2021 GEHA Medical Benefits Guide

MEDICAL PLANS 2021 GEHA

Choose from five unique medical plans designed to meet you where you are in life.

geha.com | 800.262.4342

Choose from five unique medical plans for 2021.

GEHA offers you five unique medical plans that empower you to achieve the health you need to live the life you want.

Whether you’re focused on wellness, saving for future health care needs or needing a lot of (or a little) health care, GEHA has an option that is right for you. All GEHA plans offer worldwide coverage and a mix of benefits. Choose possible.

Elevate Page 4

geha.com/Elevate

X GEHA’s lowest premium plan. X Earn up to $500 for Self Only or $1,000 for Self Plus One and Self and Family through Wellness Pays rewards. X Low $10 copays for unlimited primary care visits and $25 copays for unlimited specialist visits.

HDHP Page 6

geha.com/HDHP

X An HSA-compatible plan with a low premium. X GEHA contributes $900 (Self Only) or $1,800 (Self Plus One or Self and Family) to your HSA, which can reduce the yearly net deductible¹ to $600 or $1,200 , respectively. X You pay only 5% of medical services after your low deductible is met. X Includes a complete vision benefit along with $0 in-network preventive dental benefits, all with no deductible.

1 Net deductible is the remaining amount after you subtract the annual GEHA contribution from the annual deductible. This is your out-of-pocket cost before plan benefits begin.

Standard Option Page 8

geha.com/Standard

Elevate Plus Page 10

geha.com/ElevatePlus

X Fixed costs, no in-network deductible, copays for common medical expenses and out-of-network medical coverage. X Earn up to $500 for Self Only or $1,000 for Self Plus One and Self and Family through Wellness Pays rewards. X $0 out-of-pocket costs for common surgeries through BridgeHealth.

High Option Page 12

geha.com/High

X Comprehensive brand-name and specialty prescription coverage. X Low copays for doctor visits ( $20 primary and specialist). X $600 Medicare Part B premium reimbursement. X $2,500 hearing aid benefit. X Low cost-share for a variety of inpatient and outpatient services ( 10% coinsurance).

geha.com | 800.262.4342

Elevate

Self Only premiums.

Enroll code 254 . geha.com/Enroll

$47.32

Non-Postal worker biweekly

Get rewarded for healthy living and enjoy GEHA's lowest premium plan.

$45.43

Postal worker biweekly – Category 1

$39.28

Postal worker biweekly – Category 2

X Earn up to $500 for Self Only or $1,000 for Self Plus One and Self and Family through Wellness Pays rewards. X Low $10 copays for unlimited primary care visits and $25 copays for unlimited specialist visits. X Low copays for chiropractic and acupuncture visits. X Digital tools to navigate your health care experience. Learn more at geha.com/ElevateLearn

$102.53

Retirees monthly

Self Plus One premiums.

Enroll code 256 . geha.com/Enroll

$108.84

Non-Postal worker biweekly

Benefits included with your Elevate plan. Unlimited telehealth visits with MDLIVE

$104.49

Postal worker biweekly – Category 1

geha.com/MDLIVE geha.com/Vision geha.com/Fitness geha.com/Toothbrush geha.com/Whitening

$90.34

Postal worker biweekly – Category 2

Vision discount 6

$235.83

Retirees monthly

Gym membership 6 Electric toothbrush 6

Self and Family premiums.

Teeth whitening 6

Enroll code 255 . geha.com/Enroll

$0 out-of-pocket surgery costs and concierge care coordinator through BridgeHealth 7

geha.com/BridgeHealth

$132.51

Non-Postal worker biweekly

$127.21

Postal worker biweekly – Category 1

Yearly deductible & out-of-pocket max 2 for Elevate. What you pay in-network. 3

$109.98

Postal worker biweekly – Category 2

$500 $7,000 $1,000 $14,000

Yearly deductible Out-of-pocket max Yearly deductible Out-of-pocket max

$287.10

Retirees monthly

Self Only

Self Plus One Self and Family

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. 4

Medical benefits for Elevate. What you pay in-network. 3 geha.com/Find-Care – Unlimited telehealth visits with MDLIVE geha.com/MDLIVE – Preventive care; adult routine screenings – Well-child visit; up to age 22 – Maternity; routine preventive care – Chiropractic X-rays $0 – Primary physician office visit – MinuteClinic © (where available) geha.com/MinuteClinic – Chiropractic care; up to 12 visits per year (spinal manipulation therapy) – Acupuncture; up to 20 treatments per year $10 – Specialist care; office visit $25 – Urgent care $50 – Emergency care – Hospital care; inpatient including maternity – Hospital care; outpatient – Lab services – Other diagnostic services – Outpatient professional surgical services 25% 1 – Inpatient professional surgical services $250

1 Calendar year deductible applies. 2 The 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 of covered services. This is a combined maximum for both medical care and prescriptions. 3 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. 4 Refer to geha.com/Prescriptions for formulary and specialty coverage for specific medications. 5 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. 6 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. 7 Subject to any eligibility limitations. See info.bridgehealth.com/GEHA for more information.

