We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Coverage under this plan qualifies as minimum essential coverage (MEC) and satisfies the Patient Protection and Affordable Care Act's (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

See https://health-benefits.opm.gov/PSHB/ for enrollment information as well as

• Information on the PSHB Program and plans available to you
• A health plan comparison tool

Note: Contact the USPS for information on how to enroll in a PSHB Program Plan through the PSHB System.

Also, your employing or retirement office can answer your questions, give you other plans’ brochures and other materials you need to make an informed decision about your PSHB coverage. These materials tell you:

• When you may change your enrollment;
• How you can cover your family members;
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;
• What happens when your enrollment ends; and
• When the next Open Season for enrollment begins.

We do not determine who is eligible for coverage. You will be responsible for making changes to your enrollment status through the PSHB System. In some cases, your employing or retirement office may need to submit documentation. For information on your premium deductions, disability leave, pensions, etc. you must also contact your employing or retirement office.

Once enrolled in your PSHB Program Plan, you should contact your carrier directly for updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member.

You enroll in a PSHB Program Plan and make enrollment changes in the PSHB System located at https://health-benefits.opm.gov/PSHB/. For assistance with the PSHB System, call the PSHBP Helpline at (844) 451-1261. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment request. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s PSHB enrollment.

Use the PSHB System if you want to change from Self Only to Self Plus One or Self and Family, and to add or remove a family member. Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please report changes in family member status including your marriage, divorce, annulment, or when your child reaches age 26 through the PSHB System. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

If you or one of your family members is enrolled in one PSHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another PSHB or FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the PSHB Program, change your enrollment, or cancel coverage using the PSHB System. For a complete list of QLEs, visit the PSHB website at www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother’s maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the PSHB Program if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If this law applies to you, and only one child is involved in the court or administrative order, you may enroll for Self Plus One coverage in a health plan that provides full benefits in the area where your child lives or provide documentation to your employing office that you have obtained other health benefits coverage for the child. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no PSHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM;
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the PSHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for PSHB coverage, you must continue your PSHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

For annuitants who are required to be enrolled in Medicare Part B as a condition to continue PSHB coverage in retirement: If you enroll in Medicare Part B and continue PSHB coverage in retirement, the child equity law applies to you and you cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your child(ren) live as long as the court/administrative order is in effect. You cannot be compelled to enroll or remain enrolled in Medicare Part B to maintain your PSHB enrollment as a condition to satisfy a court/administrative order. However, if you do not enroll (or remain enrolled) in Medicare Part B as required to continue your PSHB coverage in retirement (notwithstanding an existing court/administrative order), you will not be able to continue your PSHB coverage in retirement.

Our PDP EGWP is only available to Postal Service annuitants who are Medicare Part D-eligible and their covered Medicare Part D-eligible family members. Our PDP EGWP is not an open market Medicare Part D Plan. If you are an active Postal Service employee, or covered family member, and become eligible to enroll in Medicare Part D, you are not eligible to enroll in our PDP EGWP.
Please, contact CMS for assistance at 800-MEDICARE (800-633-4227).

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage and premiums begin on January 1. If you joined at any other time during the year, your employing or retirement office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

When you retire, you can usually stay in the PSHB Program. Generally, you must have been enrolled in the FEHB and/or PSHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

You will receive an additional 31-days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment; or
• You are a family member no longer eligible for coverage.

Any person covered under the 31-day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31-day temporary extension.

If you are eligible for coverage under spouse equity, you are only eligible to enroll in the FEHB Program. If you are not eligible for coverage under spouse equity and you are otherwise eligible for Temporary Continuation of Coverage (TCC), then you could enroll in TCC under the PSHB Program.

If you are an enrollee and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must enter the date of the divorce or annulment and remove your ex-spouse in the PSHB System. We may ask for a copy of the divorce decree as proof. If you need to change your enrollment type, you must use the PSHB System. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own coverage under the spouse equity law or Temporary Continuation of Coverage (TCC). Former spouses eligible for coverage under the spouse equity law are not eligible to enroll in the PSHB Program. However, former spouses eligible for coverage under the spouse equity law may enroll in the FEHB Program. (Former Spouses seeking but not yet adjudicated as eligible for Spouse Equity may be entitled to TCC under a PSHB plan in the interim).

