Compare prescription coverage for all plans What you pay in-network. 1,2
Elevate What you pay
HDHP What you pay
Standard What you pay
Elevate Plus What you pay
High What you pay
Prescription type
$4
25% 3
$10
$10
$10 4
• 30-day retail generic
50% ($500 max)
25% 3,5
50% ($200 max 5 )
$80 5
25% ($150 max 4,5 )
• 30-day preferred brand-name
100%
40% 3,5
50% ($300 max 5 )
50% 5
40% ($200 max 4,5 )
• 30-day non-preferred brand-name
25% 3
$20
$20
$20
• 90-day mail order service generic
No benefit
• 90-day mail order service preferred brand-name
25%
50% ($500 max 5 )
$200 5
25% ($350 max 5 )
No benefit
3,5
• 90-day mail order service non-preferred brand-name
40%
50% ($600 max 5 )
50% 5
40% ($500 max 5 )
No benefit
3,5
• 30-day specialty CVS exclusive generic and preferred brand-name
50% ($500 max)
25%
50% ($250 max 5 )
40% ($500 max 5 )
25% ($150 max 5 )
3,5
• 30-day specialty CVS exclusive non-preferred brand-name
100%
40%
50% ($400 max 5 )
50% 5
40% ($200 max 5 )
3,5
Elevate and Elevate Plus do not have out-of-network pharmacy coverage and have a limited pharmacy network. Learn more about prescription coverage at geha.com/Prescriptions
Check drug costs at info.caremark.com/GEHA
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. For out-of-network benefits, refer to one of GEHA’s 2022 plan brochures: RI 71-006 (High and Standard), RI 71-014 (HDHP) or RI 71-018 (Elevate and Elevate Plus) at geha.com/PlanBrochure 2 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. 3 Calendar year deductible applies. 4 Cost for initial prescription and first refill. You pay 50% for third and additional refills at retail for 30-day supply. For long term prescriptions, use mail order or your local retail CVS Pharmacy store (90-day supply) for greater cost savings. 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.
24 2022 GEHA MEDICAL PLANS
Powered by FlippingBook