2021 GEHA Medical Benefits Guide

High Option

Self Only premiums.

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

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. geha.com/MRA 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

– Primary physician office visit – Specialist care; office visit

Self Plus One premiums.

$20

$35 10%

– Urgent care

Enroll code 313 . geha.com/Enroll

– Lab services (non-Lab Card)

$251.93

Non-Postal worker biweekly

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

$244.74

Postal worker biweekly – Category 1

10% 1

$223.18

Postal worker biweekly – Category 2

$545.85

Retirees monthly

$100 per admission plus 10%

– Hospital care; inpatient

Self and Family premiums.

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

Balance after GEHA pays $20 per visit

Enroll code 312 . geha.com/Enroll

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

– Chiropractic X-rays

– Preventive dental care, twice yearly

$314.13

Non-Postal worker biweekly

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

$306.32

Postal worker biweekly – Category 1

$282.90

Postal worker biweekly – Category 2

$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

$680.61

Retirees monthly

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

90-day mail service

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

Self Only

geha.com/High 800.262.4342

Self Plus One Self and Family

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. 12

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