1 Table of contents 32

2023 GEHA Medical Benefits Guide

Choose from five unique medical plans designed to meet you where you are in life. Download the PDF for a 508-accessible document.

Structure Bookmarks		1
2023 GEHA Medical Plans		1
2023 GEHA Medical Plans		1
2023 GEHA Medical Plans		1
2023 GEHA Medical Plans		1
Figure		1
Choose from five unique medical plans designed to meet you where you are in life.		1
Choose from five unique medical plans designed to meet you where you are in life.		1
Figure		1
Figure		1
|		1
|		1
geha.com		1
geha.com		1
800.262.4342		1
800.262.4342		1
What’s inside		2
What’s inside		2
03 Welcome		2
03 Welcome		2
03 Welcome		2
03 Welcome		2
04 Choose from five unique medical plans		2
04 Choose from five unique medical plans		2
04 Choose from five unique medical plans		2
06 Elevate		2
06 Elevate		2
06 Elevate		2
08 HDHP		2
08 HDHP		2
08 HDHP		2
10 Standard		2
10 Standard		2
10 Standard		2
12 Elevate Plus		2
12 Elevate Plus		2
12 Elevate Plus		2
14 High		2
14 High		2
14 High		2
16 Get help choosing the right plan		2
16 Get help choosing the right plan		2
16 Get help choosing the right plan		2
17 Extras if you choose Elevate		2
17 Extras if you choose Elevate		2
17 Extras if you choose Elevate		2
18 Earn Wellness Pays rewards—Elevate and Elevate Plus plans		2
18 Earn Wellness Pays rewards—Elevate and Elevate Plus plans		2
18 Earn Wellness Pays rewards—Elevate and Elevate Plus plans		2
19 Earn Health Rewards—HDHP, Standard and High plans		2
19 Earn Health Rewards—HDHP, Standard and High plans		2
19 Earn Health Rewards—HDHP, Standard and High plans		2
20 Vision discounts and benefits for GEHA plans		2
20 Vision discounts and benefits for GEHA plans		2
20 Vision discounts and benefits for GEHA plans		2
21 Benefits included in all five plans		2
21 Benefits included in all five plans		2
21 Benefits included in all five plans		2
22 GEHA works with Medicare A and B		2
22 GEHA works with Medicare A and B		2
22 GEHA works with Medicare A and B		2
24 Compare premiums		2
24 Compare premiums		2
24 Compare premiums		2
25 Compare deductibles and out-of-pocket maximum		2
25 Compare deductibles and out-of-pocket maximum		2
25 Compare deductibles and out-of-pocket maximum		2
26 Compare prescription costs		2
26 Compare prescription costs		2
26 Compare prescription costs		2
28 Compare medical benefits		2
28 Compare medical benefits		2
28 Compare medical benefits		2
30 It pays to stay in-network		2
30 It pays to stay in-network		2
30 It pays to stay in-network		2
31 Definitions and terms		2
31 Definitions and terms		2
31 Definitions and terms		2
Welcome		3
Welcome		3
Whatever stage of life you’re in, GEHA has a plan to fit your needs.		3
We believe health care isn’t one size fits all, and our plans are designed with that in mind. For more than 85 years, GEHA (Government Employees Health Association, Inc.) has provided medical plans designed exclusively for federal employees.		3
GEHA is a non-profit association and one of the largest national medical plan carriers for federal employees.		3
Choose from five medical plans:		3
Choose from five medical plans:		3
Figure		3
Figure		3
Figure		3
Figure		3
Figure		3
High		3
High		3
HDHP		3
HDHP		3
Standard		3
Standard		3
Elevate		3
Elevate		3
Elevate Plus		3
Elevate Plus		3
Choose from the following enrollment types:		3
Choose from the following enrollment types:		3
Self Only		3
Self Only covers only the enrollee and no one else.		3
Self Plus One		3
Self Plus One covers the enrollee and one eligible family member.		3
Self and Family		3
Self and Family covers the enrollee and eligible family including children up to age 26.		3
NOV		3
DEC		3
Figure		3
Figure		3
Open Season		3
Open Season		3
begins on Monday, November 14, and concludes on Monday, December 12.		3
Figure		3
All five GEHA medical plans cover pre-existing conditions.		3
All five GEHA medical plans cover pre-existing conditions.		3
Figure		3
Choose from five unique medical plans		4
Choose from five unique medical plans		4
Elevate		4
Elevate		4
HDHP		4
HDHP		4
Standard		4
Standard		4
•		4
•		4
•		4
•		4
•		4
One of the lowest national premiums and low doctor visit copays		4
•		4
•		4
•		4
Uniquely designed plan with a complete wellness focus		4
•		4
•		4
•		4
Earn up to $1,000 per household with a generous rewards program		4
geha.com/WellnessPays		4
geha.com/WellnessPays		4
How often you use your plan:		4
Prescription medication need:		4
Life-stage: early career		4
Health care style: wellness-focused, cost-conscious		4
geha.com/Elevate		4
geha.com/Elevate		4
geha.com/Elevate		4
•		4
•		4
•		4
•		4
•		4
No-cost preventive care paired with a low premium.		4
•		4
•		4
•		4
GEHA puts money in your HSA every month		4
geha.com/HSA		4
geha.com/HSA		4
•		4
•		4
•		4
Earn up to $500 per household to pay for qualified expenses		4
geha.com/HealthRewards		4
geha.com/HealthRewards		4
How often you use your plan:		4
Prescription medication need:		4
Life-stage: all career stages		4
Health care style: non-traditional, focused on saving for future needs		4
geha.com/HDHP		4
geha.com/HDHP		4
geha.com/HDHP		4
•		4
•		4
•		4
•		4
•		4
Comprehensive medical coverage for all stages of life		4
•		4
•		4
•		4
Affordable premiums and low copays for common services		4
•		4
•		4
•		4
Earn up to $500 per household to pay for qualified expenses		4
geha.com/HealthRewards		4
geha.com/HealthRewards		4
4
How often you use your plan:		4
Prescription medication need:		4
Life-stage: mid-career		4
Health care style: traditional care and coverage		4
geha.com/Standard		4
geha.com/Standard		4
geha.com/Standard		4
Sect		4
Figure		4
Sect		4
Figure		4
Sect		4
Figure		4
This is a brief description of the features of GEHA’s medical plans. Please read the Plan’s Federal brochure (RI 71-018, RI 71-014 and RI 71-006), available at . All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochure.		4
This is a brief description of the features of GEHA’s medical plans. Please read the Plan’s Federal brochure (RI 71-018, RI 71-014 and RI 71-006), available at . All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochure.		4
geha.com/PlanBrochure		4
geha.com/PlanBrochure		4
We believe health care isn’t one size fits all, and our plans are designed with that in mind. Whatever stage of life you’re in, GEHA has a plan designed to fit your needs.		5
We believe health care isn’t one size fits all, and our plans are designed with that in mind. Whatever stage of life you’re in, GEHA has a plan designed to fit your needs.		5
Elevate Plus		5
Elevate Plus		5
High		5
High		5
All plans include:		5
All plans include:		5
Story		5
Nationwide coverage		5
Telehealth visits with MDLIVE		5
24/7 Health Advice Line		5
Preventive care		5
Incentives and discounts		5
No referrals necessary		5
Rewards programs		5
•		5
•		5
•		5
•		5
•		5
$150 deductible for Self Only and $300 deductible for Self Plus One and Self and Family		5
NEW		5
•		5
•		5
•		5
15% coinsurance for some services		5
NEW		5
•		5
•		5
•		5
Earn up to $1,000 per household with a generous rewards program		5
geha.com/WellnessPays		5
geha.com/WellnessPays		5
How often you use your plan:		5
Prescription medication need:		5
Life-stage: mid-career		5
Health care style: proactive, values generous rewards		5
geha.com/ElevatePlus		5
geha.com/ElevatePlus		5
geha.com/ElevatePlus		5
•		5
•		5
•		5
•		5
•		5
Low copays for primary and specialist doctor visits		5
•		5
•		5
•		5
Get more care with GEHA and Medicare		5
geha.com/Medicare		5
geha.com/Medicare		5
•		5
•		5
•		5
Earn up to $500 per household to pay for qualified expenses		5
geha.com/HealthRewards		5
geha.com/HealthRewards		5
How often you use your plan:		5
Prescription medication need:		5
Life-stage: late-career		5
Health care style: maximum coverage, dependable support		5
geha.com/High		5
geha.com/High		5
geha.com/High		5
Sect		5
Figure		5
Sect		5
Figure		5
Sect		5
Figure		5
Figure		5
This is a brief description of the features of GEHA’s medical plans. Please read the Plan’s Federal brochure (RI 71-018, RI 71-014 and RI 71-006), available at . All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochure.		5
This is a brief description of the features of GEHA’s medical plans. Please read the Plan’s Federal brochure (RI 71-018, RI 71-014 and RI 71-006), available at . All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochure.		5
geha.com/PlanBrochure		5
geha.com/PlanBrochure		5
Elevate		6
Elevate		6
Learn all about this plan at		6
geha.com/Elevate		6
geha.com/Elevate		6
GEHA’s lowest premium plan		6
•		6
Low copays for non-traditional care, like chiropractic and acupuncture		6
•		6
Engaging digital wellness hub powered by Rally Health		6
•		6
®		6
How this plan pays you back:		6
Earn Wellness Pays rewards up to $500 (Self Only) or $1,000 (Self Plus One or Self and Family) annually. Rewards dollars can be used for qualified medical expenses such as copays, and medical, dental and vision expenses.		6
•		6
geha.com/WellnessPays		6
geha.com/WellnessPays		6
Subscribers can select an annual plan perk. Options include a Fitbit wearable device including 12-month Fitbit Premium Membership, a $125 gift card for DICK’S Sporting Goods or REI, or a 12-month Daily Burn virtual fitness subscription.		6
•		6
4		6
geha.com/PlanPerk		6
geha.com/PlanPerk		6
Figure		6
Premium and enrollment code		6
Premium and enrollment code		6
Premium and enrollment code		6
Premium and enrollment code		6
Premium and enrollment code		6
Premium and enrollment code		6
Premium and enrollment code		6
Employed – biweekly		6
Employed – biweekly		6
Retired – monthly		6
Retired – monthly		6
254 Self Only		6
254 Self Only		6
254 Self Only		6
254 Self Only		6
$50.69		6
$50.69		6
$109.83		6
$109.83		6
256 Self Plus One		6
256 Self Plus One		6
256 Self Plus One		6
$118.83		6
$118.83		6
$257.47		6
$257.47		6
255 Self and Family		6
255 Self and Family		6
255 Self and Family		6
$144.67		6
$144.67		6
$313.46		6
$313.46		6
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 which maintains your health benefits enrollment.		6
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 which maintains your health benefits enrollment.		6
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 which maintains your health benefits enrollment.		6
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 which maintains your health benefits enrollment.		6
Health care style: a wellness-focused and cost-conscious plan for those without an extensive prescription need.		6
Health care style: a wellness-focused and cost-conscious plan for those without an extensive prescription need.		6
How often you use your plan:		6
How often you use your plan:		6
Prescription benefit need:		6
Prescription benefit need:		6
Sect		6
Figure		6
Yearly deductible in-network		6
Yearly deductible in-network		6
Yearly deductible in-network		6
Yearly deductible in-network		6
Yearly deductible in-network		6
Yearly deductible in-network		6
Yearly deductible in-network		6
1		6
1		6
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.		6
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.		6
6
You pay		6
You pay		6
Self Only		6
Self Only		6
Self Only		6
Self Only		6
$500		6
$500		6
Self Plus One or Self and Family		6
Self Plus One or Self and Family		6
Self Plus One or Self and Family		6
$1,000		6
$1,000		6
Out-of-pocket maximum in-network		6
Out-of-pocket maximum in-network		6
Out-of-pocket maximum in-network		6
Out-of-pocket maximum in-network		6
Out-of-pocket maximum in-network		6
Out-of-pocket maximum in-network		6
Out-of-pocket maximum in-network		6
1		6
1		6
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.		6
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.		6
,		6
2		6
2		6
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.		6
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.		6
6
You pay		6
You pay		6
Self Only		6
Self Only		6
Self Only		6
Self Only		6
$8,500		6
$8,500		6
Self Plus One or Self and Family		6
Self Plus One or Self and Family		6
Self Plus One or Self and Family		6
$17,000		6
$17,000		6
Medical benefits in-network		7
Medical benefits in-network		7
Medical benefits in-network		7
Medical benefits in-network		7
Medical benefits in-network		7
Medical benefits in-network		7
Medical benefits in-network		7
1		7
1		7
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.		7
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.		7