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

$4 50% ($500 max) 100% 50% ($500 max) 100%

Generic Preferred brand-name Non-preferred brand-name

30-day retail

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

30-day 5 specialty CVS exclusive

geha.com/Elevate 800.262.4342

To provide a low premium, this plan does not include mail order prescriptions or out-of-network pharmacy coverage, and it has a limited pharmacy network. Find a pharmacy at geha.com/Find-Care

HDHP

Self Only premiums.

Enroll code 341 . geha.com/Enroll

$61.37

Non-Postal worker biweekly

A lower-than-expected deductible. Low premiums. GEHA contributes to an HSA. X GEHA contributes $900 (Self Only) or $1,800 (Self Plus One or Self and Family) to your HSA, which can reduce the yearly net deductible 8 to $600 or $1,200 , respectively. X Reduce your out-of-pocket expenses with a health savings account (HSA). geha.com/HSA Benefits included with your HDHP plan. Unlimited telehealth visits with MDLIVE 6 geha.com/MDLIVE Vision benefit and discount 8 geha.com/Vision Hearing aid discount 7 geha.com/Hearing Gym membership 7 geha.com/Fitness Electric toothbrush 7 geha.com/Toothbrush Teeth whitening 7 geha.com/Whitening Health Advice Line geha.com/Healthline Medical alert system 7 geha.com/LifeAlert Biometric screening geha.com/Screenings

$58.91

Postal worker biweekly – Category 1

$50.94

Postal worker biweekly – Category 2

$132.96

Retirees monthly

Self Plus One premiums.

Enroll code 343 . geha.com/Enroll

$131.94

Non-Postal worker biweekly

$126.66

Postal worker biweekly – Category 1

$109.51

Postal worker biweekly – Category 2

$285.87

Retirees monthly

Self and Family premiums.

Enroll code 342 . geha.com/Enroll

$159.04

Non-Postal worker biweekly

Yearly net deductible 8 for HDHP. What you pay in-network. 3

$152.68

Postal worker biweekly – Category 1

Yearly deductible Yearly net deductible after GEHA contribution

$132.01

Postal worker biweekly – Category 2

$1,500

$600

Self Only

$344.60

Retirees monthly

$3,000

$1,200

Self Plus One, Self and Family

Out-of-pocket max 2 for HDHP. What you pay in-network. 3 Self Only Out-of-pocket max

$5,000

$10,000

Self Plus One, Self and Family

Out-of-pocket max

Medical benefits for HDHP. What you pay in-network. 3 geha.com/Find-Care – Unlimited telehealth visits with MDLIVE geha.com/MDLIVE – Hospital care; inpatient maternity – Maternity; routine care $0 1,6 – Preventive care; adult routine screenings – Well-child visit; up to age 22 – Preventive dental care, twice yearly $0

1 Calendar year deductible applies. 2 The 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. 3 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 71-014 (HDHP) at geha.com/PlanBrochure 4 Refer to geha.com/Prescriptions for formulary and specialty coverage for specific medications. 5 If you choose a brand-name medication when a generic is available, you will be charged the generic copay plus the difference in cost between the brand- name and the generic. 6 If deductible is met, high deductible health plan (HDHP) member will be charged by MDLIVE but GEHA will then reimburse the member 100% of the billed charge. 7 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. 8 Net deductible: This is the remaining amount after you subtract the annual GEHA contribution from the annual deductible. This is your out-of-pocket cost before plan benefits begin.

– Primary physician office visit – Specialist care; office visit – Urgent care – Emergency care – Hospital care; inpatient and outpatient – MinuteClinic © (where available) geha.com/MinuteClinic – Lab services – Other diagnostic services – Professional surgical services – Acupuncture; up to 20 treatments per year – Chiropractic care; up to 20 visits per year (spinal manipulation therapy)

5% ¹

Balance after GEHA pays $20 per visit¹ Balance after GEHA pays $25 per year¹

– Chiropractic X-rays

Prescription benefits for HDHP. What you pay in-network. 1,3,4,5 geha.com/Prescriptions

25% 40% 25% 40% 25% 40%

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

30-day retail

90-day mail service

geha.com/HDHP 800.262.4342

30-day specialty CVS exclusive

Standard Option

Self Only premiums.

Enroll code 314 . geha.com/Enroll

$62.66

Non-Postal worker biweekly

Traditional coverage. Affordable premiums.

