2022 GEHA Medical Benefits Guide

Included with Elevate Plus

Medical benefits in-network. 1,2 No out-of-network coverage.

What you pay

• Unlimited telehealth visits, including behavioral health, with MDLIVE geha.com/MDLIVE • Preventive care; adult routine screenings • Well-child visit; up to age 22 • Lab services • Maternity; routine care

Telehealth visits, including behavioral health geha.com/MDLIVE Vision discount 5 (see page 20) geha.com/Vision Hearing aid discount 5 geha.com/Hearing Gym membership discount 5 geha.com/Fitness Electric toothbrush discount 5 geha.com/Toothbrush Teeth whitening discount 5 geha.com/Whitening Surgical concierge 6 $0 out-of-pocket surgery costs and care coordination geha.com/BridgeHealth For a complete list visit geha.com/Savings

$0

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

$10

• Primary physician office visit • Chiropractic care (manipulative therapy), including X-rays; up to 15 visits per year • Acupuncture; up to 20 treatments per year $25 • Specialist care; office visit $40 • Urgent care $50 • Other diagnostic services $50 3 • In-office professional surgical services $75 • Emergency care $200 • Outpatient and inpatient professional surgical services $200

$250 per day up to $1,000 per admission $250 per day per facility

• Hospital care; inpatient including maternity

• Hospital care; outpatient

Medicare A & B primary? See page 25 or visit geha.com/Medicare

Out-of-pocket maximum in-network. 1,4 No out-of-network coverage.

What you pay

5 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. 6 Subject to any eligibility limitations. For more information, see info.bridgehealth.com/GEHA

$6,000 $12,000

Self Only

Self Plus One and Self and Family

This plan has no out-of-network medical coverage. Find a provider or check if your provider is in-network at geha.com/Find-Care

Learn how to enroll at geha.com/Enroll

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. Elevate Plus has no out of network benefits. Refer to GEHA’s 2022 plan brochure RI 71-018 (Elevate and Elevate Plus) at geha.com/PlanBrochure 2 This plan has no out-of-network coverage. 3 You pay $175 ($100 professional fee, $75 facility fee) for advanced outpatient High Tech Imaging such as MRI, CT, PET, etc. Refer to GEHA’s 2022 plan brochure RI 71-018 (Elevate and Elevate Plus) at geha.com/PlanBrochure 4 The out-of-pocket maximum is the maximum amount of coinsurance and copays 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.

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2022 GEHA MEDICAL PLANS

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