2021 GEHA Medicare Benefits Guide

High Option + Medicare

Self Only premiums.

Medical benefits for High 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 Costs for initial prescription and first refill. You pay 50% for third and additional refills at retail for 30-day supply. For long-term prescriptions, use mail order or your local retail CVS Pharmacy store (90-day supply) for greater cost savings. 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 311 . geha.com/Enroll

$234.31

Retirees monthly

Medicare A & B primary members pay less for brand- name prescription medications. Plan includes a $600 Medicare Part B premium reimbursement. 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 High 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 High. What you pay in-network. 3 Self Only Out-of-pocket max $5,000 Self Plus One, Self and Family Out-of-pocket max $10,000

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– Preventive care; adult routine screenings – Lab, X-ray and diagnostic test services – MinuteClinic © (where available) geha.com/MinuteClinic

Self Plus One premiums.

Enroll code 313 . geha.com/Enroll

$0

– Primary physician office visit – Specialist care; office visit – Urgent care – Emergency care – Hospital care; inpatient and outpatient – Professional surgical services; inpatient and outpatient

$545.85

Retirees monthly

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Self and Family premiums.

Enroll code 312 . geha.com/Enroll

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$680.61

Retirees monthly

Balance after GEHA pays $20 per visit Balance after GEHA pays $25 per year Balance after GEHA pays $22 per visit

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

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How to enroll If you are a retired federal

– Chiropractic X-rays

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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

– Preventive dental care

Prescription benefits for High with Medicare A & B primary. What you pay in-network. 3,4 geha.com/Prescriptions

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$10 6 20% ($150 max 5,6 ) 35% ($200 max 5,6 ) $15 15% ($350 max 5 ) 30% ($500 max 5 ) 15% ($150 max 5 ) 30% ($200 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

geha.com/Medicare 800.262.4342

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

30-day 7 specialty CVS exclusive

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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