2021 GEHA Medicare Benefits Guide

Standard Option + Medicare

Self Only premiums.

Medical benefits for Standard with Medicare A & B primary. What you pay in- or out-of-network. geha.com/Find-Care – Unlimited telehealth visits with MDLIVE geha.com/MDLIVE

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These benefits are neither offered nor guaranteed under contract with the FEHB Program, but are made available to all enrollees who become members of a GEHA medical plan and their eligible family members. The in-network out-of-pocket maximum is the maximum amount of coinsurance, copays and deductibles you pay for all family members before GEHA begins paying for 100% of covered services. This is a combined maximum for both medical care and prescriptions. In-network providers agree to limit what they will charge you. You pay a fixed dollar amount or a percentage of the provider’s negotiated amount. For out-of-network benefits, refer to GEHA’s 2021 plan brochure RI 71-006 (High and Standard) at geha.com/PlanBrochure Refer to geha.com/Prescriptions for formulary and specialty coverage for specific medications. If you choose a brand-name medication when a generic is available, you will be charged the generic copay plus the Over 30-day specialty copay based on days of therapy. The drug cost share is two times for drugs that provide 60 days‘ worth of therapy and three times the copay for drugs that provide 90 days‘ worth of therapy. difference in cost between the brand-name and the generic.

Enroll code 314 . geha.com/Enroll

$135.77

Retirees monthly

– Preventive care; adult routine screenings – Lab, X-ray and diagnostic test services – MinuteClinic © (where available) geha.com/MinuteClinic – Primary physician office visit – Specialist care; office visit – Urgent care – Emergency care – Hospital care; inpatient and outpatient – Professional surgical services; inpatient and outpatient

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Self Plus One premiums. Enroll code 316 . geha.com/Enroll

Low premiums and a good choice for Medicare A & B primary members who take generic prescriptions. X You pay $0 for deductibles, copays and coinsurance whether your provider is in- or out-of-network. X You pay $0 for inpatient and outpatient hospital services, surgeries and office visits. X You pay $0 for unlimited telehealth visits, including licensed behavioral health therapists and dermatologists, through MDLIVE. X You pay $0 for deductibles and copays outside the United States. X $2,500 hearing aid benefit. Benefits included with your Standard plan. Unlimited telehealth visits with MDLIVE geha.com/MDLIVE Vision discount 1 geha.com/Vision Hearing aid discount 1 geha.com/Hearing Gym membership 1 geha.com/Fitness Electric toothbrush 1 geha.com/Toothbrush Teeth whitening 1 geha.com/Whitening Health Advice Line geha.com/Healthline Medical alert system 1 geha.com/LifeAlert Biometric screening geha.com/Screenings Out-of-pocket max 2 for Standard. What you pay in-network. 3 Self Only Out-of-pocket max $6,500 Self Plus One, Self and Family Out-of-pocket max $13,000

$0

$291.92

Retirees monthly

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Self and Family premiums.

Enroll code 315 . geha.com/Enroll

– Chiropractic care; up to 20 visits per year (spinal manipulation therapy)

Balance after GEHA pays $20 per visit Balance after GEHA pays $25 per year

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$357.17

Retirees monthly

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– Chiropractic X-rays

How to enroll If you are a retired federal

– Preventive dental care; twice yearly

50% ³

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employee, you can sign up for a GEHA medical plan by completing OPM form 2809, available through the Office of Personnel Management. Learn more at geha.com/Enroll OPM Open Season online system: retireefehb.opm.gov/Annuitant OPM Open Season Express: 800.332.9798

Prescription benefits for Standard. What you pay in-network. 3,4 geha.com/Prescriptions

$10 50% ($200 max 5 ) 50% ($300 max 5 ) $20 50% ($500 max 5 ) 50% ($600 max 5 ) 50% ($250 max 5 ) 50% ($400 max 5 )

Generic Preferred brand-name Non-preferred brand-name Generic Preferred brand-name Non-preferred brand-name

30-day retail

90-day mail service

Generic and preferred brand-name Non-preferred brand-name

30-day 6 specialty CVS exclusive

geha.com/Medicare 800.262.4342

These rates do not apply to all enrollees. If you are in a special enrollment category, please refer to the FEHB Program website or contact the agency or Tribal Employer that maintains your health benefits enrollment.

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www.geha.com

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