You pay		7
You pay		7
Unlimited telehealth visits, including mental health, with MDLIVE		7
Unlimited telehealth visits, including mental health, with MDLIVE		7
Unlimited telehealth visits, including mental health, with MDLIVE		7
Unlimited telehealth visits, including mental health, with MDLIVE		7
Preventive care; adult routine screenings		7
Well-child visit; up to age 22		7
Maternity; routine care		7
Vision coverage; eye exams		7
2		7
2		7
2 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.		7
2 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.		7
$0		7
$0		7
Primary physician office visit		7
Primary physician office visit		7
Primary physician office visit		7
Mental health office visit		7
MinuteClinic where available		7
®		7
Chiropractic care (manipulative therapy), including X-rays; up to 12 visits per year		7
Acupuncture; up to 20 treatments per year		7
$10		7
$10		7
Specialist care office visit		7
Specialist care office visit		7
Specialist care office visit		7
$30		7
$30		7
Urgent care facility		7
Urgent care facility		7
Urgent care facility		7
$50		7
$50		7
ER visit		7
ER visit		7
ER visit		7
Maternity; inpatient care		7
Hospital care; inpatient and outpatient		7
Lab services		7
X-ray and other diagnostic services		7
Outpatient professional surgical services		7
25%		7
25%		7
3		7
3		7
3 Calendar year deductible applies.		7
3 Calendar year deductible applies.		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.		7
Inpatient professional surgical services		7
Inpatient professional surgical services		7
Inpatient professional surgical services		7
$250		7
$250		7
Prescription benefits in-network		7
Prescription benefits in-network		7
Prescription benefits in-network		7
Prescription benefits in-network		7
Prescription benefits in-network		7
Prescription benefits in-network		7
Prescription benefits in-network		7
1		7
1		7
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.		7
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.		7
,		7
2		7
2		7
2 Refer to  for formulary and specialty coverage for specific medications.		7
2 Refer to  for formulary and specialty coverage for specific medications.		7
geha.com/Prescriptions		7
geha.com/Prescriptions		7
,		7
3		7
3		7
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		7
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		7
geha.com/Find-Care		7
geha.com/Find-Care		7
You pay		7
You pay		7
30-day retail generic		7
30-day retail generic		7
30-day retail generic		7
30-day retail generic		7
$4		7
$4		7
30-day retail preferred brand-name		7
30-day retail preferred brand-name		7
30-day retail preferred brand-name		7
50% ($500 max)		7
50% ($500 max)		7
30-day retail non-preferred brand-name		7
30-day retail non-preferred brand-name		7
30-day retail non-preferred brand-name		7
100%		7
100%		7
30-day specialty CVS exclusive generic and preferred brand-name		7
30-day specialty CVS exclusive generic and preferred brand-name		7
30-day specialty CVS exclusive generic and preferred brand-name		7
50% ($500 max)		7
50% ($500 max)		7
30-day specialty CVS exclusive non-preferred brand-name		7
30-day specialty CVS exclusive non-preferred brand-name		7
30-day specialty CVS exclusive non-preferred brand-name		7
100%		7
100%		7
HDHP		8
HDHP		8
Learn all about this plan at		8
geha.com/HDHP		8
geha.com/HDHP		8
Low premiums with a lower net deductible than many traditional plans		8
•		8
Reduce out-of-pocket expenses and enjoy a triple tax advantage with a health savings account (HSA)		8
•		8
geha.com/HSA		8
geha.com/HSA		8
GEHA contributes to your HSA. Use your HSA money to reduce your net deductible or save it and let it grow tax-free in your account.		8
•		8
How this plan pays you back:		8
•		8
•		8
•		8
•		8
Up to two adults ages 18 and over can earn up to $250 (maximum $500 per household) per year in Health Rewards		8
geha.com/HealthRewards		8
geha.com/HealthRewards		8
•		8
•		8
•		8
GEHA contributes $900 (Self Only) or $1,800 (Self Plus One or Self and Family) to your HSA		8
Figure		8
Premium and enrollment code		8
Premium and enrollment code		8
Premium and enrollment code		8
Premium and enrollment code		8
Premium and enrollment code		8
Premium and enrollment code		8
Premium and enrollment code		8
Employed – biweekly		8
Employed – biweekly		8
Retired – monthly		8
Retired – monthly		8
341 Self Only		8
341 Self Only		8
341 Self Only		8
341 Self Only		8
$69.37		8
$69.37		8
$150.30		8
$150.30		8
343 Self Plus One		8
343 Self Plus One		8
343 Self Plus One		8
$149.15		8
$149.15		8
$323.15		8
$323.15		8
342 Self and Family		8
342 Self and Family		8
342 Self and Family		8
$183.28		8
$183.28		8
$397.11		8
$397.11		8
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 which maintains your health benefits enrollment.		8
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 which maintains your health benefits enrollment.		8
Health care style: for the analytical health care consumer, focused on savings		8
Health care style: for the analytical health care consumer, focused on savings		8
How often you use your plan:		8
How often you use your plan:		8
Prescription benefit need:		8
Prescription benefit need:		8
Sect		8
Figure		8
Sect		8
Figure		8
Yearly deductible in-network		8
Yearly deductible in-network		8
Yearly deductible in-network		8
Yearly deductible in-network		8
Yearly deductible in-network		8
Yearly deductible in-network		8
Yearly deductible in-network		8
1		8
1		8
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.		8
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.		8
Annual deductible		8
Annual deductible		8
GEHA HSA contribution		8
GEHA HSA contribution		8
You pay		8
You pay		8
2		8
2		8
2 The net deductible is the remaining amount after you subtract the annual GEHA contribution from the annual deductible. This is your out-of-pocket cost before plan benefits begin.		8
2 The net deductible is the remaining amount after you subtract the annual GEHA contribution from the annual deductible. This is your out-of-pocket cost before plan benefits begin.		8
Self Only		8
Self Only		8
Self Only		8
Self Only		8
$1,500		8
$1,500		8
$900		8
$900		8
$600		8
$600		8
Self Plus One or Self and Family		8
Self Plus One or Self and Family		8
Self Plus One or Self and Family		8
$3,000		8
$3,000		8
$1,800		8
$1,800		8
$1,200		8
$1,200		8
Out-of-pocket maximum in-network		8
Out-of-pocket maximum in-network		8
Out-of-pocket maximum in-network		8
Out-of-pocket maximum in-network		8
Out-of-pocket maximum in-network		8
Out-of-pocket maximum in-network		8
Out-of-pocket maximum in-network		8
1		8
1		8
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.		8
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.		8
,		8
2		8
2		8
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.		8
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.		8
You pay		8
You pay		8
Self Only		8
Self Only		8
Self Only		8
Self Only		8
$5,000		8
$5,000		8
Self Plus One or Self and Family		8
Self Plus One or Self and Family		8
Self Plus One or Self and Family		8
$10,000		8
$10,000		8
Medical benefits in-network		9
Medical benefits in-network		9
Medical benefits in-network		9
Medical benefits in-network		9
Medical benefits in-network		9
Medical benefits in-network		9
Medical benefits in-network		9
1		9
1		9
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.		9
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.		9
You pay		9
You pay		9
Unlimited telehealth visits, including mental health, with MDLIVE		9
Unlimited telehealth visits, including mental health, with MDLIVE		9
Unlimited telehealth visits, including mental health, with MDLIVE		9
Unlimited telehealth visits, including mental health, with MDLIVE		9
$0		9
$0		9
2		9
2		9
2 Calendar year deductible applies.		9
2 Calendar year deductible applies.		9
,		9
3		9
3		9
3 HDHP members who have met their deductible will be charged by MDLIVE, but GEHA will reimburse the member 100% of the plan allowance.		9
3 HDHP members who have met their deductible will be charged by MDLIVE, but GEHA will reimburse the member 100% of the plan allowance.		9
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.		9
Maternity; routine care		9
Maternity; routine care		9
Maternity; routine care		9
Maternity; inpatient care		9
$0		9
$0		9
2		9
2		9
Preventive care; adult routine screenings		9
Preventive care; adult routine screenings		9
Preventive care; adult routine screenings		9
Well-child visit; up to age 22		9
Preventive dental care, twice yearly		9
$0		9
$0		9
Vision coverage; eye exam and additional benefits		9
Vision coverage; eye exam and additional benefits		9
Vision coverage; eye exam and additional benefits		9
$5		9
$5		9
Primary physician office visit		9
Primary physician office visit		9
Primary physician office visit		9
Mental health office visit		9
Specialist care office visit		9
Urgent care facility		9
ER visit		9
Hospital care; inpatient and outpatient		9
MinuteClinic where available		9
®		9
Lab services		9
X-ray and other diagnostic services		9
Professional surgical services		9
Chiropractic care (manipulative therapy), including X-rays; up to 20 visits per year		9
Acupuncture; up to 20 treatments per year		9
5%		9
5%		9
2		9
2		9
Prescription benefits in-network		9
Prescription benefits in-network		9
Prescription benefits in-network		9
Prescription benefits in-network		9
Prescription benefits in-network		9
Prescription benefits in-network		9
Prescription benefits in-network		9
1		9
1		9
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.		9
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.		9
,		9
2		9
2		9
2 Refer to  for formulary and specialty coverage for specific medications.		9
2 Refer to  for formulary and specialty coverage for specific medications.		9
geha.com/Prescriptions		9
geha.com/Prescriptions		9
,		9
3		9
3		9
3 Calendar year deductible applies.		9
3 Calendar year deductible applies.		9
You pay		9
You pay		9
30-day retail generic		9
30-day retail generic		9
30-day retail generic		9
30-day retail generic		9
25%		9
25%		9
30-day retail preferred brand-name		9
30-day retail preferred brand-name		9
30-day retail preferred brand-name		9
25%		9
25%		9
4		9
4		9
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.		9
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.		9
30-day retail non-preferred brand-name		9
30-day retail non-preferred brand-name		9
30-day retail non-preferred brand-name		9
40%		9
40%		9
4		9
4		9
90-day mail service generic		9
90-day mail service generic		9
90-day mail service generic		9
25%		9
25%		9
90-day mail service preferred brand-name		9
90-day mail service preferred brand-name		9
90-day mail service preferred brand-name		9
25%		9
25%		9
4		9
4		9
90-day mail service non-preferred brand-name		9
90-day mail service non-preferred brand-name		9
90-day mail service non-preferred brand-name		9
40%		9
40%		9
4		9
4		9
30-day specialty CVS exclusive generic and preferred brand-name		9
30-day specialty CVS exclusive generic and preferred brand-name		9
30-day specialty CVS exclusive generic and preferred brand-name		9
25%		9
25%		9
4		9
4		9
30-day specialty CVS exclusive non-preferred brand-name		9
30-day specialty CVS exclusive non-preferred brand-name		9
30-day specialty CVS exclusive non-preferred brand-name		9
40%		9
40%		9
4		9
4		9
Standard		10
Standard		10
Learn all about this plan at		10
geha.com/Standard		10
geha.com/Standard		10
Dependable, traditional coverage		10
•		10
Affordable premiums		10
•		10
Some of the FEHB’s lowest copays for in-network primary care and specialist visits		10
•		10
How this plan pays you back:		10
•		10
•		10
•		10
•		10
Up to two adults ages 18 and over can earn up to $250 (maximum $500 per household) per year in Health Rewards		10
geha.com/HealthRewards		10
geha.com/HealthRewards		10
Figure		10
Premium and enrollment code		10
Premium and enrollment code		10
Premium and enrollment code		10
Premium and enrollment code		10
Premium and enrollment code		10
Premium and enrollment code		10
Premium and enrollment code		10
Employed – biweekly		10
Employed – biweekly		10
Retired – monthly		10
Retired – monthly		10
314 Self Only		10
314 Self Only		10
314 Self Only		10
314 Self Only		10
$68.77		10
$68.77		10
$149.01		10
$149.01		10
316 Self Plus One		10
316 Self Plus One		10
316 Self Plus One		10
$147.87		10
$147.87		10
$320.39		10
$320.39		10
315 Self and Family		10