Former spouses not meeting the spouse equity requirements may be eligible for TCC under the PSHB Program provided you otherwise meet the eligibility requirements for TCC. If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices, https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee’s PSHB enrollment.

When a Postal Service annuitant who is Medicare Part D-eligible or their covered Medicare-eligible family member opts out of or disenrolls from our PDP EGWP, they will not have our prescription drug coverage under this plan. If you do not maintain creditable coverage, re-enrollment in our PDP EGWP may be subject to a late enrollment penalty.

Contact us for additional information at 800-821-6136.

If you leave Federal service or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your PSHB enrollment after you retire, if you lose your Federal job, or if you are a covered child and you turn age 26, regardless of marital status, etc.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing PSHB Program coverage.

If you leave Federal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the PSHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-821-6136 or visit our website at www.geha.com.

If you would like to purchase health insurance through the ACA’s Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the PSHB System enrollment confirmation.

Note: If you are enrolled in our Medicare Part D PDP EGWP, you will receive a second ID card for your prescription drug benefits.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-821-6136 or write to us at GEHA Enrollment, PO Box 21262, Eagan, MN 55121. You may also request replacement cards through our website: www.geha.com.

You can get care from any “covered provider” or “covered facility”. How much we pay – and you pay – depends on the type of covered provider or facility you use and who bills for the covered services. If you use our preferred providers, you will pay less.

PSHB Carriers must have clauses in their in-network (participating) provider agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in-network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

Under the Plan, we consider covered providers to be medical practitioners who perform covered services when acting within the scope of their license or certification under applicable state law. 

These covered providers may include: a licensed doctor of medicine ( M.D.) or a licensed doctor of osteopathy (D.O.); chiropractor; nurse midwife; nurse anesthetist; audiologist; dentist; optometrist; licensed clinical social worker; licensed clinical psychologist; licensed professional counselor; licensed marriage and family therapist; podiatrist; speech, physical and occupational therapist; nurse practitioner/clinical specialist; nursing school administered clinic; physician assistant; registered nurse first assistants; certified surgical assistants; board certified behavior analyst; board certified assistant behavior analyst; registered behavior technician; certified doula, and a dietitian as long as they are providing covered services which fall within the scope of their state licensure or statutory certification.

The terms "doctor", "physician", "practitioner" or "professional provider" includes any provider when the covered service is performed within the scope of their license or certification. The term "primary care provider" includes family or general practitioners, pediatricians, obstetricians/gynecologists and medical internists, and mental health/substance use disorder treatment providers.

Practitioners must be licensed in the state where the patient is physically located at the time services are rendered.

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.

We list network-contracted covered providers in our network provider directory, which we update periodically, and make available on our website. 

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender. 

This plan provides Care Coordinators for complex conditions and can be reached at 800-821-6136. 

Covered facilities include:

• Freestanding ambulatory facility
  • A facility which is licensed by the state as an ambulatory surgery center or has Medicare certification as an ambulatory surgical center, has permanent facilities and equipment for the primary purpose of performing surgical and/or renal dialysis procedures on an outpatient basis; provides treatment by or under the supervision of doctors and nursing services whenever the patient is in the facility; does not provide inpatient accommodations; and is not, other than incidentally, a facility used as an office or clinic for the private practice of a doctor or other professional.
  • If the state does not license Ambulatory Surgical Centers and the facility is not Medicare certified as an ambulatory surgical center, then they must be accredited with AAAHC (Accreditation Association for Ambulatory Health Care), AAAASF (American Association for Accreditation for Ambulatory Surgery Facilities), IMQ (Institute for Medical Quality) or TJC (The Joint Commission).
  • Ambulatory Surgical Facilities in the state of California do not require a license if they are physician owned. To be covered, these facilities must be accredited by one of the following: AAAHC (Accreditation Association for Ambulatory Health Care), AAAASF (American Association for Accreditation for Ambulatory Surgery Facilities), IMQ (Institute for Medical Quality) or TJC (The Joint Commission).
• Hospital
  • An institution or distinct portion of an institution that is primarily engaged in providing: (1) general inpatient acute care and treatment of sick and injured persons through medical, diagnostic, and major surgical facilities; or (2) specialized inpatient acute medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory); or (3) comprehensive specialized services relating to the individual's specific medical, physical, mental health, and/or substance use disorder therapy needs, and has, for each patient, an individualized written treatment plan, which includes diagnostic assessment of the patient and a description of the treatment to be rendered, and provides for follow-up assessments by, or under, the direction of the supervising doctor.
  • All services must be provided on its premises, under its control, or through a written agreement with a hospital or with a specialized provider of those facilities.
  • A hospital must be operated pursuant to law, accredited as a hospital under the Hospital Accreditation Program of the Joint Commission (TJC) or meet the states' applicable licensing or certification requirements for a hospital, and is operating under the supervision of a staff of physicians with 24-hour-a-day registered nursing services.
  • The term hospital does not include a convalescent home, extended care facility, skilled nursing facility, or any institution or part thereof which: (1) is used principally as a convalescent facility, nursing facility, or long-term care facility; (2) furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or (3) is operating as or is licensed as a school or residential treatment facility (except as listed in Section 5(e)).