$60.16

Postal worker biweekly – Category 1

X $15 copay for in-network primary care visits, $30 copay for in-network specialist visits. X Pay $0 for routine, in-network maternity care. X Pay $0 for unlimited telehealth visits, including behavioral health therapists and dermatologists, through MDLIVE. X Plan works well with Medicare. geha.com/Medicare Benefits included with your Standard plan. Unlimited telehealth visits with MDLIVE geha.com/MDLIVE Vision discount 7 geha.com/Vision Hearing aid discount 7 geha.com/Hearing Gym membership 7 geha.com/Fitness Electric toothbrush 7 geha.com/Toothbrush Teeth whitening 7 geha.com/Whitening Health Advice Line geha.com/Healthline Medical alert system 7 geha.com/LifeAlert Biometric screening geha.com/Screenings Lab Card services geha.com/LabCard

$52.01

Postal worker biweekly – Category 2

$135.77

Retirees monthly

Self Plus One premiums.

Enroll code 316 . geha.com/Enroll

$134.73

Non-Postal worker biweekly

$129.35

Postal worker biweekly – Category 1

$111.83

Postal worker biweekly – Category 2

$291.92

Retirees monthly

Self and Family premiums.

Enroll code 315 . geha.com/Enroll

$164.85

Non-Postal worker biweekly

$158.26

Postal worker biweekly – Category 1

$136.83

Postal worker biweekly – Category 2

Yearly deductible & out-of-pocket max 2 for Standard. What you pay in-network. 3

$357.17

Retirees monthly

$350 $6,500 $700 $13,000

Yearly deductible Out-of-pocket max Yearly deductible Out-of-pocket max

Self Only

Self Plus One Self and Family

Medical benefits for Standard. What you pay in-network. 3 geha.com/Find-Care – Unlimited telehealth visits with MDLIVE geha.com/MDLIVE – Preventive care; adult routine screenings – Well-child visit; up to age 22

1 Calendar year deductible applies. 2 The 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. 3 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 4 Refer to geha.com/Prescriptions for formulary and specialty coverage for specific medications. 5 If you choose a brand-name medication when a generic is available, you will be charged the generic copay plus the difference in cost between the brand- name and the generic. 6 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. 7 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.

– Maternity; routine preventive care – Hospital care; inpatient maternity – Lab Card services geha.com/LabCard

– MinuteClinic © (where available) geha.com/MinuteClinic

$10 $15 $30 $35 15%

– Primary physician office visit

– Specialist care; office visit

– Urgent care

– Lab services (non-Lab Card)

– Emergency care – Hospital care; inpatient and outpatient – Professional surgical services – X-ray services – Other diagnostic services – Acupuncture; up to 20 treatments per year

15% 1

50%

– Preventive dental care; twice yearly

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

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

– Chiropractic X-rays

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

geha.com/Standard 800.262.4342

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

30-day 6 specialty CVS exclusive

Elevate Plus

Self Only premiums.

Enroll code 251 . geha.com/Enroll

$75.36

Non-Postal worker biweekly

Predictable costs and no in-network deductible. Copays for common medical expenses and includes out-of-network medical coverage. X Earn up to $500 for Self Only or $1,000 for Self Plus One and Self and Family through Wellness Pays rewards. X $0 out-of-pocket surgery costs and concierge care coordinator through BridgeHealth. 7 X Low copays for chiropractic and acupuncture visits. X Digital tools to navigate your health care experience. Learn more at geha.com/ElevateLearn Benefits included with your Elevate Plus plan. Unlimited telehealth visits with MDLIVE geha.com/MDLIVE Vision discount 6 geha.com/Vision Hearing aid discount 6 geha.com/Hearing Gym membership 6 geha.com/Fitness Electric toothbrush 6 geha.com/Toothbrush Teeth whitening 6 geha.com/Whitening $0 out-of-pocket surgery costs and concierge care coordinator through BridgeHealth 7 geha.com/BridgeHealth

$72.35

Postal worker biweekly – Category 1

$62.55

Postal worker biweekly – Category 2

$163.28

Retirees monthly

Self Plus One premiums.

Enroll code 253 . geha.com/Enroll

$175.81

Non-Postal worker biweekly

$168.62

Postal worker biweekly – Category 1

$147.06

Postal worker biweekly – Category 2

$380.93

Retirees monthly

Self and Family premiums.

