2021 GEHA Medical Benefits Guide

Medical benefits for Standard. 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

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 71-006 (High and Standard) 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 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. 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.

$0

– Maternity; routine preventive care – Hospital care; inpatient maternity – Lab Card services geha.com/LabCard

– MinuteClinic © (where available) geha.com/MinuteClinic

$10 $15 $30 $35 15%

– Primary physician office visit

– Specialist care; office visit

– Urgent care

– Lab services (non-Lab Card)

– Emergency care – Hospital care; inpatient and outpatient – Professional surgical services – X-ray services – Other diagnostic services – Acupuncture; up to 20 treatments per year

15% 1

50%

– Preventive dental care; twice yearly

Balance after GEHA pays $20 per visit Balance after GEHA pays $25 per year

– Chiropractic care; up to 20 visits per year (spinal manipulation therapy)

– Chiropractic X-rays

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

$10 50% ($200 max 5 ) 50% ($300 max 5 ) $20 50% ($500 max 5 ) 50% ($600 max 5 ) 50% ($250 max 5 ) 50% ($400 max 5 )

Generic Preferred brand-name Non-preferred brand-name Generic Preferred brand-name Non-preferred brand-name

30-day retail

90-day mail service

geha.com/Standard 800.262.4342

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

30-day 6 specialty CVS exclusive

9

www.geha.com

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