2021 GEHA Medical Benefits Guide

Example: It pays to stay in-network.

Compare out-of-pocket max for all plans.

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 .

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

Elevate

HDHP

Standard

Elevate Plus

High

Example

In-network

Out-of-network

Self Only

$7,000

$5,000

$6,500

$6,000

$5,000

$150

$150

Provider’s billed rate

Self Plus One Self and Family

$14,000

$10,000

$13,000

$12,000

$10,000

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

$100

$100

90% of $100: $90

75% of $100: $75

What GEHA pays

Compare deductibles for all plans.

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

No

Yearly deductible. What you pay in-network. 2

What you pay total for this service

$10

$75

Elevate

HDHP

Standard

Elevate Plus

High

1 See page 26 for definition.

$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

$0

$350

Resources for all plans

Self Plus One Self and Family

$1,000

$700

$0

$700

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

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.

geha.com/Select-A-Plan

Help me select a plan

info.caremark.com/GEHA

Check my 2021 drug costs

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