2021 GEHA Medical Benefits Guide

Medical benefits for HDHP. What you pay in-network. 3 geha.com/Find-Care – Unlimited telehealth visits with MDLIVE geha.com/MDLIVE – Hospital care; inpatient maternity – Maternity; routine care $0 1,6 – Preventive care; adult routine screenings – Well-child visit; up to age 22 – Preventive dental care, twice yearly $0

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 71-014 (HDHP) 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 If deductible is met, high deductible health plan (HDHP) member will be charged by MDLIVE but GEHA will then reimburse the member 100% of the billed charge. 7 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. 8 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.

– Primary physician office visit – Specialist care; office visit – Urgent care – Emergency care – Hospital care; inpatient and outpatient – MinuteClinic © (where available) geha.com/MinuteClinic – Lab services – Other diagnostic services – Professional surgical services – Acupuncture; up to 20 treatments per year – Chiropractic care; up to 20 visits per year (spinal manipulation therapy)

5% ¹

Balance after GEHA pays $20 per visit¹ Balance after GEHA pays $25 per year¹

– Chiropractic X-rays

Prescription benefits for HDHP. What you pay in-network. 1,3,4,5 geha.com/Prescriptions

25% 40% 25% 40% 25% 40%

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

30-day retail

90-day mail service

geha.com/HDHP 800.262.4342

30-day specialty CVS exclusive

7

www.geha.com

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