• Hospice
  • A facility which meets all of the following:
    • Primarily provides inpatient hospice care to terminally ill persons;
    • Is certified by Medicare as such, or is licensed or accredited as such, by the jurisdiction it is in;
    • Is supervised by a staff of M.D.'s or D.O.'s at least one of whom must be on call at all times;
    • Provides 24-hour-a-day nursing services under the direction of an R.N. and has a full-time administrator; and
    • Provides an ongoing quality assurance program.
• Skilled Nursing Facility licensed by the state or certified by Medicare if the state does not license these facilities. See limitations in Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services.
• Birth Center
  • A birth center is a health facility that is not a hospital or physician's office, where childbirth is planned to occur away from the pregnant woman's residence, that is licensed or otherwise approved by the state to provide prenatal labor and delivery or postpartum care that is covered by the plan.
• Residential Treatment Centers (RTCs)
  • An institution that is primarily engaged in providing: (1) 24-hour residential evaluation, treatment, and comprehensive specialized services relating to the individual's specific mental health, and/or substance use disorder therapy needs, all under the active participation and direction of a licensed physician who is practicing within the scope of the physician's license; and (2) specialized programs for persons who need short-term services designed to achieve predicted outcomes focused on fostering improvement or stability in mental health and/or substance use disorder, recognizing the individuality, strengths, and needs of the persons served; and (3) care that meets evidence-based treatment guidelines or criteria as determined by the plan.
  • The services are provided for a fee from its patients and include both: (1) room and board; and (2) 24-hour-a-day registered nursing services. Additionally, the RTC keeps adequate patient records which include: (1) the individualized treatment plan; and (2) the person's progress; and (3) discharge summary; and (4) follow-up programs.  Benefits are available for services performed and billed by RTCs, as described in Section 5(e). Mental Health and Substance Use Disorder Benefits.
  • RTCs must be: (1) operated pursuant to law; and (2) accredited by a nationally recognized organization, and licensed by the state, district or territory to provide residential treatment for mental health conditions and/or substance use disorder; or (3) credentialed by a network partner.
  • The term RTC does not include a convalescent home, extended care facility, skilled nursing facility, group home, halfway house, sober home, transitional living center or treatment, or any institution or part thereof which: (1) is used principally as a convalescent facility, nursing facility, or long-term care; (2) furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or (3) is operating or licensed as a school.

Specialty care: If you have a chronic or disabling condition and

• lose access to your specialist because your coverage changed from the FEHB to the PSHB and your health plan does not participate in the PSHB;
• lose access to your specialist because we drop out of the Postal Service Health Benefits (PSHB) Program and you enroll in another PSHB Plan; or
• lose access to your in-network specialist because we terminate our contract with your specialist for reasons other than for cause.

You may be able to continue seeing your specialist and receiving any in-network benefits for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your in-network specialist based on the above circumstances, you can continue to see your specialist and your in-network benefits will continue until the end of your postpartum care, even if it is beyond the 90 days.

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, refer to the back of your member ID card under the heading Prior Authorization for the contact information. If you do not have a member ID card, call our customer service department at 800-821-6136. If you are new to the PSHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to this PSHB plan, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the PSHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized person’s benefits under the new plan begin on the effective date of enrollment.