315 Self and Family		10
315 Self and Family		10
$180.92		10
$180.92		10
$392.00		10
$392.00		10
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 which maintains your health benefits enrollment.		10
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 which maintains your health benefits enrollment.		10
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 which maintains your health benefits enrollment.		10
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 which maintains your health benefits enrollment.		10
Health care style: traditional care and coverage to stay on a healthy path		10
Health care style: traditional care and coverage to stay on a healthy path		10
How often you use your plan:		10
How often you use your plan:		10
Prescription benefit need:		10
Prescription benefit need:		10
Sect		10
Figure		10
Yearly deductible in-network		10
Yearly deductible in-network		10
Yearly deductible in-network		10
Yearly deductible in-network		10
Yearly deductible in-network		10
Yearly deductible in-network		10
Yearly deductible in-network		10
1		10
1		10
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.		10
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.		10
You pay		10
You pay		10
Self Only		10
Self Only		10
Self Only		10
Self Only		10
$350		10
$350		10
Self Plus One or Self and Family		10
Self Plus One or Self and Family		10
Self Plus One or Self and Family		10
$700		10
$700		10
Out-of-pocket maximum in-network		10
Out-of-pocket maximum in-network		10
Out-of-pocket maximum in-network		10
Out-of-pocket maximum in-network		10
Out-of-pocket maximum in-network		10
Out-of-pocket maximum in-network		10
Out-of-pocket maximum in-network		10
1		10
1		10
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.		10
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.		10
,		10
2		10
2		10
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.		10
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.		10
You pay		10
You pay		10
Self Only		10
Self Only		10
Self Only		10
Self Only		10
$6,500		10
$6,500		10
Self Plus One or Self and Family		10
Self Plus One or Self and Family		10
Self Plus One or Self and Family		10
$13,000		10
$13,000		10
Medical benefits in-network		11
Medical benefits in-network		11
Medical benefits in-network		11
Medical benefits in-network		11
Medical benefits in-network		11
Medical benefits in-network		11
Medical benefits in-network		11
1		11
1		11
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.		11
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.		11
You pay		11
You pay		11
Unlimited telehealth visits, including mental health, with MDLIVE		11
Unlimited telehealth visits, including mental health, with MDLIVE		11
Unlimited telehealth visits, including mental health, with MDLIVE		11
Unlimited telehealth visits, including mental health, with MDLIVE		11
Preventive care; adult routine screenings		11
Well-child visit; up to age 22		11
Maternity; routine care		11
Maternity; inpatient care		11
QuestSelect Lab Benefit (formerly Lab Card)		11
TM		11
®		11
$0		11
$0		11
Vision coverage; eye exams		11
Vision coverage; eye exams		11
Vision coverage; eye exams		11
2		11
2		11
2 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.		11
2 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.		11
$5		11
$5		11
MinuteClinic where available		11
MinuteClinic where available		11
MinuteClinic where available		11
®		11
$10		11
$10		11
Primary physician office visit		11
Primary physician office visit		11
Primary physician office visit		11
Mental health office visit		11
$20		11
$20		11
Specialist care office visit		11
Specialist care office visit		11
Specialist care office visit		11
Urgent care facility		11
Chiropractic care (manipulative therapy), including X-rays; up to 20 visits per year		11
$35		11
$35		11
Lab services (other than QuestSelect)		11
Lab services (other than QuestSelect)		11
Lab services (other than QuestSelect)		11
15%		11
15%		11
ER visit		11
ER visit		11
ER visit		11
Hospital care; inpatient and outpatient		11
Professional surgical services		11
X-ray and other diagnostic services		11
Acupuncture; up to 20 treatments per year		11
15%		11
15%		11
3		11
3		11
3 Calendar year deductible applies.		11
3 Calendar year deductible applies.		11
Preventive dental care, twice yearly		11
Preventive dental care, twice yearly		11
Preventive dental care, twice yearly		11
50%		11
50%		11
Outpatient professional High Tech Imaging (MRI, CT, PET, etc.)		11
Outpatient professional High Tech Imaging (MRI, CT, PET, etc.)		11
Outpatient professional High Tech Imaging (MRI, CT, PET, etc.)		11
$100		11
$100		11
Outpatient facility High Tech Imaging (MRI, CT, PET, etc.)		11
Outpatient facility High Tech Imaging (MRI, CT, PET, etc.)		11
Outpatient facility High Tech Imaging (MRI, CT, PET, etc.)		11
$150		11
$150		11
Prescription benefits in-network		11
Prescription benefits in-network		11
Prescription benefits in-network		11
Prescription benefits in-network		11
Prescription benefits in-network		11
Prescription benefits in-network		11
Prescription benefits in-network		11
1		11
1		11
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.		11
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.		11
,		11
2		11
2		11
2 Refer to  for formulary and specialty coverage for specific medications.		11
2 Refer to  for formulary and specialty coverage for specific medications.		11
geha.com/Prescriptions		11
geha.com/Prescriptions		11
You pay		11
You pay		11
30-day retail generic		11
30-day retail generic		11
30-day retail generic		11
30-day retail generic		11
$10		11
$10		11
30-day retail preferred brand-name		11
30-day retail preferred brand-name		11
30-day retail preferred brand-name		11
50% ($200 max)		11
50% ($200 max)		11
3		11
3		11
3 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.		11
3 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.		11
30-day retail non-preferred brand-name		11
30-day retail non-preferred brand-name		11
30-day retail non-preferred brand-name		11
50% ($300 max)		11
50% ($300 max)		11
3		11
3		11
90-day mail service generic		11
90-day mail service generic		11
90-day mail service generic		11
$20		11
$20		11
90-day mail service preferred brand-name		11
90-day mail service preferred brand-name		11
90-day mail service preferred brand-name		11
50% ($500 max)		11
50% ($500 max)		11
3		11
3		11
90-day mail service non-preferred brand-name		11
90-day mail service non-preferred brand-name		11
90-day mail service non-preferred brand-name		11
50% ($600 max)		11
50% ($600 max)		11
3		11
3		11
30-day specialty CVS exclusive generic and preferred brand-name		11
30-day specialty CVS exclusive generic and preferred brand-name		11
30-day specialty CVS exclusive generic and preferred brand-name		11
50% ($250 max)		11
50% ($250 max)		11
3		11
3		11
30-day specialty CVS exclusive non-preferred brand-name		11
30-day specialty CVS exclusive non-preferred brand-name		11
30-day specialty CVS exclusive non-preferred brand-name		11
50% ($400 max)		11
50% ($400 max)		11
3		11
3		11
Elevate Plus		12
Elevate Plus		12
Learn all about this plan at		12
geha.com/ElevatePlus		12
geha.com/ElevatePlus		12
$150 deductible for Self Only. $300 for Self Plus One and Self and Family. 15% coinsurance for some services.		12
•		12
Low copays for non-traditional care, like chiropractic and acupuncture		12
•		12
Engaging digital wellness hub powered by Rally Health		12
•		12
How this plan pays you back:		12
•		12
•		12
•		12
•		12
Earn Wellness Pays rewards up to $500 (Self Only) or $1,000 (Self Plus One or Self and Family) annually. Rewards dollars can be used for qualified medical expenses such as copays, and medical, dental and vision expenses.		12
geha.com/WellnessPays		12
geha.com/WellnessPays		12
Figure		12
Premium and enrollment code		12
Premium and enrollment code		12
Premium and enrollment code		12
Premium and enrollment code		12
Premium and enrollment code		12
Premium and enrollment code		12
Premium and enrollment code		12
Employed – biweekly		12
Employed – biweekly		12
Retired – monthly		12
Retired – monthly		12
251 Self Only		12
251 Self Only		12
251 Self Only		12
251 Self Only		12
$85.77		12
$85.77		12
$185.84		12
$185.84		12
253 Self Plus One		12
253 Self Plus One		12
253 Self Plus One		12
$187.64		12
$187.64		12
$406.55		12
$406.55		12
252 Self and Family		12
252 Self and Family		12
252 Self and Family		12
$209.83		12
$209.83		12
$454.64		12
$454.64		12
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 which maintains your health benefits enrollment.		12
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 which maintains your health benefits enrollment.		12
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 which maintains your health benefits enrollment.		12
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 which maintains your health benefits enrollment.		12
Health care style: health-focused and proactive		12
Health care style: health-focused and proactive		12
How often you use your plan:		12
How often you use your plan:		12
Prescription benefit need:		12
Prescription benefit need:		12
Sect		12
Figure		12
Sect		12
Figure		12
Yearly deductible in-network		12
Yearly deductible in-network		12
Yearly deductible in-network		12
Yearly deductible in-network		12
Yearly deductible in-network		12
Yearly deductible in-network		12
Yearly deductible in-network		12
1		12
1		12
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.		12
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.		12
,		12
2		12
2		12
2 This plan has no out-of-network coverage.		12
2 This plan has no out-of-network coverage.		12
You pay		12
You pay		12
Self Only		12
Self Only		12
Self Only		12
Self Only		12
$150		12
$150		12
Self Plus One or Self and Family		12
Self Plus One or Self and Family		12
Self Plus One or Self and Family		12
$300		12
$300		12
Out-of-pocket maximum in-network		12
Out-of-pocket maximum in-network		12
Out-of-pocket maximum in-network		12
Out-of-pocket maximum in-network		12
Out-of-pocket maximum in-network		12
Out-of-pocket maximum in-network		12
Out-of-pocket maximum in-network		12
1		12
1		12
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.		12
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.		12
,		12
2		12
2		12
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.		12
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.		12
You pay		12
You pay		12
Self Only		12
Self Only		12
Self Only		12
Self Only		12
$6,000		12
$6,000		12
Self Plus One or Self and Family		12
Self Plus One or Self and Family		12
Self Plus One or Self and Family		12
$12,000		12
$12,000		12
Medical benefits in-network		13
Medical benefits in-network		13
Medical benefits in-network		13
Medical benefits in-network		13
Medical benefits in-network		13
Medical benefits in-network		13
Medical benefits in-network		13
1		13
1		13
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.		13
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.		13
,		13
2		13
2		13
2 This plan has no out-of-network coverage.		13
2 This plan has no out-of-network coverage.		13
You pay		13
You pay		13
Unlimited telehealth visits, including mental health, with MDLIVE		13
Unlimited telehealth visits, including mental health, with MDLIVE		13
Unlimited telehealth visits, including mental health, with MDLIVE		13
Unlimited telehealth visits, including mental health, with MDLIVE		13
Preventive care; adult routine screenings		13
Well-child visit; up to age 22		13
Lab services		13
Maternity; routine care		13
Vision coverage; eye exams		13
3		13
3		13
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.		13
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.		13
$0		13
$0		13
MinuteClinic where available		13
MinuteClinic where available		13
MinuteClinic where available		13
®		13
$10		13
$10		13
Primary physician office visit		13
Primary physician office visit		13
Primary physician office visit		13
Mental health office visit		13
Chiropractic care (manipulative therapy), including X-rays;  up to 15 visits per year		13
Acupuncture; up to 20 treatments per year		13
$30		13
$30		13
Specialist care office visit		13
Specialist care office visit		13
Specialist care office visit		13
$45		13
$45		13
Urgent care facility		13
Urgent care facility		13
Urgent care facility		13
$50		13
$50		13
X-ray and other diagnostic services		13
X-ray and other diagnostic services		13
