2021 GEHA Medical Benefits Guide

Elevate

Self Only premiums.

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.

Enroll code 254 . geha.com/Enroll

$47.32

Non-Postal worker biweekly

Get rewarded for healthy living and enjoy GEHA's lowest premium plan.

$45.43

Postal worker biweekly – Category 1

$39.28

Postal worker biweekly – Category 2

X Earn up to $500 for Self Only or $1,000 for Self Plus One and Self and Family through Wellness Pays rewards. X Low $10 copays for unlimited primary care visits and $25 copays for unlimited specialist visits. X Low copays for chiropractic and acupuncture visits. X Digital tools to navigate your health care experience. Learn more at geha.com/ElevateLearn

$102.53

Retirees monthly

Self Plus One premiums.

Enroll code 256 . geha.com/Enroll

$108.84

Non-Postal worker biweekly

Benefits included with your Elevate plan. Unlimited telehealth visits with MDLIVE

$104.49

Postal worker biweekly – Category 1

geha.com/MDLIVE geha.com/Vision geha.com/Fitness geha.com/Toothbrush geha.com/Whitening

$90.34

Postal worker biweekly – Category 2

Vision discount 6

$235.83

Retirees monthly

Gym membership 6 Electric toothbrush 6

Self and Family premiums.

Teeth whitening 6

Enroll code 255 . geha.com/Enroll

$0 out-of-pocket surgery costs and concierge care coordinator through BridgeHealth 7

geha.com/BridgeHealth

$132.51

Non-Postal worker biweekly

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

$127.21

Postal worker biweekly – Category 1

Yearly deductible & out-of-pocket max 2 for Elevate. What you pay in-network. 3

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

Generic Preferred brand-name Non-preferred brand-name

$109.98

Postal worker biweekly – Category 2

30-day retail

$500 $7,000 $1,000 $14,000

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

$287.10

Retirees monthly

Self Only

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

30-day 5 specialty CVS exclusive

Self Plus One Self and Family

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

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.

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