The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for other services, are detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care or services. In other words, a pre-service claim for benefits (1) requires precertification or preauthorization and (2) will result in a reduction of benefits if you do not obtain precertification or preauthorization.

Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. Unless we are misled by the information given to us, we won’t change our decision on medical necessity.

In most cases, your physician or hospital will take care of requesting precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician or hospital whether or not they have contacted us.

First, you, your representative, your physician or your hospital must call to obtain preauthorization before an inpatient hospital admission, residential treatment center (RTC) admission, or for services requiring precertification are rendered. Refer to the back of your member ID card under the heading Prior Authorization for the contact information.

For admissions to Skilled Nursing Facilities, Long Term Acute Care Facilities, or Rehabilitation Facilities please refer to the back of your member ID card under the heading Prior Authorization for the contact information.

Next, provide the following information:

• enrollee's name and plan identification number;
• patient's name, birth date, and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting doctor; 
• name of hospital or facility; and 
• number of days requested for hospital stay.

We will then tell the doctor and/or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your doctor, and the hospital. 

You must get precertification for certain services prior to admission.  Failure to do so will result in the following penalties:

• In-network: We will reduce our benefits for the Inpatient Hospital, Long-Term Acute Care, Residential Treatment Facility (RTC), Skilled Nursing (SNF), or Rehabilitation Facility stay by $500 if precertification is not obtained prior to admission. If the stay is not medically necessary, we will only pay for any covered medical services and supplies that are otherwise payable on an outpatient basis.
• Out-of-network:
  • We will reduce our benefits for the Inpatient Hospital stay, Long-Term Acute Care, Residential Treatment Facility (RTC), Skilled Nursing (SNF), or Rehabilitation Facility stay by $500 per day for each day that is not precertified prior to admission. If the stay is not medically necessary, we will only pay for any covered medical services and supplies that are otherwise payable on an outpatient basis.
  • Out-of-network facilities must, prior to admission, agree to abide by the terms established by the Plan for the care of the particular member and for the submission and processing of related claims.

You do not need precertification in these cases:

• You are admitted to a hospital outside the United States;
• You have another group health insurance policy that is the primary payor for the hospital stay; or
• Medicare Part A is the primary payor for the hospital stay.

Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payor and you do need precertification.

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have preauthorization. We will make our decision within 15 days of receipt of the pre-service claim.

If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information, or (2) the end of time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-821-6136.  You may also call OPM’s Postal Insurance Operations (PSIO) at 202-936-0002 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, then call us at 800-821-6136. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

A concurrent care claim involves care provided over time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

A reduction or termination of care can occur due to lack of medical necessity or the member's failure to demonstrate measurable progress towards the established treatment goals and further medical professional intervention is not expected to result in a significant improvement of the patient's condition.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

You do not need precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.

Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

If your hospital stay – including for maternity care – needs to be extended, you, your representative, your doctor or the hospital must ask us to approve the additional days. If you remain in the hospital beyond the number of days we approved and did not get the additional days precertified, then:

• for the part of the admission that was medically necessary, we will pay inpatient benefits, but,
• for the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits.

Some surgeries and procedures, services and equipment require precertification or preauthorization such as, but not limited to, the following list.  Please note this list is subject to change, please call to verify if your procedure requires preauthorization.  Refer to the back of your member ID card under the heading Prior Authorization for the contact information.

Services requiring preauthorization or medical necessity determination may be reviewed with guidelines as described at www.geha.com/CriteriaSources. GEHA has coverage policies for many services and procedures; refer to www.geha.com/Coverage-Policies for a complete list of policies.