X-ray and other diagnostic services		13
$50		13
$50		13
4		13
4		13
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		13
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		13
geha.com/PlanBrochure		13
geha.com/PlanBrochure		13
ER visit		13
ER visit		13
ER visit		13
Outpatient and inpatient professional surgery services		13
Maternity; inpatient care		13
Hospital care; inpatient and outpatient		13
15%		13
15%		13
5		13
5		13
5 Calendar year deductible applies.		13
5 Calendar year deductible applies.		13
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.		13
Prescription benefits in-network		13
Prescription benefits in-network		13
Prescription benefits in-network		13
Prescription benefits in-network		13
Prescription benefits in-network		13
Prescription benefits in-network		13
Prescription benefits in-network		13
1		13
1		13
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.		13
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.		13
,		13
2		13
2		13
2 Refer to  for formulary and specialty coverage for specific medications.		13
2 Refer to  for formulary and specialty coverage for specific medications.		13
geha.com/Prescriptions		13
geha.com/Prescriptions		13
,		13
3		13
3		13
3 This plan has no out-of-network pharmacy coverage.		13
3 This plan has no out-of-network pharmacy coverage.		13
You pay		13
You pay		13
30-day retail generic		13
30-day retail generic		13
30-day retail generic		13
30-day retail generic		13
$10		13
$10		13
30-day retail preferred brand-name		13
30-day retail preferred brand-name		13
30-day retail preferred brand-name		13
$80		13
$80		13
4		13
4		13
30-day retail non-preferred brand-name		13
30-day retail non-preferred brand-name		13
30-day retail non-preferred brand-name		13
50%		13
50%		13
4		13
4		13
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
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
90-day mail service generic		13
90-day mail service generic		13
90-day mail service generic		13
$20		13
$20		13
90-day mail service preferred brand-name		13
90-day mail service preferred brand-name		13
90-day mail service preferred brand-name		13
$200		13
$200		13
4		13
4		13
90-day mail service non-preferred brand-name		13
90-day mail service non-preferred brand-name		13
90-day mail service non-preferred brand-name		13
50%		13
50%		13
4		13
4		13
30-day specialty CVS exclusive generic and preferred brand-name		13
30-day specialty CVS exclusive generic and preferred brand-name		13
30-day specialty CVS exclusive generic and preferred brand-name		13
40% ($500 max)		13
40% ($500 max)		13
4		13
4		13
30-day specialty CVS exclusive non-preferred brand-name		13
30-day specialty CVS exclusive non-preferred brand-name		13
30-day specialty CVS exclusive non-preferred brand-name		13
50%		13
50%		13
4		13
4		13
High		14
High		14
Learn all about this plan at		14
geha.com/High		14
geha.com/High		14
Comprehensive brand-name and specialty prescription coverage		14
•		14
$1,000 Medicare Part B premium reimbursement.		14
•		14
NEW!		14
geha.com/MRA		14
geha.com/MRA		14
Low copays for doctor visits		14
•		14
$2,500 hearing aid benefit and additional discount		14
•		14
How this plan pays you back:		14
•		14
•		14
•		14
•		14
$1,000 Medicare Part B premium reimbursement		14
NEW!		14
•		14
•		14
•		14
Adults ages 18 and over can earn up to $250 (maximum $500 per household) per year in Health Rewards.		14
geha.com/HealthRewards		14
geha.com/HealthRewards		14
Figure		14
Premium and enrollment code		14
Premium and enrollment code		14
Premium and enrollment code		14
Premium and enrollment code		14
Premium and enrollment code		14
Premium and enrollment code		14
Premium and enrollment code		14
Employed – biweekly		14
Employed – biweekly		14
Retired – monthly		14
Retired – monthly		14
311 Self Only		14
311 Self Only		14
311 Self Only		14
311 Self Only		14
$105.74		14
$105.74		14
$229.10		14
$229.10		14
313 Self Plus One		14
313 Self Plus One		14
313 Self Plus One		14
$243.49		14
$243.49		14
$527.56		14
$527.56		14
312 Self and Family		14
312 Self and Family		14
312 Self and Family		14
$304.39		14
$304.39		14
$659.52		14
$659.52		14
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 which maintains your health benefits enrollment.		14
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 which maintains your health benefits enrollment.		14
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 which maintains your health benefits enrollment.		14
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 which maintains your health benefits enrollment.		14
Health care style: maximum coverage and dependable support		14
Health care style: maximum coverage and dependable support		14
How often you use your plan:		14
How often you use your plan:		14
Prescription benefit need:		14
Prescription benefit need:		14
Sect		14
Figure		14
Sect		14
Figure		14
Sect		14
Figure		14
Sect		14
Figure		14
Yearly deductible in-network		14
Yearly deductible in-network		14
Yearly deductible in-network		14
Yearly deductible in-network		14
Yearly deductible in-network		14
Yearly deductible in-network		14
Yearly deductible in-network		14
1		14
1		14
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.		14
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.		14
You pay		14
You pay		14
Self Only		14
Self Only		14
Self Only		14
Self Only		14
$350		14
$350		14
Self Plus One or Self and Family		14
Self Plus One or Self and Family		14
Self Plus One or Self and Family		14
$700		14
$700		14
Out-of-pocket maximum in-network		14
Out-of-pocket maximum in-network		14
Out-of-pocket maximum in-network		14
Out-of-pocket maximum in-network		14
Out-of-pocket maximum in-network		14
Out-of-pocket maximum in-network		14
Out-of-pocket maximum in-network		14
1		14
1		14
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.		14
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.		14
,		14
2		14
2		14
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.		14
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.		14
You pay		14
You pay		14
Self Only		14
Self Only		14
Self Only		14
Self Only		14
$5,000		14
$5,000		14
Self Plus One or Self and Family		14
Self Plus One or Self and Family		14
Self Plus One or Self and Family		14
$10,000		14
$10,000		14
Medical benefits in-network		15
Medical benefits in-network		15
Medical benefits in-network		15
Medical benefits in-network		15
Medical benefits in-network		15
Medical benefits in-network		15
Medical benefits in-network		15
1		15
1		15
You pay		15
You pay		15
Unlimited telehealth visits, including mental health, with MDLIVE		15
Unlimited telehealth visits, including mental health, with MDLIVE		15
Unlimited telehealth visits, including mental health, with MDLIVE		15
Unlimited telehealth visits, including mental health, with MDLIVE		15
Preventive care; adult routine screenings		15
Well-child visit; up to age 22		15
Maternity; routine care		15
Maternity; inpatient care		15
Outpatient accidental injury, including ER (within 72 hours)		15
Lab services		15
$0		15
$0		15
Vision coverage; eye exams		15
Vision coverage; eye exams		15
Vision coverage; eye exams		15
2		15
$5		15
$5		15
MinuteClinic where available		15
MinuteClinic where available		15
MinuteClinic where available		15
®		15
$10		15
$10		15
Primary physician office visit		15
Primary physician office visit		15
Primary physician office visit		15
Mental health office visit		15
Specialist care office visit		15
Chiropractic care (manipulative therapy), including X-rays; up to 20 visits per year		15
$20		15
$20		15
Urgent care facility		15
Urgent care facility		15
Urgent care facility		15
$35		15
$35		15
ER visit; medical emergency		15
ER visit; medical emergency		15
ER visit; medical emergency		15
Hospital care; outpatient		15
Professional surgical services		15
X-ray and other diagnostic services		15
Acupuncture; up to 20 treatments per year		15
10%		15
10%		15
3		15
Hospital care; inpatient		15
Hospital care; inpatient		15
Hospital care; inpatient		15
$100 per admission plus 10%		15
$100 per admission plus 10%		15
Preventive dental; twice yearly		15
Preventive dental; twice yearly		15
Preventive dental; twice yearly		15
Balance after GEHA pays $22 per visit		15
Balance after GEHA pays $22 per visit		15
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.		15
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.		15
2 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		15
3 Calendar year deductible applies.		15
Prescription benefits in-network		15
Prescription benefits in-network		15
Prescription benefits in-network		15
Prescription benefits in-network		15
Prescription benefits in-network		15
Prescription benefits in-network		15
Prescription benefits in-network		15
1		15
1		15
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.		15
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.		15
,		15
2		15
2		15
2 Refer to  for formulary and specialty coverage for specific medications.		15
2 Refer to  for formulary and specialty coverage for specific medications.		15
geha.com/Prescriptions		15
geha.com/Prescriptions		15
You pay		15
You pay		15
30-day retail generic		15
30-day retail generic		15
30-day retail generic		15
30-day retail generic		15
$10		15
$10		15
3		15
3		15
3 Costs 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.		15
3 Costs 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.		15
30-day retail preferred brand-name		15
30-day retail preferred brand-name		15
30-day retail preferred brand-name		15
25% ($150 max)		15
25% ($150 max)		15
3		15
3		15
,		15
4		15
4		15
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.		15
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.		15
30-day retail non-preferred brand-name		15
30-day retail non-preferred brand-name		15
30-day retail non-preferred brand-name		15
40% ($200 max)		15
40% ($200 max)		15
3		15
3		15
,		15
4		15
4		15
90-day mail service generic		15
90-day mail service generic		15
90-day mail service generic		15
$20		15
$20		15
90-day mail service preferred brand-name		15
90-day mail service preferred brand-name		15
90-day mail service preferred brand-name		15
25% ($350 max)		15
25% ($350 max)		15
4		15
4		15
90-day mail service non-preferred brand-name		15
90-day mail service non-preferred brand-name		15
90-day mail service non-preferred brand-name		15
40% ($500 max)		15
40% ($500 max)		15
4		15
4		15
30-day specialty CVS exclusive generic and preferred brand-name		15
30-day specialty CVS exclusive generic and preferred brand-name		15
30-day specialty CVS exclusive generic and preferred brand-name		15
25% ($150 max)		15
25% ($150 max)		15
4		15
4		15
30-day specialty CVS exclusive non-preferred brand-name		15
30-day specialty CVS exclusive non-preferred brand-name		15
30-day specialty CVS exclusive non-preferred brand-name		15
40% ($200 max)		15
40% ($200 max)		15
4		15
4		15
Figure		16
Get help choosing the right plan		16
Get help choosing the right plan		16
GEHA has a plan for every stage of your life. We are here to help you discover which plan is the right fit for you.		16
Sect		16
Figure		16
Call us		16
Call us		16
Talk to a GEHA Benefits Adviser Monday – Friday, 7 a.m. – 7 p.m. Central time.		16
800.262.4342		16
800.262.4342		16
800.262.4342		16
Sect		16
Figure		16
Book an appointment		16
Book an appointment		16
Meet one-on-one with a GEHA Benefits Adviser to help answer your questions.		16
geha.com/		16
geha.com/		16
geha.com/		16
Meet		16
Sect		16
Figure		16
Watch on-demand webinars		16
Watch on-demand webinars		16
Learn how to find a plan that’s right for you with an on-demand webinar.		16
geha.com/BenefitsWebinars		16
geha.com/BenefitsWebinars		16
geha.com/BenefitsWebinars		16
Sect		16
Figure		16
Chat online		16
Chat online		16
Chat or text with a GEHA Benefits Adviser in real time Monday – Friday, 7 a.m. – 7 p.m. Central time.		16
geha.com		16
geha.com		16
geha.com		16
Compare plans		16
Compare plans		16
Compare plans		16
Easily compare GEHA’s five medical plans.		16
geha.com/		16
geha.com/		16
geha.com/		16
CompareMedical		16
Plan recommender tool		16
Plan recommender tool		16
Plan recommender tool		16
Answer a few questions to see a plan that matches your individual or family needs.		16
geha.com/Select-A-Plan		16
geha.com/Select-A-Plan		16
geha.com/Select-A-Plan		16
For more information about FEHB plans, visit the U.S. Office of Personnel Management at		16
