SAVINGS PLAN (HSP) CHOICE PLUS TIERED TABLE OF CONTENTS SECTION 1 - WELCOME ................................................................................................................. 1 SECTION 2 - INTRODUCTION ......................................................................................................... 4 Eligibility ....................................................................................................................................... 4 Cost of Coverage ......................................................................................................................... 4 How to Enroll .............................................................................................................................. 5 When Coverage Begins ............................................................................................................... 5 Changing Your Coverage ............................................................................................................ 6 SECTION 3 - HOW THE PLAN WORKS .......................................................................................... 8 Accessing Benefits ....................................................................................................................... 8 Eligible Expenses ....................................................................................................................... 11 Annual Deductible ..................................................................................................................... 12 Coinsurance ................................................................................................................................ 12 Out-of-Pocket Maximum ......................................................................................................... 13 SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION ......................... 14 Care Management ...................................................................................................................... 14 Prior Authorization .................................................................................................................... 15 Special Note Regarding Medicare ............................................................................................ 16 SECTION 5 - PLAN HIGHLIGHTS ................................................................................................. 17 Payment Terms and Features ................................................................................................... 17 Schedule of Benefits .................................................................................................................. 19 SECTION 6 - ADDITIONAL COVERAGE DETAILS ...................................................................... 26 Acupuncture Services ................................................................................................................ 26 Ambulance Services ................................................................................................................... 26 Cellular and Gene Therapy ....................................................................................................... 27 Clinical Trials .............................................................................................................................. 27 Congenital Heart Disease (CHD) Surgeries ........................................................................... 29 Dental Services - Accident Only .............................................................................................. 31 Diabetes Services ....................................................................................................................... 32 Durable Medical Equipment (DME) ...................................................................................... 32 Emergency Health Services - Outpatient ............................................................................... 34 Enteral Nutrition ........................................................................................................................ 34 i TABLE OF CONTENTS GW HEALTH SAVINGS PLAN (HSP) CHOICE PLUS TIERED Gender Dysphoria ..................................................................................................................... 35 Home Health Care ..................................................................................................................... 37 Hospice Care .............................................................................................................................. 37 Hospital - Inpatient Stay ........................................................................................................... 38 Lab, X-Ray and Diagnostics - Outpatient .............................................................................. 39 Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient................................................................................................................................. 39 Mental Health Services .............................................................................................................. 40 Neurobiological Disorders - Autism Spectrum Disorder Services ..................................... 41 Nutritional Counseling .............................................................................................................. 42 Orthognathic Surgery ................................................................................................................ 43 Ostomy Supplies ........................................................................................................................ 43 Pharmaceutical Products - Outpatient .................................................................................... 43 Physician Fees for Surgical and Medical Services ................................................................. 44 Physician's Office Services - Sickness and Injury .................................................................. 44 Pregnancy - Maternity Services ................................................................................................ 45 Preventive Care Services ........................................................................................................... 45 Private Duty Nursing - Outpatient .......................................................................................... 47 Prosthetic Devices ..................................................................................................................... 47 Reconstructive Procedures ....................................................................................................... 48 Rehabilitation and Habilitative Services - Outpatient Therapy and Manipulative Treatment .................................................................................................................................... 49 Scopic Procedures - Outpatient Diagnostic and Therapeutic ............................................. 51 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services .................................... 51 Substance Use Disorder Services ............................................................................................ 52 Surgery - Outpatient .................................................................................................................. 53 Temporomandibular Joint (TMJ) Services ............................................................................. 54 Therapeutic Treatments - Outpatient ..................................................................................... 54 Transplantation Services ........................................................................................................... 55 Urgent Care Center Services .................................................................................................... 56 Urinary Catheters ....................................................................................................................... 56 Virtual Visits ............................................................................................................................... 56 Vision Examinations ................................................................................................................. 56 Wigs ............................................................................................................................................. 57 ii TABLE OF CONTENTS GW HEALTH SAVINGS PLAN (HSP) CHOICE PLUS TIERED SECTION 7 - CLINICAL PROGRAMS AND RESOURCES ........................................................... 58 Consumer Solutions and Self-Service Tools .......................................................................... 58 Disease Management Services ................................................................................................. 60 Complex Medical Conditions Programs and Services .......................................................... 61 Women's Health/Reproductive ............................................................................................... 65 SECTION 8 - EXCLUSIONS AND LIMITATIONS: WHAT THE MEDICAL PLAN WILL NOT COVER ..........................................................................................................................................