• ACI (Autologous Cultured Chondrocytes), also called Genzyme tissue repair (or Carticel) for knee cartilage damage;
• Abdominoplasty/panniculectomy/lipectomy;
• Ablative and surgical treatment of venous insufficiency including sclerotherapy and microphlebectomy;
• Advanced wound therapy provided in an outpatient setting such as negative pressure wound therapy (wound vac systems);
• Applied behavioral therapy;
• Arthroplasty, including revisions to a prior arthroplasty;
• Artificial insemination (AI) drugs and IVF-related drugs;
• Artificial insemination procedures (intravaginal insemination, intracervical insemination, intrauterine insemination);
• Back/spine surgeries;
• Bariatric procedures;
• Bone growth stimulators;
• Botox injections;
• Breast reconstruction except for diagnosis of cancer;
• Cellular and gene therapy;
• Certain prescription drugs;
• Cochlear and auditory implants and implant procedures;
• Correction of choanal atresia and intranasal synechia;
• Discectomy/fusion;
• Durable medical equipment (DME) over $1,000;
• Experimental/investigational surgery or treatment;
• Eyelid surgery or brow lift;
• Functional Endoscopic Sinus Surgery (FESS);
• Genetic testing;
• Growth hormone therapy (GHT);
• Gynecomastia treatment-cosmetic (see mammoplasty);
• Harvesting of sperm/eggs and storage of sperm/embryos/eggs for iatrogenic infertility diagnosis;
• High tech outpatient radiology/imaging;
• Hyoid myotomy and suspension;
• Hysterectomy except for diagnosis with cancer;
• Implantable cardiac monitoring;
• Injectable drugs for arthritis, psoriasis or hepatitis;
• Injectable hematopoietic drugs (drugs for anemia, low white blood count);
• Inpatient hospital mental health and substance use disorder benefits, inpatient care at residential treatment centers and intensive day treatment;
• Intrathecal pump insertion for pain management (morphine pump, baclofen pump);
• Low-dose computed tomography (LDCT);
• Mammoplasty, reduction (unilateral/bilateral);
• Neurostimulation, including devices and implantation procedures for cranial, gastric, peripheral, spinal, or vagus nerve stimulation;
• Non-emergency air ambulance; 
• Non-surgical outpatient cancer treatment, including chemotherapy and radiation;
• Organ and tissue transplant procedures;
• Orthognathic surgery (jaw), including TMJ;
• Orthopedic and prosthetic devices over $1,000;
• Osteochondral grafting (allogeneic);
• Prostate implants, destruction and removal;
• Psychological testing exceeding 8 hours/calendar year;
• Rhinoplasty;
• Scar revisions;
• Severe obesity surgeries;
• Sinuplasty;
• Sleep studies (in-lab) attended or performed in a healthcare facility (home sleep studies do not require preauthorization);
• Speech generating devices;
• Surgical correction of congenital anomalies;
• Surgical treatment of gender dysphoria;
• Transcatheter aortic and pulmonary valve repair or replacement;
• Transcatheter arrhythmia ablation;
• Transplants; and
• UPPP Uvulopalatopharyngoplasty.

Radiology preauthorization is the process by which prior to scheduling specific imaging procedures we evaluate the medical necessity of your proposed procedure to ensure the appropriate procedure is being requested for your condition.  In most cases your physician will take care of preauthorization.  Because you are still responsible for ensuring that we are asked to preauthorize your procedure, you should ask your doctor to contact us.  Refer to the back of your member ID card under the heading Prior Authorization for the contact information.

The following outpatient radiology/imaging services need to be preauthorized:

• CT - Computerized Axial Tomography;
• MRI - Magnetic Resonance Imaging;
• MRA - Magnetic Resonance Angiography;
• NC - Nuclear Cardiac Imaging Studies; and 
• PET - Positron Emission Tomography.

You must get preauthorization for certain services.  If the procedure is not medically necessary, we will not pay any benefits.

You do not need preauthorization in these cases:

• You have another health insurance policy that is the primary payor, including Medicare Part A and B or Part B only;
• The procedure is performed outside the United States;
• You are an inpatient in a hospital or observation stay; or
• The procedure is performed as an emergency.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or preauthorization of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 844-4GEHARX or 844-443-4279.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to:

1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for preauthorization for a service, drug, or supply; or
2. Ask you or your provider for more information. You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

Note: If you are enrolled in our Medicare PDP EGWP and do not agree with our benefit coverage decision you have the right to appeal. See Section 8(a) for information about the PDP EGWP appeal process.

For covered services you receive by physicians and hospitals outside the United States and Puerto Rico, send a completed Overseas Claim form and the itemized bills to:

GEHA Medical Claims
PO Box 21172
Eagan, MN 55121

Obtain Overseas Claims Forms from www.geha.com.

Eligibility and/or medical necessity review is required when procedures are performed or you are admitted to a hospital outside of the United States. Review includes the procedure/ service to be performed, the number of days required to treat your condition, and any other applicable benefit criteria.