For more information about FEHB plans, visit the U.S. Office of Personnel Management at		16
opm.gov/Healthcare-Insurance		16
opm.gov/Healthcare-Insurance		16
Extras if you choose Elevate		17
Extras if you choose Elevate		17
Elevate subscribers can choose among three options annually to support a healthy lifestyle.		17
Elevate subscribers can choose among three options annually to support a healthy lifestyle.		17
It pays to be a GEHA Elevate plan member. This plan includes an exclusive plan perk option to support a healthy lifestyle.		17
It’s quick and easy for Elevate subscribers to claim their plan perk. Sign up for a account (or log in to your existing account) and update your contact preferences.		17
geha.com		17
geha.com		17
Figure		17
Choice of one Fitbit device including a 12-month Fitbit Premium Membership.		17
Choice of one Fitbit device including a 12-month Fitbit Premium Membership.		17
Figure		17
12-month Daily Burn virtual fitness subscription.		17
12-month Daily Burn virtual fitness subscription.		17
Figure		17
GEHA’s unique position as a nonprofit member association allows us to offer this bonus plan perk exclusively for the Elevate plan. We don’t have stockholders, which means our priority is putting money back into supporting our members.		17
GEHA’s unique position as a nonprofit member association allows us to offer this bonus plan perk exclusively for the Elevate plan. We don’t have stockholders, which means our priority is putting money back into supporting our members.		17
For more information, visit		17
geha.com/PlanPerk		17
geha.com/PlanPerk		17
$125 gift card for DICK’s Sporting Goods or REI.		17
$125 gift card for DICK’s Sporting Goods or REI.		17
Figure		17
Figure		17
These products and services are neither offered nor guaranteed under contract with the FEHB Program, but are made available to eligible Subscribers who become members of the GEHA Elevate medical plan.		17
These products and services are neither offered nor guaranteed under contract with the FEHB Program, but are made available to eligible Subscribers who become members of the GEHA Elevate medical plan.		17
Only Subscribers in the 50 United States and the District of Columbia are eligible at this time.		17
Figure		17
Earn Wellness Pays rewards		18
Earn Wellness Pays rewards		18
Elevate and Elevate Plus plans		18
Get rewarded for activities you’re probably already doing.		18
Figure		18
HOW IT WORKS		18
HOW IT WORKS		18
Earn rewards automatically for healthy activities you’re probably already doing		18
•		18
Register on our Rally platform to manage your health goals, enroll with a wellness coach and more		18
•		18
®		18
Complete your first rewardable activity and receive your Wellness Pays reloadable debit card in the mail		18
•		18
Redeem the rewards for qualified medical expenses such as copays		18
•		18
Figure		18
geha.com/WellnessPays		18
geha.com/WellnessPays		18
geha.com/WellnessPays		18
geha.com/WellnessPays		18
HOW MUCH YOU CAN EARN		18
HOW MUCH YOU CAN EARN		18
•		18
•		18
•		18
•		18
$500 per individual, per year		18
•		18
•		18
•		18
$1,000 per family per year		18
ACTIVITIES THAT EARN YOU WELLNESS PAYS REWARDS		18
ACTIVITIES THAT EARN YOU WELLNESS PAYS REWARDS		18
Sect		18
Figure		18
Figure		18
Figure		18
$10		18
$10		18
per month to hit your Stride step goal		18
$100		18
$100		18
cervical, colorectal or breast cancer screening		18
1		18
$100		18
$100		18
first trimester prenatal appointment		18
1		18
1		18
$50		18
$50		18
annual flu shot		18
1		18
1		18
Figure		18
Figure		18
Figure		18
Figure		18
$50		18
$50		18
one MDLIVE telehealth or mental health visit		18
$75		18
$75		18
one time Rally health survey; $50 to do Rally missions/wellness quizzes		18
$100		18
$100		18
annual physical or digital wellness coaching		18
$200		18
$200		18
complete Real Appeal or Quit for Life		18
Activity must be reported online to earn rewards.		18
Activity must be reported online to earn rewards.		18
1		18
Restrictions may apply.		18
2		18
This is a brief description of the features of the Elevate and Elevate Plus plans. Before making a final decision, please read the Plan’s Federal brochure (RI 71-018), available at . All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure.		18
geha.com/PlanBrochure		18
geha.com/PlanBrochure		18
Earn Health Rewards		19
Earn Health Rewards		19
HDHP, Standard and High plans		19
The tools and incentives you need to help you live healthier.		19
Figure		19
HOW IT WORKS		19
HOW IT WORKS		19
Complete your first rewardable activity and receive your Health Rewards reloadable debit card in the mail automatically		19
•		19
Redeem the rewards for qualified medical expenses such as copays		19
•		19
Complete rewardable activities to add funds to your Health Rewards debit card		19
•		19
Figure		19
geha.com/HealthRewards		19
geha.com/HealthRewards		19
geha.com/HealthRewards		19
geha.com/HealthRewards		19
HOW MUCH YOU CAN EARN		19
HOW MUCH YOU CAN EARN		19
•		19
•		19
•		19
•		19
$250 per individual, per year		19
•		19
•		19
•		19
$500 per family per year		19
ACTIVITIES THAT EARN YOU HEALTH REWARDS		19
ACTIVITIES THAT EARN YOU HEALTH REWARDS		19
Sect		19
Figure		19
Figure		19
Figure		19
$10		19
$10		19
per online wellness workshop		19
$25		19
$25		19
annual flu shot		19
1		19
1		19
$50		19
$50		19
cervical, colorectal or breast cancer screening		19
2		19
$50		19
$50		19
first trimester prenatal appointment		19
1		19
1		19
Figure		19
Figure		19
Figure		19
$50		19
$50		19
one MDLIVE telehealth or mental health visit		19
$75		19
$75		19
health risk assessment		19
$50		19
$50		19
participate in a targeted health program		19
3		19
Activity must be reported online to earn rewards.		19
Activity must be reported online to earn rewards.		19
1		19
Restrictions may apply.		19
2		19
By invitation only.		19
3		19
This is a brief description of the features of the HDHP, Standard and High plans. Before making a final decision, please read the Plan’s Federal brochure (RI 71-014 or RI 71-006), available at . All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure.		19
geha.com/PlanBrochure		19
geha.com/PlanBrochure		19
Vision discounts and benefits for GEHA plans		20
Vision discounts and benefits for GEHA plans		20
With all GEHA medical and dental plans, you get discounts on eye exams, frames and lenses through EyeMed. The EyeMed network includes Independent Provider Network, LensCrafters, Pearle Vision, Target Optical, ,  and more. Members also save on LASIK at participating US Laser Network locations.		20
With all GEHA medical and dental plans, you get discounts on eye exams, frames and lenses through EyeMed. The EyeMed network includes Independent Provider Network, LensCrafters, Pearle Vision, Target Optical, ,  and more. Members also save on LASIK at participating US Laser Network locations.		20
®		20
contactsdirect.com		20
contactsdirect.com		20
glasses.com		20
glasses.com		20
Learn more at The HDHP plan includes additional vision benefits. Learn more at		20
geha.com/Vision		20
geha.com/Vision		20
20
geha.com/HDHPVision		20
geha.com/HDHPVision		20
Figure		20
Figure		20
Figure		20
Figure		20
Figure		20
Vision benefit		20
Vision benefit		20
Vision benefit		20
Vision benefit		20
Vision benefit		20
Vision benefit		20
Vision benefit		20
Elevate you pay		20
Elevate you pay		20
1		20
HDHP you pay		20
HDHP you pay		20
Standardyou pay		20
Standardyou pay		20
1		20
Elevate Plusyou pay		20
Elevate Plusyou pay		20
1		20
High you pay		20
High you pay		20
1		20
Eye exams retail price		20
Eye exams retail price		20
Eye exams retail price		20
Eye exams retail price		20
$0		20
$0		20
$5		20
$5		20
$5		20
$5		20
$0		20
$0		20
$5		20
$5		20
Frames retail price		20
Frames retail price		20
Frames retail price		20
60% of price		20
60% of price		20
$0 under $100 plus 80% over $100		20
$0 under $100 plus 80% over $100		20
60% of price		20
60% of price		20
60% of price		20
60% of price		20
60% of price		20
60% of price		20
Eyeglass lenses, standard plastic single vision retail price		20
Eyeglass lenses, standard plastic single vision retail price		20
Eyeglass lenses, standard plastic single vision retail price		20
Up to $50		20
Up to $50		20
$10		20
$10		20
Up to $50		20
Up to $50		20
Up to $50		20
Up to $50		20
Up to $50		20
Up to $50		20
Eyeglass lenses, standard plastic bifocal retail price		20
Eyeglass lenses, standard plastic bifocal retail price		20
Eyeglass lenses, standard plastic bifocal retail price		20
Up to $70		20
Up to $70		20
$10		20
$10		20
Up to $70		20
Up to $70		20
Up to $70		20
Up to $70		20
Up to $70		20
Up to $70		20
Eyeglass lenses, standard plastic progressive lens retail price		20
Eyeglass lenses, standard plastic progressive lens retail price		20
Eyeglass lenses, standard plastic progressive lens retail price		20
Up to $135		20
Up to $135		20
No more than $75		20
No more than $75		20
Up to $135		20
Up to $135		20
Up to $135		20
Up to $135		20
Up to $135		20
Up to $135		20
Eyeglass lens options, UV treatment, tint (solid and gradient), standard plastic scratch coating		20
Eyeglass lens options, UV treatment, tint (solid and gradient), standard plastic scratch coating		20
Eyeglass lens options, UV treatment, tint (solid and gradient), standard plastic scratch coating		20
$15		20
$15		20
$15		20
$15		20
$15		20
$15		20
$15		20
$15		20
$15		20
$15		20
Eyeglass lens options, standard anti-reflective coating		20
Eyeglass lens options, standard anti-reflective coating		20
Eyeglass lens options, standard anti-reflective coating		20
$45		20
$45		20
$45		20
$45		20
$45		20
$45		20
$45		20
$45		20
$45		20
$45		20
Contact lens, conventional retail price		20
Contact lens, conventional retail price		20
Contact lens, conventional retail price		20
85% of price		20
85% of price		20
$10 under $110 plus 85% over $110		20
$10 under $110 plus 85% over $110		20
85% of price		20
85% of price		20
85% of price		20
85% of price		20
85% of price		20
85% of price		20
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.		20
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.		20
1		20
Benefits included in all five plans		21
Benefits included in all five plans		21
Figure		21
Figure		21
24/7 Health Advice Line		21
24/7 Health Advice Line		21
Talk to a nurse 24/7.		21
geha.com/Healthline		21
geha.com/Healthline		21
geha.com/Healthline		21
Gym membership discount		21
2		21
2		21
Access 11,600+ Active&Fit Direct locations nationwide with GEHA’s Connection Fitness program.		21
™		21
®		21
geha.com/Fitness		21
geha.com/Fitness		21
geha.com/Fitness		21
Teeth whitening discounts		21
2		21
2		21
Get a 20% discount on the lowest published price on all Smile Brilliant home teeth whitening and oral care products.		21
®		21
geha.com/Whitening		21
geha.com/Whitening		21
geha.com/Whitening		21
Hearing aid discounts		21
2		21
2		21
Get discounts through TruHearing on hearing aids. Save up to 30% to 60% off hearing aids. Some average more than $2,600 in savings per pair.		21
®		21
geha.com/Hearing		21
geha.com/Hearing		21
geha.com/Hearing		21
Medical alert system discount		21
2		21
2		21
Get free activation on Life Alert services, plus a 10% monthly discount, for you and your extended family.		21
®		21
geha.com/LifeAlert		21
geha.com/LifeAlert		21
geha.com/LifeAlert		21
1 HDHP members who have met their deductible will be charged by MDLIVE, but GEHA will reimburse the member 100% of the Plan Allowance.		21
2 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.		21
3 The cariPROpremium toothbrush removes seven times more plaque than a regular brush, is completely waterproof and comes with a two-year manufacturer’s warranty. Replacement brush heads with high-quality DuPont bristles are also available at this exclusive, member-only price.		21
®		21
TM		21
Unlimited $0 MDLIVE telehealth visits		21
Unlimited $0 MDLIVE telehealth visits		21
1		21
1		21
Get access to certified doctors, including pediatricians, mental health therapists and dermatologists.		21
geha.com/MDLIVE		21
geha.com/MDLIVE		21
geha.com/MDLIVE		21
Electric toothbrush discount		21
21
2		21
2		21
,		21
3		21
3		21
Enjoy 70% off a cariPRO premium electric toothbrush.		21
®		21
geha.com/Toothbrush		21
geha.com/Toothbrush		21
geha.com/Toothbrush		21
Figure		21
Figure		21
Figure		21
Figure		21
Figure		21
GEHA works with Medicare A and B		22
GEHA works with Medicare A and B		22
