2021 GEHA Medical Benefits Guide

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



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