2021 GEHA Medical Benefits Guide

Medical benefits for Elevate. 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 – Chiropractic X-rays $0 – Primary physician office visit – MinuteClinic © (where available) geha.com/MinuteClinic – Chiropractic care; up to 12 visits per year (spinal manipulation therapy) – Acupuncture; up to 20 treatments per year $10 – Specialist care; office visit $25 – Urgent care $50 – Emergency care – Hospital care; inpatient including maternity – Hospital care; outpatient – Lab services – Other diagnostic services – Outpatient professional surgical services 25% 1 – Inpatient professional surgical services $250

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 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. 4 Refer to geha.com/Prescriptions for formulary and specialty coverage for specific medications. 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. See info.bridgehealth.com/GEHA for more information.

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

$4 50% ($500 max) 100% 50% ($500 max) 100%

Generic Preferred brand-name Non-preferred brand-name

30-day retail

Generic and preferred brand-name Non-preferred brand-name

30-day 5 specialty CVS exclusive

geha.com/Elevate 800.262.4342

To provide a low premium, this plan does not include mail order prescriptions or out-of-network pharmacy coverage, and it has a limited pharmacy network. Find a pharmacy at geha.com/Find-Care

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www.geha.com

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