Medical benefits in-network 1,2
You pay
Unlimited telehealth visits, including mental health, with MDLIVE Preventive care; adult routine screenings Well-child visit; up to age 22 Lab services Maternity; routine care Vision coverage; eye exams 3
$0
$10
MinuteClinic ® where available
Primary physician office visit Mental health office visit Chiropractic care (manipulative therapy), including X-rays; up to 15 visits per year Acupuncture; up to 20 treatments per year
$30
$45
Specialist care office visit
$50
Urgent care facility
$50 4
X-ray and other diagnostic services
ER visit Outpatient and inpatient professional surgery services Maternity; inpatient care Hospital care; inpatient and outpatient
15% 5
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. 2 This plan has no out-of-network coverage. 3 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. 4 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 2023 plan brochure RI 71-018 (Elevate and Elevate Plus) at geha.com/PlanBrochure 5 Calendar year deductible applies. 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. Prescription benefits in-network 1,2,3 You pay 30-day retail generic $10 30-day retail preferred brand-name $80 4 30-day retail non-preferred brand-name 50% 4 90-day mail service generic $20 90-day mail service preferred brand-name $200 4 90-day mail service non-preferred brand-name 50% 4 30-day specialty CVS exclusive generic and preferred brand-name 40% ( $500 max 4 ) 30-day specialty CVS exclusive non-preferred brand-name 50% 4 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. 2 Refer to geha.com/Prescriptions for formulary and specialty coverage for specific medications. 3 This plan has no out-of-network pharmacy coverage. 4 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.
13
2023 GEHA medical plans
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