Enroll code 252 . geha.com/Enroll

$186.89

Non-Postal worker biweekly

$179.42

Postal worker biweekly – Category 1

$155.12

Postal worker biweekly – Category 2

Yearly deductibles & out-of-pocket max 1 for Elevate Plus. What you pay in-network. 2

$404.93

Retirees monthly

$0 $6,000 $0 $12,000

Yearly deductible Out-of-pocket max Yearly deductible Out-of-pocket max

Self Only

Self Plus One Self and Family

Medical benefits for Elevate Plus. What you pay in-network. 2 geha.com/Find-Care – Unlimited telehealth visits with MDLIVE geha.com/MDLIVE – Preventive care; adult routine screenings – Well-child visit; up to age 22 – Lab services $0 – MinuteClinic © (where available) geha.com/MinuteClinic $10 – Primary physician office visit – Chiropractic care; up to 15 visits per year (spinal manipulation therapy) – Acupuncture; up to 20 treatments per year $20 – Specialist care; office visit $35 – Urgent care $50 – Other diagnostic services $50 8 – Emergency care – Outpatient and in-office professional surgical services $150 – Inpatient professional surgical services $200

1 The in-network out-of-pocket maximum is the maximum amount of coinsurance and copays 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. 2 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. 3 Refer to geha.com/Prescriptions for formulary and specialty coverage for specific medications. 4 If you choose a brand-name medication when a generic is available, you will be charged the generic copay plus the difference in cost between the brand-name and the generic. 5 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. 6 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. 7 Subject to any eligibility limitations. For more information, see info.bridgehealth.com/GEHA 8 You pay 25% for advanced outpatient diagnostic tests such as, CT scans and MRIs. Refer to GEHA’s 2021 plan brochure RI 71-018 (Elevate and Elevate Plus) for a complete list at geha.com/PlanBrochure

$200 per day up to $1,000 per admission $200 per day per facility

– Hospital care; inpatient including maternity

– Hospital care; outpatient

Prescription benefits for Elevate Plus. What you pay in-network. 2,3 geha.com/Prescriptions

$5 $80 4 40% 4 $12 $200 4 40% 4

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

30-day retail

90-day mail service

40% ($500 max 4 ) 40% 4

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

30-day 5 specialty CVS exclusive

geha.com/ElevatePlus 800.262.4342

This plan has no out-of-network pharmacy coverage and a limited pharmacy network. Find a pharmacy at geha.com/Find-Care

High Option

Self Only premiums.

Enroll code 311 . geha.com/Enroll

$108.14

Non-Postal worker biweekly

Comprehensive brand-name and specialty prescription coverage. Works best with Medicare and includes a $600 Medicare Part B premium reimbursement. X Low copays for doctor visits ( $20 primary and specialist). X $600 Medicare Part B premium reimbursement. geha.com/Medicare X $2,500 hearing aid benefit. X Low cost-share for a variety of inpatient and outpatient services ( 10% coinsurance). Benefits included with your High plan. Unlimited telehealth visits with MDLIVE geha.com/MDLIVE Vision discount 8 geha.com/Vision Hearing aid discount 8 geha.com/Hearing Gym membership 8 geha.com/Fitness Electric toothbrush 8 geha.com/Toothbrush Teeth whitening 8 geha.com/Whitening Health Advice Line geha.com/Healthline Medical alert system 8 geha.com/LifeAlert Biometric screening geha.com/Screenings Lab Card services geha.com/LabCard Yearly deductible & out-of-pocket max 2 for High. What you pay in-network. 3

$104.78

Postal worker biweekly – Category 1

$94.72

Postal worker biweekly – Category 2

$234.31

Retirees monthly

Self Plus One premiums.

Enroll code 313 . geha.com/Enroll

$251.93

Non-Postal worker biweekly

$244.74

Postal worker biweekly – Category 1

$223.18

Postal worker biweekly – Category 2

$545.85

Retirees monthly

Self and Family premiums.

Enroll code 312 . geha.com/Enroll

$314.13

Non-Postal worker biweekly

$306.32

Postal worker biweekly – Category 1

$282.90

Postal worker biweekly – Category 2

$680.61

Retirees monthly

$350 $5,000 $700 $10,000

Yearly deductible Out-of-pocket max Yearly deductible Out-of-pocket max

Self Only

Self Plus One Self and Family

Medical benefits for High. What you pay in-network. 3 geha.com/Find-Care – Unlimited telehealth visits with MDLIVE geha.com/MDLIVE – Preventive care; adult routine screenings – Well-child visit; up to age 22 – Maternity; routine preventive care – Emergency care; accidental (must be within 72 hours) – Hospital care; inpatient maternity – Lab Card services geha.com/LabCard $0 – MinuteClinic © (where available) geha.com/MinuteClinic $10

1 Calendar year deductible applies. 2 The 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. 3 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 4 Refer to geha.com/Prescriptions for formulary and specialty coverage for specific medications. 5 If you choose a brand-name medication when a generic is available, you will be charged the generic copay plus the difference in cost between the brand-name and the generic. 6 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. 7 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. 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. 8 These benefits are neither offered

– Primary physician office visit – Specialist care; office visit

$20

$35 10%

– Urgent care

– Lab services (non-Lab Card)

– Emergency care; medical – Hospital care; outpatient – Professional surgical services – X-ray services – Other diagnostic services – Acupuncture; up to 20 treatments per year

10% 1

$100 per admission plus 10%

– Hospital care; inpatient

– 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 Balance after GEHA pays $22 per visit

– Chiropractic X-rays

– Preventive dental care, twice yearly

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

$10 6 25% ($150 max 5,6 ) 40% ($200 max 5,6 ) $20 25% ($350 max 5 ) 40% ($500 max 5 ) 25% ($150 max 5 ) 40% ($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/High 800.262.4342

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

30-day 7 specialty CVS exclusive

Vision benefits & discounts for GEHA plans.