GEHA offers five medical plans, each with coverage that coordinates with Medicare. For more information, including benefits and rates, visit		22
GEHA offers five medical plans, each with coverage that coordinates with Medicare. For more information, including benefits and rates, visit		22
geha.com/Medicare		22
geha.com/Medicare		22
Plan service		22
Plan service		22
Plan service		22
Plan service		22
Plan service		22
Plan service		22
Plan service		22
Elevate and Medicare		22
Elevate and Medicare		22
HDHP and Medicare		22
HDHP and Medicare		22
Standard and Medicare		22
Standard and Medicare		22
Elevate Plus and Medicare		22
Elevate Plus and Medicare		22
High and Medicare		22
High and Medicare		22
$1,000 Medicare Part B premium reimbursement		22
$1,000 Medicare Part B premium reimbursement		22
$1,000 Medicare Part B premium reimbursement		22
$1,000 Medicare Part B premium reimbursement		22
NEW!		22
No		22
No		22
No		22
No		22
No		22
No		22
No		22
No		22
Yes		22
Yes		22
100% medical coverage (copays and deductibles waived) with Medicare A & B primary		22
100% medical coverage (copays and deductibles waived) with Medicare A & B primary		22
100% medical coverage (copays and deductibles waived) with Medicare A & B primary		22
No		22
No		22
No		22
No		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Hearing aid benefit		22
Hearing aid benefit		22
Hearing aid benefit		22
1		22
No		22
No		22
No		22
No		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Coverage for in-network and out-of-network care		22
Coverage for in-network and out-of-network care		22
Coverage for in-network and out-of-network care		22
1		22
1		22
1 Though the Elevate Plus plan on its own does not provide out-of-network medical coverage, when it’s combined with Medicare and the provider accepts Medicare assignment, out-of-network cost shares are waived. There are no out-of-network pharmacy benefits for Elevate and Elevate Plus.		22
1 Though the Elevate Plus plan on its own does not provide out-of-network medical coverage, when it’s combined with Medicare and the provider accepts Medicare assignment, out-of-network cost shares are waived. There are no out-of-network pharmacy benefits for Elevate and Elevate Plus.		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Coverage for care outside of the United States		22
Coverage for care outside of the United States		22
Coverage for care outside of the United States		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Non-preferred drug coverage		22
Non-preferred drug coverage		22
Non-preferred drug coverage		22
2		22
2		22
2 With High plan, when Medicare A & B is primary, you pay a lower coinsurance for preferred and non-preferred brand medications.		22
2 With High plan, when Medicare A & B is primary, you pay a lower coinsurance for preferred and non-preferred brand medications.		22
No		22
No		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Mail service pharmacy		22
Mail service pharmacy		22
Mail service pharmacy		22
No		22
No		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Yes		22
Choice of plan perk		22
Choice of plan perk		22
Choice of plan perk		22
3		22
3		22
3 These benefits are neither offered nor guaranteed under contract with the FEHB Program, but are made available to subscribers who become a member of GEHA’s Elevate medical plan.		22
3 These benefits are neither offered nor guaranteed under contract with the FEHB Program, but are made available to subscribers who become a member of GEHA’s Elevate medical plan.		22
This is a brief description of the features of Government Employees Health Association, Inc.’s medical plans. Before making a final decision, please read the GEHA Federal brochures which are available at . All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochures.		22
geha.com/PlanBrochure		22
Yes		22
Yes		22
No		22
No		22
No		22
No		22
No		22
No		22
No		22
No		22
GEHA and Medicare EyeMed vision coverage		23
GEHA and Medicare EyeMed vision coverage		23
®		23
Vision services in-network		23
Vision services in-network		23
Vision services in-network		23
Vision services in-network		23
Vision services in-network		23
Vision services in-network		23
Vision services in-network		23
Elevate and Elevate Plus you pay		23
Elevate and Elevate Plus you pay		23
Standard and High you pay		23
Standard and High you pay		23
HDHP you pay		23
HDHP you pay		23
Eye exams; retail price		23
Eye exams; retail price		23
Eye exams; retail price		23
Eye exams; retail price		23
$0		23
$0		23
$5		23
$5		23
$5		23
$5		23
Frames; retail price		23
Frames; retail price		23
Frames; retail price		23
60% of price		23
60% of price		23
60% of price		23
60% of price		23
$0 under $100 plus 80% over $100		23
$0 under $100 plus 80% over $100		23
Eyeglass lenses, standard plastic, single vision; retail price		23
Eyeglass lenses, standard plastic, single vision; retail price		23
Eyeglass lenses, standard plastic, single vision; retail price		23
Up to $50		23
Up to $50		23
Up to $50		23
Up to $50		23
$10		23
$10		23
Contact lens, conventional; retail price		23
Contact lens, conventional; retail price		23
Contact lens, conventional; retail price		23
85% of price		23
85% of price		23
85% of price		23
85% of price		23
$10 under $110 plus 85% over $100		23
$10 under $110 plus 85% over $100		23
GEHA’s HDHP plan includes a complete vision benefit in addition to vision discounts through EyeMed. Learn more at		23
geha.com/HDHPVision		23
geha.com/HDHPVision		23
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.		23
Figure		23
Compare premiums		24
Compare premiums		24
Self Only premium and enrollment code		24
Self Only premium and enrollment code		24
Self Only premium and enrollment code		24
Self Only premium and enrollment code		24
Self Only premium and enrollment code		24
Self Only premium and enrollment code		24
Self Only premium and enrollment code		24
Employed – biweekly		24
Employed – biweekly		24
Retired – monthly		24
Retired – monthly		24
254 Elevate		24
254 Elevate		24
254 Elevate		24
254 Elevate		24
$50.69		24
$50.69		24
$109.83		24
$109.83		24
341 HDHP		24
341 HDHP		24
341 HDHP		24
$69.37		24
$69.37		24
$150.30		24
$150.30		24
314 Standard		24
314 Standard		24
314 Standard		24
$68.77		24
$68.77		24
$149.01		24
$149.01		24
251 Elevate Plus		24
251 Elevate Plus		24
251 Elevate Plus		24
$85.77		24
$85.77		24
$185.84		24
$185.84		24
311 High		24
311 High		24
311 High		24
$105.74		24
$105.74		24
$229.10		24
$229.10		24
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 which maintains your health benefits enrollment.		24
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 which maintains your health benefits enrollment.		24
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 which maintains your health benefits enrollment.		24
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 which maintains your health benefits enrollment.		24
Self Plus One premium and enrollment code		24
Self Plus One premium and enrollment code		24
Self Plus One premium and enrollment code		24
Self Plus One premium and enrollment code		24
Self Plus One premium and enrollment code		24
Self Plus One premium and enrollment code		24
Employed – biweekly		24
Employed – biweekly		24
Retired – monthly		24
Retired – monthly		24
256 Elevate		24
256 Elevate		24
256 Elevate		24
256 Elevate		24
$118.83		24
$118.83		24
$257.47		24
$257.47		24
343 HDHP		24
343 HDHP		24
343 HDHP		24
$149.15		24
$149.15		24
$323.15		24
$323.15		24
316 Standard		24
316 Standard		24
316 Standard		24
$147.87		24
$147.87		24
$320.39		24
$320.39		24
253 Elevate Plus		24
253 Elevate Plus		24
253 Elevate Plus		24
$187.64		24
$187.64		24
$406.55		24
$406.55		24
313 High		24
313 High		24
313 High		24
$243.49		24
$243.49		24
$527.56		24
$527.56		24
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 which maintains your health benefits enrollment.		24
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 which maintains your health benefits enrollment.		24
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 which maintains your health benefits enrollment.		24
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 which maintains your health benefits enrollment.		24
Self and Family premium and enrollment code		24
Self and Family premium and enrollment code		24
Self and Family premium and enrollment code		24
Self and Family premium and enrollment code		24
Self and Family premium and enrollment code		24
Self and Family premium and enrollment code		24
Employed – biweekly		24
Employed – biweekly		24
Retired – monthly		24
Retired – monthly		24
255 Elevate		24
255 Elevate		24
255 Elevate		24
255 Elevate		24
$144.67		24
$144.67		24
$313.46		24
$313.46		24
342 HDHP		24
342 HDHP		24
342 HDHP		24
$183.28		24
$183.28		24
$397.11		24
$397.11		24
315 Standard		24
315 Standard		24
315 Standard		24
$180.92		24
$180.92		24
$392.00		24
$392.00		24
252 Elevate Plus		24
252 Elevate Plus		24
252 Elevate Plus		24
$209.83		24
$209.83		24
$454.64		24
$454.64		24
312 High		24
312 High		24
312 High		24
$304.39		24
$304.39		24
$659.52		24
$659.52		24
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 which maintains your health benefits enrollment.		24
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 which maintains your health benefits enrollment.		24
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 which maintains your health benefits enrollment.		24
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 which maintains your health benefits enrollment.		24
Compare deductibles and out-of-pocket maximum		25
Compare deductibles and out-of-pocket maximum		25
Compare deductibles		25
What you pay each year before the plan begins to pay out benefits.		25
Yearly deductible in-network		25
Yearly deductible in-network		25
Yearly deductible in-network		25
Yearly deductible in-network		25
Yearly deductible in-network		25
Yearly deductible in-network		25
Yearly deductible in-network		25
1		25
1		25
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.		25
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.		25
Elevate		25
Elevate		25
You pay		25
HDHP		25
HDHP		25
You pay		25
Standard		25
Standard		25
You pay		25
Elevate Plus		25
Elevate Plus		25
2		25
2		25
2 This plan has no out-of-network coverage.		25
2 This plan has no out-of-network coverage.		25
You pay		25
High		25
High		25
You pay		25
Self Only		25
Self Only		25
Self Only		25
Self Only		25
$500		25
$500		25
$600		25
$600		25
3		25
3		25
3 The net deductible is the remaining amount after you subtract the GEHA contribution from the annual deductible. This is your out-of-pocket cost before plan benefits begin.		25
3 The net deductible is the remaining amount after you subtract the GEHA contribution from the annual deductible. This is your out-of-pocket cost before plan benefits begin.		25
$350		25
$350		25
$150		25
$150		25
$350		25
$350		25
Self Plus One or Self and Family		25
Self Plus One or Self and Family		25
Self Plus One or Self and Family		25
$1,000		25
$1,000		25
$1,200		25
$1,200		25
3		25
$700		25
$700		25
$300		25
$300		25
$700		25
$700		25
Compare out-of-pocket maximum		25
Compare out-of-pocket maximum		25
The maximum amount of coinsurance, copays and deductibles you pay for all family members before GEHA begins to pay 100% of covered services. This is a combined maximum of medical care and prescriptions.		25
Out-of-pocket maximum in-network		25
Out-of-pocket maximum in-network		25
Out-of-pocket maximum in-network		25
Out-of-pocket maximum in-network		25
Out-of-pocket maximum in-network		25
Out-of-pocket maximum in-network		25
Out-of-pocket maximum in-network		25
1		25
1		25
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.		25
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.		25
Elevate		25
Elevate		25
You pay		25
HDHP		25
HDHP		25
You pay		25
Standard		25
Standard		25
You pay		25
Elevate Plus You pay		25
Elevate Plus You pay		25
2		25
2		25
2 This plan has no out-of-network coverage.		25
2 This plan has no out-of-network coverage.		25
High		25
High		25
You pay		25
Self Only		25
Self Only		25
Self Only		25
Self Only		25
$8,500		25
$8,500		25
$5,000		25
$5,000		25
$6,500		25
$6,500		25
$6,000		25
$6,000		25
$5,000		25
$5,000		25
Self Plus One or Self and Family		25
Self Plus One or Self and Family		25
Self Plus One or Self and Family		25
$17,000		25
$17,000		25
$10,000		25
$10,000		25
$13,000		25
$13,000		25
$12,000		25
