Elevate + Medicare geha.com/Elevate 800.262.4342 • GEHA’s lowest premium plan • Low copays for non-traditional care, like chiropractic and acupuncture • Engaging digital wellness portal powered by Rally ® How this plan pays you back • NEW! Subscribers can select an annual plan perk. See page 5. geha.com/PlanPerk • Earn Wellness Pays rewards up to $500 (Self Only) or $1,000 (Self Plus One or Self and Family) annually geha.com/WellnessPays
Self Only What you pay
Self Plus One What you pay
Self and Family What you pay
Premiums
254
256
255
Enrollment codes Monthly – retired
$105.61 $295.71 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. $242.90
Yearly deductible in-network 1
What you pay
$500
Self Only
$1,000
Self Plus One and Self and Family
What you pay
Prescription benefits in-network 1 ,2,3
• 30-day retail generic
$4
• 30-day retail preferred brand-name • 30-day retail non-preferred brand-name
50% ($500 max)
100%
• 30-day specialty CVS exclusive generic and preferred brand-name • 30-day specialty CVS exclusive non-preferred brand-name
50% ($500 max)
100%
Check prescription costs at geha.com/Prescriptions
Health care style: wellness-focused, cost-conscious
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
How often you use your plan
Low
Average
High
Prescription medication need
Low
Average
High
1 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. Refer to GEHA’s 2022 plan brochure RI 71-018 (Elevate and Elevate Plus) at geha.com/PlanBrochure 2 Refer to geha.com/Prescriptions for formulary and specialty coverage for specific medications. 3 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
06 2022 GEHA MEDICARE BENEFITS
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