Included benefits & discounts.

Unlimited MDLIVE 4 telehealth visits Access certified doctors, including pediatricians, licensed behavioral health therapists and dermatologists, through MDLIVE. geha.com/MDLIVE Gym membership 3 10,000+ Active&Fit ™ fitness centers nationwide. geha.com/Fitness Electric toothbrush 2,3 70% off a cariPRO ™ premium electric toothbrush. geha.com/Toothbrush

With all GEHA medical plans, you get discounts on eye exams, frames and lenses through EyeMed. ™ The EyeMed network includes LensCrafters, Target Optical, independent eye doctors and top optical retailers. Members also save on LASIK at participating locations.

To learn more, visit geha.com/Vision

The HDHP plan also includes additional vision benefits. Learn more at geha.com/HDHPVision Examples of what you pay for common in-network 1 vision services for all plans. 3

Health Advice Line Talk with a nurse 24/7. geha.com/Healthline

What you pay Elevate HDHP Standard Elevate Plus

High

Eye exams retail price

Biometric screening Free screenings at select nationwide locations for HDHP, Standard Option and High Option plan members. geha.com/Screenings Medical alert system 3 Get free activation, plus a 10% monthly discount. geha.com/LifeAlert Teeth whitening 3 Discounts for Smile Brilliant home teeth whitening products such as trays, whitening and desensitizing gel. geha.com/Whitening

$0 under $100 plus 80% over $100

Frames retail price

60% of price

Eyeglass lenses, standard plastic single vision retail price

Up to $50 $10

Up to $50

$10 under $110 plus 85% over $110

Contact lens, conventional retail price

85% of price

Hearing aid benefits & discounts for GEHA plans.

Three GEHA plans – Standard Option, Elevate Plus and High Option – offer a hearing aid benefit, with no deductible. When you combine with TruHearing discount pricing³, you can save thousands of dollars off the retail price for new hearing aids. Although GEHA’s Elevate and HDHP plans don’t include hearing aid benefits, members of those plans can use the TruHearing hearing aid discount program. For more information, visit geha.com/Hearing Elevate Plus plan benefit. GEHA’s Elevate Plus hearing aid benefit is $1,500 per person every 36 months for adults. Subtract the GEHA benefit from the TruHearing discounted price to determine what you pay. Standard Option and High Option plan benefit. GEHA’s Standard and High hearing aid benefit is $2,500 per person every 36 months for adults. Subtract the GEHA benefit from the TruHearing discounted price to determine what you pay.

Example: Starkey® Livio ™ 1000

Standard

Elevate Plus

High

Average retail price

- $3,590

- $1,950

TruHearing discounted price

-$2,500

-$1,500

-$2,500

GEHA benefit pays

- $0

- $450

- $0

You pay

1 Elevate, Standard, Elevate Plus and High only when you visit an EyeMed provider. 2 The cariPRO TM premium toothbrush removes seven times more plaque than a regular brush, is completely waterproof and comes with a two-year manufacturer‘s warranty. Replacement brush heads with high-quality DuPont TM bristles are also available at this exclusive, member-only price. 3 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. 4 If deductible is met, high deductible health plan (HDHP) member will be charged by MDLIVE but GEHA will then reimburse the member 100% of the billed charge.

Elevate & Elevate Plus plans earn Wellness Pays rewards.

It’s easy to earn rewards with Wellness Pays.

GEHA‘s digital platform hosted by Rally A fun, interactive health and wellness portal that keeps you motivated to live healthier. geha.com/ElevateLearn

Achieve your health & wellness goals on your terms and earn rewards for healthy living. Two adult members per household (18+) can earn dollars on a Wellness Pays rewards card as you complete activities. Earn up to $500 each (maximum $1,000 per household) per year.

Learn more at geha.com/WellnessPays

Health survey Get rewarded for healthy habits and get personalized recommendations for activities and programs that you can work into your daily routine.

Rewardable activities

Elevate

Elevate Plus

$10 per month

– Achieve Stride step goal

– Flu shot – One MDLIVE telehealth visit – Complete three Rally missions – Complete wellness quizzes – Biometric screening

$50

Online health coaching This coaching program creates a personalized program for your preferred learning style and commitment level.

