Summary Plan Description The George Washington University GW PPO Choice Plus Tiered Effective: January 1, 2021 Group Number: 730193 GW PPO CHOICE PLUS PLAN 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 Copayment .................................................................................................................................. 12 Coinsurance ................................................................................................................................ 13 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 ...................................................................... 28 Acupuncture Services ................................................................................................................ 28 Ambulance Services ................................................................................................................... 28 Cellular and Gene Therapy ....................................................................................................... 29 Clinical Trials .............................................................................................................................. 29 Congenital Heart Disease (CHD) Surgeries ........................................................................... 31 Dental Services - Accident Only .............................................................................................. 33 Diabetes Services ....................................................................................................................... 34 Durable Medical Equipment (DME) ...................................................................................... 34 Emergency Health Services - Outpatient ............................................................................... 36 i TABLE OF CONTENTS GW PPO CHOICE PLUS PLAN TIERED Enteral Nutrition ........................................................................................................................ 36 Gender Dysphoria ..................................................................................................................... 37 Hearing Aids ............................................................................................................................... 39 Home Health Care ..................................................................................................................... 40 Hospice Care .............................................................................................................................. 40 Hospital - Inpatient Stay ........................................................................................................... 41 Infertility Services ...................................................................................................................... 42 Lab, X-Ray and Diagnostics - Outpatient .............................................................................. 43 Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient................................................................................................................................. 44 Mental Health Services .............................................................................................................. 45 Neurobiological Disorders - Autism Spectrum Disorder Services ..................................... 46 Nutritional Counseling .............................................................................................................. 47 Obesity Surgery .......................................................................................................................... 47 Orthognathic Surgery ................................................................................................................ 48 Ostomy Supplies ........................................................................................................................ 48 Pharmaceutical Products - Outpatient .................................................................................... 48 Physician Fees for Surgical and Medical Services ................................................................. 49 Physician's Office Services - Sickness and Injury .................................................................. 50 Pregnancy - Maternity Services ................................................................................................ 50 Preventive Care Services ........................................................................................................... 51 Private Duty Nursing - Outpatient .......................................................................................... 52 Prosthetic Devices ..................................................................................................................... 52 Reconstructive Procedures ....................................................................................................... 53 Rehabilitation and Habilitative Services - Outpatient Therapy and Manipulative Treatment .................................................................................................................................... 54 Scopic Procedures - Outpatient Diagnostic and Therapeutic ............................................. 56 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services .................................... 57 Substance Use Disorder Services ............................................................................................ 58 Surgery - Outpatient .................................................................................................................. 59 Temporomandibular Joint (TMJ) Services ............................................................................. 60 Therapeutic Treatments - Outpatient ..................................................................................... 60 Transplantation Services ........................................................................................................... 61 Urgent Care Center Services .................................................................................................... 62 ii TABLE OF CONTENTS GW PPO CHOICE PLUS PLAN TIERED Urinary Catheters ....................................................................................................................... 62 Virtual Visits ............................................................................................................................... 62 Vision Examinations ................................................................................................................. 62 Wigs ............................................................................................................................................. 63 SECTION 7 - CLINICAL PROGRAMS AND RESOURCES ........................................................... 64 Consumer Solutions and Self-Service Tools .......................................................................... 64 Disease