$12,000		25
$10,000		25
$10,000		25
Compare prescription costs		26
Compare prescription costs		26
Prescription benefits in-network		26
Prescription benefits in-network		26
Prescription benefits in-network		26
Prescription benefits in-network		26
Prescription benefits in-network		26
Prescription benefits in-network		26
Prescription benefits in-network		26
1		26
1		26
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.		26
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.		26
,		26
2		26
2		26
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.		26
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.		26
,		26
3		26
3		26
3 Refer to for formulary and specialty coverage for specific medications.		26
3 Refer to for formulary and specialty coverage for specific medications.		26
geha.com/Prescriptions		26
geha.com/Prescriptions		26
Elevate		26
Elevate		26
4		26
4		26
4 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		26
4 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		26
geha.com/Find-Care		26
geha.com/Find-Care		26
You pay		26
HDHP		26
HDHP		26
5		26
5		26
5 Calendar year deductible applies.		26
5 Calendar year deductible applies.		26
You pay		26
Standard		26
Standard		26
You pay		26
30-day retail generic		26
30-day retail generic		26
30-day retail generic		26
30-day retail generic		26
$4		26
$4		26
25%		26
25%		26
$10		26
$10		26
30-day retail preferred brand-name		26
30-day retail preferred brand-name		26
30-day retail preferred brand-name		26
50% ($500 max)		26
50% ($500 max)		26
25%		26
25%		26
6		26
6		26
6 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.		26
6 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.		26
50% ($200 max)		26
50% ($200 max)		26
6		26
6		26
30-day retail non-preferred brand-name		26
30-day retail non-preferred brand-name		26
30-day retail non-preferred brand-name		26
100%		26
100%		26
40%		26
40%		26
6		26
6		26
50% ($300 max)		26
50% ($300 max)		26
6		26
6		26
90-day mail service generic		26
90-day mail service generic		26
90-day mail service generic		26
No benefit		26
No benefit		26
25%		26
25%		26
$20		26
$20		26
90-day mail service preferred brand-name		26
90-day mail service preferred brand-name		26
90-day mail service preferred brand-name		26
No benefit		26
No benefit		26
25%		26
25%		26
6		26
6		26
50% ($500 max)		26
50% ($500 max)		26
6		26
6		26
90-day mail service non-preferred brand-name		26
90-day mail service non-preferred brand-name		26
90-day mail service non-preferred brand-name		26
No benefit		26
No benefit		26
40%		26
40%		26
6		26
6		26
50% ($600 max)		26
50% ($600 max)		26
6		26
6		26
30-day specialty CVS exclusive generic and preferred brand-name		26
30-day specialty CVS exclusive generic and preferred brand-name		26
30-day specialty CVS exclusive generic and preferred brand-name		26
50% ($500 max)		26
50% ($500 max)		26
25%		26
25%		26
6		26
6		26
50% ($250 max)		26
50% ($250 max)		26
6		26
6		26
30-day specialty CVS exclusive non-preferred brand-name		26
30-day specialty CVS exclusive non-preferred brand-name		26
30-day specialty CVS exclusive non-preferred brand-name		26
100%		26
100%		26
40%		26
40%		26
6		26
6		26
50% ($400 max)		26
50% ($400 max)		26
6		26
6		26
Figure		26
You’ve got options with retail prescriptions		26
You’ve got options with retail prescriptions		26
Pay less for prescriptions filled at an in-network pharmacy location. Locations include any CVS Pharmacy location, but you don’t have to go to a CVS to pay in-network prices.		26
Find an in-network pharmacy location at		26
geha.com		26
geha.com		26
/Find-Care		26
Check drug costs at		27
Check drug costs at		27
info.caremark.com/oe/geha		27
info.caremark.com/oe/geha		27
Prescription benefits in-network		27
Prescription benefits in-network		27
Prescription benefits in-network		27
Prescription benefits in-network		27
Prescription benefits in-network		27
Prescription benefits in-network		27
Prescription benefits in-network		27
1		27
1		27
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.		27
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.		27
,		27
2		27
2		27
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.		27
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.		27
,		27
3		27
3		27
3 Refer to for formulary and specialty coverage for specific medications.		27
3 Refer to for formulary and specialty coverage for specific medications.		27
geha.com/Prescriptions		27
geha.com/Prescriptions		27
Elevate Plus		27
Elevate Plus		27
4		27
4		27
4 This plan has no out-of-network coverage		27
4 This plan has no out-of-network coverage		27
You pay		27
High		27
High		27
You pay		27
30-day retail generic		27
30-day retail generic		27
30-day retail generic		27
30-day retail generic		27
$10		27
$10		27
$10		27
$10		27
5		27
5		27
5 Costs 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.		27
5 Costs 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.		27
30-day retail preferred brand-name		27
30-day retail preferred brand-name		27
30-day retail preferred brand-name		27
$80		27
$80		27
6		27
6		27
25% ($150 max)		27
25% ($150 max)		27
5		27
5		27
,		27
6		27
6		27
30-day retail non-preferred brand-name		27
30-day retail non-preferred brand-name		27
30-day retail non-preferred brand-name		27
50%		27
50%		27
6		27
6		27
40% ($200 max)		27
40% ($200 max)		27
5		27
5		27
,		27
6		27
6		27
90-day mail service generic		27
90-day mail service generic		27
90-day mail service generic		27
$20		27
$20		27
$20		27
$20		27
90-day mail service preferred brand-name		27
90-day mail service preferred brand-name		27
90-day mail service preferred brand-name		27
$200		27
$200		27
6		27
6		27
25% ($350 max)		27
25% ($350 max)		27
6		27
6		27
90-day mail service non-preferred brand-name		27
90-day mail service non-preferred brand-name		27
90-day mail service non-preferred brand-name		27
50%		27
50%		27
6		27
6		27
40% ($500 max)		27
40% ($500 max)		27
6		27
6		27
30-day specialty CVS exclusive generic and preferred brand-name		27
30-day specialty CVS exclusive generic and preferred brand-name		27
30-day specialty CVS exclusive generic and preferred brand-name		27
40% ($500 max)		27
40% ($500 max)		27
6		27
6		27
25% ($150 max)		27
25% ($150 max)		27
6		27
6		27
30-day specialty CVS exclusive non-preferred brand-name		27
30-day specialty CVS exclusive non-preferred brand-name		27
30-day specialty CVS exclusive non-preferred brand-name		27
50%		27
50%		27
6		27
6		27
40% ($200 max)		27
40% ($200 max)		27
6		27
6		27
6 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.		27
6 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.		27
Figure		27
Save more with mail order prescriptions		27
Save more with mail order prescriptions		27
With CVS Caremark’s Mail Service Pharmacy, you can save money and have your routine prescriptions delivered to your home, postage-paid, within about 14 days from the time you submit your prescription.		27
Mail order is not available for the Elevate plan option.		27
Compare medical benefits		28
Compare medical benefits		28
Medical benefits in-network		28
Medical benefits in-network		28
Medical benefits in-network		28
Medical benefits in-network		28
Medical benefits in-network		28
Medical benefits in-network		28
Medical benefits in-network		28
1		28
1		28
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.		28
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.		28
Elevate		28
Elevate		28
You pay		28
HDHP		28
HDHP		28
You pay		28
Standard		28
Standard		28
You pay		28
Unlimited telehealth visits, including mental health, with MDLIVE		28
Unlimited telehealth visits, including mental health, with MDLIVE		28
Unlimited telehealth visits, including mental health, with MDLIVE		28
Unlimited telehealth visits, including mental health, with MDLIVE		28
$0		28
$0		28
$0		28
$0		28
2		28
2		28
2 HDHP members who have met their deductible will be charged by MDLIVE, but GEHA will reimburse the member 100% of the plan allowance.		28
2 HDHP members who have met their deductible will be charged by MDLIVE, but GEHA will reimburse the member 100% of the plan allowance.		28
,		28
3		28
3		28
$0		28
$0		28
Preventive care; adult routine screenings		28
Preventive care; adult routine screenings		28
Preventive care; adult routine screenings		28
Well-child visit; up to age 22		28
$0		28
$0		28
$0		28
$0		28
$0		28
$0		28
Vision coverage; eye exams		28
Vision coverage; eye exams		28
Vision coverage; eye exams		28
$0		28
$0		28
$5		28
$5		28
$5		28
$5		28
Maternity; routine care		28
Maternity; routine care		28
Maternity; routine care		28
$0		28
$0		28
$0		28
$0		28
3		28
3		28
$0		28
$0		28
MinuteClinic where available		28
MinuteClinic where available		28
MinuteClinic where available		28
®		28
$10		28
$10		28
5%		28
5%		28
3		28
3		28
$10		28
$10		28
Primary physician office visit		28
Primary physician office visit		28
Primary physician office visit		28
$10		28
$10		28
5%		28
5%		28
3		28
3		28
$20		28
$20		28
Mental health office visit		28
Mental health office visit		28
Mental health office visit		28
$10		28
$10		28
5%		28
5%		28
3		28
3		28
$20		28
$20		28
Specialist care office visit		28
Specialist care office visit		28
Specialist care office visit		28
$30		28
$30		28
5%		28
5%		28
3		28
3		28
$35		28
$35		28
Urgent care facility		28
Urgent care facility		28
Urgent care facility		28
$50		28
$50		28
5%		28
5%		28
3		28
3		28
$35		28
$35		28
ER visit; accidental		28
ER visit; accidental		28
ER visit; accidental		28
25%		28
25%		28
3		28
3		28
3 Calendar year deductible applies.		28
3 Calendar year deductible applies.		28
5%		28
5%		28
3		28
3		28
15%		28
15%		28
3		28
3		28
ER visit; medical		28
ER visit; medical		28
ER visit; medical		28
25%		28
25%		28
3		28
3		28
5%		28
5%		28
3		28
3		28
15%		28
15%		28
3		28
3		28
Hospital care; inpatient		28
Hospital care; inpatient		28
Hospital care; inpatient		28
25%		28
25%		28
3		28
3		28
5%		28
5%		28
3		28
3		28
15%		28
15%		28
3		28
3		28
Maternity; inpatient care		28
Maternity; inpatient care		28
Maternity; inpatient care		28
25%		28
25%		28
3		28
3		28
$0		28
$0		28
3		28
3		28
$0		28
$0		28
Hospital care; outpatient		28
Hospital care; outpatient		28
Hospital care; outpatient		28
25%		28
25%		28
3		28
3		28
5%		28
5%		28
3		28
3		28
15%		28
15%		28
3		28
3		28
Inpatient professional surgical services		28
Inpatient professional surgical services		28
Inpatient professional surgical services		28
$250		28
$250		28
5%		28
5%		28
3		28
3		28
15%		28
15%		28
3		28
3		28
Outpatient professional services		28
Outpatient professional services		28
Outpatient professional services		28
25%		28
25%		28
3		28
3		28
5%		28
5%		28
3		28
3		28
15%		28
15%		28
3		28
3		28
Lab services		28
Lab services		28
Lab services		28
25%		28
25%		28
3		28
3		28
5%		28
5%		28
3		28
3		28
15% (QuestSelect $0)		28
15% (QuestSelect $0)		28
X-rays and other diagnostic services		28
X-rays and other diagnostic services		28
X-rays and other diagnostic services		28
25%		28
25%		28
3		28
3		28
5%		28
5%		28
3		28
3		28
15%		28
15%		28
3		28
3		28
,		28
4		28
4		28
4 Standard, you pay $250 ($100 professional fee, $150 facility fee) for advanced outpatient High Tech Imaging such as MRI, CT, PET, etc. Refer to GEHA’s 2023 plan brochure RI 71-006 (High and Standard) at		28
4 Standard, you pay $250 ($100 professional fee, $150 facility fee) for advanced outpatient High Tech Imaging such as MRI, CT, PET, etc. Refer to GEHA’s 2023 plan brochure RI 71-006 (High and Standard) at		28
geha.com/PlanBrochure		28
geha.com/PlanBrochure		28
Chiropractic care visit (manipulative therapy), including X-rays. Limited per year.		28
Chiropractic care visit (manipulative therapy), including X-rays. Limited per year.		28
Chiropractic care visit (manipulative therapy), including X-rays. Limited per year.		28
$10		28
$10		28
5%		28
5%		28
3		28
3		28
$35		28
$35		28
Acupuncture visit; up to 20 treatments per year		28
Acupuncture visit; up to 20 treatments per year		28
Acupuncture visit; up to 20 treatments per year		28
$10		28
$10		28
5%		28
5%		28
3		28
15%		28
15%		28
3		28
3		28
Preventive dental care		28
Preventive dental care		28
Preventive dental care		28
No benefit		28
No benefit		28
$0		28
$0		28
50%		28
50%		28
Medical benefits in-network		29
Medical benefits in-network		29
Medical benefits in-network		29
Medical benefits in-network		29
Medical benefits in-network		29