$75

– Health survey

– Annual physical – Cervical cancer screening (Pap)* – Colorectal cancer screening (colonoscopy)* – Breast cancer screening (mammogram)* – First trimester prenatal appointment – Complete online Rally coaching

Hit your Stride, online Use the app to monitor your daily Stride goal. Get rewarded monthly when you hit your goals.

$100

– Complete Real Appeal – Quit for Life

$200

HDHP, Standard Option and High Option plans earn Health Rewards.

Earn Health Rewards for completing healthy activities like a health risk assessment, a biometric screening, and online wellness workshops such as weight management, stress management or smoking cessation.

Two adult members per household (18+) can earn dollars on a Health Rewards card as you complete activities. Earn up to $250 each (maximum $500 per household) per year. The money you earn can be used for qualified medical expenses with your Health Rewards card. Learn more about Health Rewards available for HDHP, Standard Option and High Option plans at geha.com/HealthRewards

Rewardable activities

HDHP

Standard

High

$10 per workshop

– Online wellness workshops

$25

– Flu shot

– Cervical cancer screening (Pap)* – Colorectal cancer screening (colonoscopy or in-home kit)* – Breast cancer screening (mammogram)*

$50

– First trimester prenatal appointment – One MDLIVE telehealth visit per year

– Health risk assessment – Biometric screening

$75

$10 - $175

– Wellness portal activities and preventive services

* Restrictions may apply.

Compare medical benefits for all plans.

Medical benefits. What you pay in-network. 2

geha.com/Find-Care

Elevate

HDHP

Standard

$0 1,3

Unlimited telehealth visits with MDLIVE geha.com/MDLIVE $0

- Preventive care; adult routine screenings - Well-child visit; up to age 22 - Maternity; routine preventive care

MinuteClinic © (where available) geha.com/MinuteClinic Primary physician office visit geha.com/Find-Care

$10 $10 $25 $50

5% 1 5% 1 5% 1 5% 1 5% 1 5% 1 5% 1 $0 1 5% 1 5% 1 5% ¹

$10 $15 $30 $35

Specialist care; office visit

Urgent care

25% 1 25% 1 25% 1 25% 1 25% 1 $250 25% 1

15% 1 15% 1 15% 1

Emergency care; accidental Emergency care; medical Hospital care; inpatient Hospital care; inpatient maternity

15% 1 15% 1 15% 1

Hospital care; outpatient

Inpatient professional surgical services Outpatient professional surgical services Lab Card services geha.com/LabCard

No benefit

25% 1 25% 1

5% 1 5% ¹

15% 15% 1

Lab services (non-Lab Card) Other diagnostic services

Balance after GEHA pays $20 per visit, up to 20 visits per year¹ Balance after GEHA pays $25 per year¹

Balance after GEHA pays $20 per visit, up to 20 visits per year Balance after GEHA pays $25 per year

$10 per visit, up to 12 visits per year

Chiropractic (spinal manipulation therapy)

Chiropractic X-rays

$0 twice yearly, no deductible

50% twice yearly

Preventive dental care

No benefit

$10

5% 1

15% 1

Acupuncture; up to 20 treatments per year

Calendar year deductible applies.

2 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 one of GEHA‘s 2021 plan brochures: RI 71-006 (High and Standard), RI 71-014 (HDHP) or RI 71-018 (Elevate and Elevate Plus) at geha.com/PlanBrochure

Medical benefits. What you pay in-network. 2

geha.com/Find-Care

Elevate Plus

High

Unlimited telehealth visits with MDLIVE geha.com/MDLIVE $0

- Preventive care; adult routine screenings - Well-child visit; up to age 22 - Maternity; routine preventive care

MinuteClinic © (where available) geha.com/MinuteClinic Primary physician office visit geha.com/Find-Care

$10 $20 $35 $50

$10 $20 $20 $35

Specialist care; office visit

Urgent care

$150 $150

$0 (must be within 72 hours)

Emergency care; accidental Emergency care; medical Hospital care; inpatient Hospital care; inpatient maternity

10% 1

$200 per day up to $1,000 per admission $200 per day up to $1,000 per admission

$100 per admission plus 10%

$200 per day per facility

10% 1 10% 1 10% 1

Hospital care; outpatient

$200 $150

Inpatient professional surgical services Outpatient professional surgical services Lab Card services geha.com/LabCard

No benefit

10% 10% 1

Lab services (non-Lab Card) Other diagnostic services

$50 4

Balance after GEHA pays $20 per visit, up to 20 visits per year

$20 per visit, up to 15 visits per year

Chiropractic (spinal manipulation therapy)

Balance after GEHA pays $25 per year

Chiropractic X-rays

Balance after GEHA pays $22 per visit, twice yearly

Preventive dental care

No benefit

$20

10% 1

Acupuncture; up to 20 treatments per year

3 If deductible is met, high deductible health plan (HDHP) member will be charged by MDLIVE but GEHA will then reimburse the member 100% of the billed charge. 4 You pay 25% for advanced outpatient diagnostic tests such as, CT Scans and MRI’s. Refer to GEHA’s 2021 plan brochure RI 71-018 (Elevate and Elevate Plus) for a complete list at geha.com/PlanBrochure

Compare out-of-pocket max for all plans.

