2021 GEHA Medical Benefits Guide

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

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www.geha.com

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