2021 GEHA Medical Benefits Guide

What you pay in-network. 2,3

geha.com/Prescriptions

Elevate Plus

High

$5

$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.

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www.geha.com

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