Out-of-pocket maximum. 1 What you pay in-network. 2

Elevate

HDHP

Standard

Elevate Plus

High

Self Only

$7,000

$5,000

$6,500

$6,000

$5,000

Self Plus One Self and Family

$14,000

$10,000

$13,000

$12,000

$10,000

Compare deductibles for all plans.

Yearly deductible. What you pay in-network. 2

Elevate

HDHP

Standard

Elevate Plus

High

$1,500 Yearly deductible -$900 GEHA contribution $600 Your net deductible 3 -$3,000 Yearly deductible -$1,800 GEHA contribution -$1,200 Your net deductible 3

Self Only

$500

$350

Self Plus One Self and Family

$1,000

$700

1 The 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. 2 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 one of GEHA‘s 2021 plan brochures: RI 71-006 (High and Standard), RI 71-014 (HDHP) or RI 71-018 (Elevate and Elevate Plus) at geha.com/PlanBrochure 3 Net deductible: This is the remaining amount after you subtract the annual GEHA contribution from the annual deductible. This is your out-of-pocket cost before plan benefits begin.

Example: It pays to stay in-network.

Whether it’s a fixed dollar amount, or a percentage, we want you to understand what you pay for in- or out-of-network services. We’ve included an example below for a plan with a 10% coinsurance 1 for services in-network and 25% coinsurance for services out-of-network .

Example

In-network

Out-of-network

$150

Provider’s billed rate

– In-network provider’s contracted rate with GEHA – GEHA’s plan allowance¹ for out-of-network providers

$100

90% of $100: $90

75% of $100: $75

What GEHA pays

10% of $100: $10

25% of $100: $25

What you pay (coinsurance)

Yes: $50

You also pay the difference between the provider’s billed rate and GEHA’s plan allowance

What you pay total for this service

$10

$75

1 See page 26 for definition.

Resources for all plans

800.262.4342

Talk to a Benefits Adviser who can help me choose a GEHA plan

800.821.6136

Talk to GEHA Customer Care

geha.com/Find-Care

Find an in-network provider near me

geha.com/Select-A-Plan

Help me select a plan

info.caremark.com/GEHA

Check my 2021 drug costs

Compare premiums for all plans.

Self Only. What you pay.

Learn how to enroll at geha.com/Enroll

Elevate

HDHP

Standard

Enrollment codes

254

341

314

$47.32 $45.43 $39.28 $102.53

$61.37 $58.91 $50.94 $132.96

$62.66 $60.16 $52.01 $135.77

Non-Postal worker biweekly

Postal worker biweekly – Category 1

Postal worker biweekly – Category 2

Retirees monthly

Self Plus One. What you pay.

Elevate

HDHP

Standard

Enrollment codes

256

343

316

$108.84 $104.49

$131.94 $126.66 $109.51 $285.87

$134.73 $129.35 $111.83 $291.92

Non-Postal worker biweekly

Postal worker biweekly – Category 1

$90.34

Postal worker biweekly – Category 2

$235.83

Retirees monthly

Self and Family. What you pay.

Elevate

HDHP

Standard

Enrollment codes

255

342

315

$132.51 $127.21 $109.98 $287.10

$159.04 $152.68 $132.01 $344.60

$164.85 $158.26 $136.83 $357.17

Non-Postal worker biweekly

Postal worker biweekly – Category 1

Postal worker biweekly – Category 2

Retirees monthly

Self Only. What you pay.

Learn how to enroll at geha.com/Enroll

Elevate Plus

High

Enrollment codes

251

311

$75.36 $72.35 $62.55 $163.28

$108.14 $104.78

Non-Postal worker biweekly

Postal worker biweekly – Category 1

$94.72

Postal worker biweekly – Category 2

$234.31

Retirees monthly

Self Plus One. What you pay.

Elevate Plus

High

Enrollment codes

253

313

$175.81 $168.62 $147.06 $380.93

$251.93 $244.74 $223.18 $545.85

Non-Postal worker biweekly

Postal worker biweekly – Category 1

Postal worker biweekly – Category 2

Retirees monthly

Self and Family. What you pay.

Elevate Plus

High

Enrollment codes

252

312

$186.89 $179.42 $155.12 $404.93

$314.13 $306.32 $282.90 $680.61

Non-Postal worker biweekly

Postal worker biweekly – Category 1

Postal worker biweekly – Category 2

Retirees monthly

Compare prescription coverage for all plans.