Medical benefits in-network		29
Medical benefits in-network		29
1		29
1		29
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.		29
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.		29
Elevate Plus		29
Elevate Plus		29
2		29
2		29
2 This plan has no out-of-network coverage.		29
2 This plan has no out-of-network coverage.		29
You pay		29
High		29
High		29
You pay		29
Unlimited telehealth visits, including mental health, with MDLIVE		29
Unlimited telehealth visits, including mental health, with MDLIVE		29
Unlimited telehealth visits, including mental health, with MDLIVE		29
Unlimited telehealth visits, including mental health, with MDLIVE		29
$0		29
$0		29
$0		29
$0		29
Preventive care; adult routine screenings		29
Preventive care; adult routine screenings		29
Preventive care; adult routine screenings		29
Well-child visit; up to age 22		29
$0		29
$0		29
$0		29
$0		29
Vision coverage; eye exams		29
Vision coverage; eye exams		29
Vision coverage; eye exams		29
$0		29
$0		29
$5		29
$5		29
Maternity; routine care		29
Maternity; routine care		29
Maternity; routine care		29
$0		29
$0		29
$0		29
$0		29
MinuteClinic where available		29
MinuteClinic where available		29
MinuteClinic where available		29
®		29
$10		29
$10		29
$10		29
$10		29
Primary physician office visit		29
Primary physician office visit		29
Primary physician office visit		29
$30		29
$30		29
$20		29
$20		29
Mental health office visit		29
Mental health office visit		29
Mental health office visit		29
$30		29
$30		29
$20		29
$20		29
Specialist care office visit		29
Specialist care office visit		29
Specialist care office visit		29
$45		29
$45		29
$20		29
$20		29
Urgent care facility		29
Urgent care facility		29
Urgent care facility		29
$50		29
$50		29
$35		29
$35		29
ER visit; accidental		29
ER visit; accidental		29
ER visit; accidental		29
15%		29
15%		29
3		29
3		29
3 Calendar year deductible applies.		29
3 Calendar year deductible applies.		29
$0		29
$0		29
ER visit; medical		29
ER visit; medical		29
ER visit; medical		29
15%		29
15%		29
3		29
3		29
10%		29
10%		29
3		29
3		29
Hospital care; inpatient		29
Hospital care; inpatient		29
Hospital care; inpatient		29
15%		29
15%		29
3		29
3		29
$100 per admission plus 10%		29
$100 per admission plus 10%		29
Maternity; inpatient care		29
Maternity; inpatient care		29
Maternity; inpatient care		29
15%		29
15%		29
3		29
3		29
$0		29
$0		29
Hospital care; outpatient		29
Hospital care; outpatient		29
Hospital care; outpatient		29
15%		29
15%		29
3		29
3		29
10%		29
10%		29
3		29
3		29
Inpatient professional surgical services		29
Inpatient professional surgical services		29
Inpatient professional surgical services		29
15%		29
15%		29
3		29
3		29
10%		29
10%		29
3		29
3		29
Outpatient professional services		29
Outpatient professional services		29
Outpatient professional services		29
15%		29
15%		29
3		29
3		29
10%		29
10%		29
3		29
3		29
Lab services		29
Lab services		29
Lab services		29
$0		29
$0		29
$0		29
$0		29
X-rays and other diagnostic services		29
X-rays and other diagnostic services		29
X-rays and other diagnostic services		29
$50		29
$50		29
4		29
4		29
4 Elevate Plus, you pay $100 copay for advanced outpatient diagnostic tests such as, High Tech Imaging such as MRI, CT, PET, etc. Refer to GEHA’s 2023 plan brochure RI 71-018 (Elevate and Elevate Plus) for a complete list at		29
4 Elevate Plus, you pay $100 copay for advanced outpatient diagnostic tests such as, High Tech Imaging such as MRI, CT, PET, etc. Refer to GEHA’s 2023 plan brochure RI 71-018 (Elevate and Elevate Plus) for a complete list at		29
geha.com/PlanBrochure		29
geha.com/PlanBrochure		29
10%		29
10%		29
3		29
3		29
Chiropractic care visit (manipulative therapy), including X-rays. Limited per year.		29
Chiropractic care visit (manipulative therapy), including X-rays. Limited per year.		29
Chiropractic care visit (manipulative therapy), including X-rays. Limited per year.		29
$30		29
$30		29
$20		29
$20		29
Acupuncture visit; up to 20 treatments per year		29
Acupuncture visit; up to 20 treatments per year		29
Acupuncture visit; up to 20 treatments per year		29
$30		29
$30		29
10%		29
10%		29
3		29
3		29
Preventive dental care		29
Preventive dental care		29
Preventive dental care		29
No benefit		29
No benefit		29
Balance after GEHA pays $22 per visit		29
Balance after GEHA pays $22 per visit		29
It pays to stay in-network		30
It pays to stay in-network		30
Whether it’s a fixed dollar amount, or a percentage, we want you to understand what you pay for in-network or out-of-network services. We’ve included an example below for a plan with a 10% coinsurance for services in-network and 25% coinsurance for services out-of-network.		30
1		30
The Elevate Plus medical plan does not offer out-of-network coverage.		30
The Elevate Plus medical plan does not offer out-of-network coverage.		30
The Elevate Plus medical plan does not offer out-of-network coverage.		30
Figure		30
In-network		30
In-network		30
Out-of-network		30
Out-of-network		30
$150		30
$150		30
$150		30
$150		30
Provider’s billed rate		30
Provider’s billed rate		30
•		30
•		30
•		30
•		30
•		30
In-network provider’s contracted rate with GEHA		30
•		30
•		30
•		30
GEHA’s plan allowance for out-of-network providers		30
30
$100		30
$100		30
$100		30
$100		30
$90		30
$90		30
90% of $100		30
$75		30
$75		30
75% of $100		30
What GEHA pays		30
What GEHA pays		30
$25		30
$25		30
25% of $100		30
$10		30
$10		30
10% of $100		30
What you pay (coinsurance)		30
What you pay (coinsurance)		30
You also pay the difference between the out-of-network provider’s billed rate and GEHA’s plan allowance		30
You also pay the difference between the out-of-network provider’s billed rate and GEHA’s plan allowance		30
$50		30
$50		30
$0		30
$0		30
$75		30
$75		30
$10		30
$10		30
What you pay total for this service		30
What you pay total for this service		30
See for definition.		30
See for definition.		30
1		30
page 31		30
page 31		30
Definitions and terms		31
Definitions and terms		31
We know some terms can be confusing. As you work your way through this guide, these definitions may help.		31
Term		31
Term		31
Term		31
Term		31
Term		31
Term		31
Term		31
Definition		31
Definition		31
Calendar year deductible		31
Calendar year deductible		31
Calendar year deductible		31
Calendar year deductible		31
What you pay each year before the plan begins to pay out benefits.		31
What you pay each year before the plan begins to pay out benefits.		31
Coinsurance		31
Coinsurance		31
Coinsurance		31
The percentage you pay for a covered health care service, after you’ve met your deductible.		31
The percentage you pay for a covered health care service, after you’ve met your deductible.		31
31
Copay		31
Copay		31
Copay		31
A fixed amount you pay for a service or prescription.		31
A fixed amount you pay for a service or prescription.		31
GEHA contribution		31
GEHA contribution		31
GEHA contribution		31
Portion of monthly HDHP premium that GEHA contributes to a health savings account (HSA) or health reimbursement arrangement (HRA).		31
Portion of monthly HDHP premium that GEHA contributes to a health savings account (HSA) or health reimbursement arrangement (HRA).		31
In-network provider		31
In-network provider		31
In-network provider		31
A health care provider who is a part of GEHA’s provider network. These providers agree to limit what they will charge you.		31
A health care provider who is a part of GEHA’s provider network. These providers agree to limit what they will charge you.		31
Net deductible (HDHP)		31
Net deductible (HDHP)		31
Net deductible (HDHP)		31
The remaining amount after you subtract the annual GEHA contribution from the annual deductible. This is your out-of-pocket cost before plan benefits begin.		31
The remaining amount after you subtract the annual GEHA contribution from the annual deductible. This is your out-of-pocket cost before plan benefits begin.		31
Out-of-pocket max		31
Out-of-pocket max		31
Out-of-pocket max		31
The maximum amount you pay each year for coverage. Includes copays, deductibles and coinsurance, but not premiums. Once the limit is met, the plan pays the remainder of your covered health care expenses for the rest of the year.		31
The maximum amount you pay each year for coverage. Includes copays, deductibles and coinsurance, but not premiums. Once the limit is met, the plan pays the remainder of your covered health care expenses for the rest of the year.		31
Plan allowance		31
Plan allowance		31
Plan allowance		31
Cost of health care goods and services after subtracting the insurance company’s negotiated discount. For complete details see the definition of “Plan allowance” in Section 10 of any GEHA plan brochure.		31
Cost of health care goods and services after subtracting the insurance company’s negotiated discount. For complete details see the definition of “Plan allowance” in Section 10 of any GEHA plan brochure.		31
geha.com/PlanBrochure		31
geha.com/PlanBrochure		31
PPO		31
PPO		31
PPO		31
A preferred provider organization.		31
A preferred provider organization.		31
Premium		31
Premium		31
Premium		31
What you pay monthly or biweekly for coverage.		31
What you pay monthly or biweekly for coverage.		31
Prescription benefits		31
Prescription benefits		31
Prescription benefits		31
What you pay as a copay or percentage of coinsurance for medication.		31
What you pay as a copay or percentage of coinsurance for medication.		31
This is a brief description of the features of Government Employees Health Association, Inc.’s medical plans. Before making a final decision, please read the GEHA Federal brochures which are available at . All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochures.		31
This is a brief description of the features of Government Employees Health Association, Inc.’s medical plans. Before making a final decision, please read the GEHA Federal brochures which are available at . All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochures.		31
geha.com/PlanBrochure		31
geha.com/PlanBrochure		31
Sect		32
Figure		32
Ready to enroll?		32
Ready to enroll?		32
If you’ve found a plan that aligns with your needs, learn how to enroll in a plan today.		32
geha.com/Enroll		32
geha.com/Enroll		32
geha.com/Enroll		32
This is a brief description of the features of Government Employees Health Association, Inc.’s medical plans. Before making a final decision, please read the GEHA Federal brochures which are available at . All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochure.		32
This is a brief description of the features of Government Employees Health Association, Inc.’s medical plans. Before making a final decision, please read the GEHA Federal brochures which are available at . All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochure.		32
geha.com/PlanBrochure		32
geha.com/PlanBrochure		32
Download the plan brochureFor information and changes to GEHA’s medical plans, see our three plan brochures – RI 71-006 (High and Standard), RI 71-014 (HDHP) and RI 71-018 (Elevate and Elevate Plus) – which are available at		32
32
geha.com/PlanBrochure		32
geha.com/PlanBrochure		32
Notice of Summary of Benefits and Coverage (SBC): Availability of Summary Health Information: The Federal Employees Health Benefit (FEHB) program offers numerous health benefits plans and coverage options. Choosing a health plan and coverage option is an important decision. To help you make an informed choice, each FEHB plan makes available a Summary of Benefits and Coverage (SBC) about each of its health coverage options, online and in paper. The SBC summarizes important information in a standard format to		32
geha.com/SBC		32
geha.com/SBC		32
800.821.6136		32
800.821.6136		32
To find out more information about plans available under the FEHB program, including SBCs for other FEHB plans, please visit		32
opm.gov/Insure		32
opm.gov/Insure		32
|		32
|		32
geha.com		32
geha.com		32
800.262.4342		32
800.262.4342		32
_P__Social_footer		32
Link		32
Figure		32
Link		32
Figure		32
Link		32
Figure		32
Link		32
Figure		32
Link		32
Figure		32
©2022-2023 Government Employees Health Association, Inc. All rights reserved. Please recycle.		32
©2022-2023 Government Employees Health Association, Inc. All rights reserved. Please recycle.		32
Figure		32

www.geha.com

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