What you pay in-network. 2,3

geha.com/Prescriptions

Elevate

HDHP

Standard

25% 1

$10

Generic

50% ($500 max)

25% 1,4

50% ($200 max 4 )

30-day retail

Preferred brand-name

100%

40% 1,4

50% ($300 max 4 )

Non-preferred brand-name

25% 1

$20

Generic

No benefit

25% 1,4

50% ($500 max 4 )

90-day mail service

Preferred brand-name

No benefit

40% 1,4

50% ($600 max 4 )

Non-preferred brand-name

No benefit

50% ($500 max)

25% 1,4

50% ($250 max 4 )

Generic and preferred brand-name

30-day 6 specialty CVS exclusive

100%

40% 1,4

50% ($400 max 4 )

Non-preferred brand-name

Elevate and Elevate Plus do not have out-of-network pharmacy coverage and have a limited pharmacy network. Learn more about prescription coverage at geha.com/Prescriptions

You‘ve got options with retail prescriptions. Pay less for prescriptions that are filled at an in-network pharmacy location. Locations include any CVS Pharmacy location, but you don‘t have to go to a CVS to pay in-network prices.

Save more with mail order prescriptions.

With CVS Caremark’s Mail Service Pharmacy, you can save money and have your routine prescriptions delivered to your home, postage- paid, within about 14 days from the time you submit your prescription. Mail order is not available for the Elevate plan option.

Find an in-network pharmacy location at geha.com/Find-Care

What you pay in-network. 2,3

geha.com/Prescriptions

Elevate Plus

High

$10 5

Generic

$80 4

25% ($150 max 4,5 )

30-day retail

Preferred brand-name

40% 4

40% ($200 max 4,5 )

Non-preferred brand-name

$12

$20

Generic

$200 4

25% ($350 max 4 )

90-day mail service

Preferred brand-name

40% 4

40% ($500 max 4 )

Non-preferred brand-name

40% ($500 max 4 )

25% ($150 max 4 )

Generic and preferred brand-name

30-day 6 specialty CVS exclusive

40% 4

40% ($200 max 4 )

Non-preferred brand-name

Elevate and Elevate Plus do not have out-of-network pharmacy coverage and have a limited pharmacy network. Learn more about prescription coverage at geha.com/Prescriptions

1 Calendar year deductible applies. 2 The 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. 3 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, see one of GEHA‘s 2021 plan brochures: RI 71-006 (High and Standard), RI 71-014 (HDHP) or RI 71-018 (Elevate and Elevate Plus) at geha.com/PlanBrochure 4 If you choose a brand-name medication when a generic is available, you will be charged the generic copay plus the difference in cost between the brand-name and the generic. 5 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. 6 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.

Definitions.

Calendar year deductible

What you pay each year before the plan begins to pay out benefits.

Coinsurance

The percentage you pay for a covered health care service, after you‘ve met your deductible.

Copay

A fixed amount you pay for a service or prescription.

Portion of monthly HDHP premium that GEHA contributes to a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA). A health care provider who is a part of GEHA‘s provider network. These providers agree to limit what they will charge you. The remaining amount after you subtract the annual GEHA contribution from the annual deductible. This is your out-of-pocket cost before plan benefits begin. The maximum amount you pay each year for coverage. Includes copays, deductibles and coinsurance, but not premiums. Once the limit is met, the plan pays the remainder of your covered health care expenses for the rest of the year. Cost of health care goods and services after subtracting the insurance company’s negotiated discount. For complete details see the definition of “Plan allowance” in Section 10 of any GEHA plan brochure. geha.com/PlanBrochure

GEHA contribution

In-network provider

Net deductible (HDHP)

Out-of-pocket max

Plan allowance

PPO

A preferred provider organization.

Premium

What you pay monthly or biweekly for coverage.

Prescription benefits

What you pay as a copay or percentage of coinsurance for medication.

Helpful resources.

If you have questions about the information contained in this benefits guide please call one of our helpful Benefits Advisers.

800.262.4342

Talk to a Benefits Adviser who can help you choose from GEHA‘s portfolio of plans.

geha.com/Select-A-Plan

Answer a few questions to see which plan may be your best fit.

Search our extensive nationwide network for a provider or a medical facility (including urgent care clinics) near you.

geha.com/Find-Care

geha.com/Prescriptions

Verify drug costs based on your medical plan and prescription dosage.

geha.com/Rates

Get details on medical plans and supplemental benefits for each.

geha.com/Medicare

Explore how GEHA medical plans work with Medicare.

geha.com/MinuteClinic

Find a MinuteClinic® near you, where available.

geha.com/OutsideUSA

Learn about your coverage when you’re outside of the United States.

U.S. Office of Personnel Management. The official source of information for federal employees eligible for FEHB plans.

opm.gov/Healthcare-Insurance

geha.com/Enroll

Tips for new enrollees or for those who are changing plans.

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