If you have questions about the processing of overseas claims, contact us at 800-821-6136 or by email at overseas@geha.com. Covered providers outside the United States will be paid at the in-network level of benefits, subject to deductible and coinsurance.  We will provide translation and currency conversion for claims for overseas (foreign) services. The conversion rate will be based on the date services were rendered.

When members living abroad are stateside and seeking medical care, contact us at 800-821-6136, or visit www.geha.com to locate an in-network provider. If you utilize an out-of-network provider, out-of-network benefits would apply.

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible and coinsurance) for the covered care you receive.

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Coinsurance amounts do not count toward any deductible. When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply counts toward the deductible.

• In-network:  Under a Self Only enrollment, the deductible is considered satisfied, and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $1,650.  Under a Self Plus One enrollment or a Self and Family enrollment, the deductible is considered satisfied, and benefits are payable for you and other eligible family members when the combined covered expenses applied to the calendar year deductible for your enrollment reach $3,300.  Only plan allowance paid for services or supplies from in-network providers counts toward this amount.
• Out-of-network: Under a Self Only enrollment, the deductible is considered satisfied, and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $3,300.  Under a Self Plus One enrollment or a Self and Family enrollment, the deductible is considered satisfied, and benefits are payable for you and other eligible family members when the combined covered expenses applied to the calendar year deductible for your enrollment reach $6,600.  Only plan allowance paid for services or supplies from out-of-network providers counts towards this amount.

If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full) is less than the remaining portion of your deductible, you pay the lower amount.

Example: If the billed amount is $100, the in-network provider has an agreement with us to accept $80, and you have not paid any amount toward meeting your calendar year deductible, you must pay $80. We will apply $80 to your deductible. We will begin paying benefits once the remaining portion of your calendar year deductible $1,650 for Self Only and $3,300 for Self and Family and $3,300 Self Plus One) has been satisfied.

Note: If you change PSHB plans during Open Season the effective date of your new PSHB plan is January 1 of the next year, and a new deductible starts on January 1. If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn't begin until you have met your deductible.  We will base this percentage on either the billed charge or the Plan allowance, whichever is less.

Example: Under the HDHP, you pay 35% of our allowance for out-of-network office visits.

If your provider routinely waives (does not require you to pay) your deductibles or coinsurance, the provider is misstating the fee and may be violating the law. In this case, when we calculate our share, we will reduce the provider’s fee by the amount waived.

For example, if your physician ordinarily charges $100 for a service but routinely waives your 35% coinsurance, the actual charge is $65. We will pay $42.25 (65% of the actual charge of $65).

In some instances, a provider may ask you to sign a “waiver” prior to receiving care. This waiver may state that you accept responsibility for the total charge for any care that is not covered by your health plan. If you sign such a waiver, whether or not you are responsible for the total charge depends on the contracts that the Plan has with its providers. If you are asked to sign this type of waiver, please be aware that, if benefits are denied for the services, you could be legally liable for the related expenses. If you would like more information about waivers, please contact us at 800-821-6136, or write to GEHA Enrollment, PO Box 21262, Eagan, MN 55121.

Our “Plan allowance” is the amount we use to calculate our payment for covered services. Fee-for-service plans arrive at their allowances in different ways, so their allowances vary. For more information about how we determine our Plan allowance, see the definition of Plan allowance in Section 10.

Often, the provider’s bill is more than a fee-for-service plan’s allowance. Whether or not you have to pay the difference between our allowance and the bill will depend on the provider you use.  For more information about out-of-area services, see Section 1, We have preferred providers through a Point of Service (POS) network.

• In-network providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered charges consists only of your deductible and coinsurance. Here is an example about coinsurance: You see an in-network physician who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, with HDHP, you pay just 5% of our $100 allowance ($5). Because of the agreement, your in-network physician will not bill you for the $50 difference between our allowance and the bill.
• Out-of-network providers, on the other hand, have no agreement to limit what they will bill you. When you use an out-of-network provider, you will pay your deductible and coinsurance, plus any difference between our allowance and charges on the bill. Here is an example: You see an out-of-network physician who charges $150 and our allowance is again $100. Because you’ve met your deductible, you are responsible for your coinsurance, so with HDHP you pay 35% of our $100 allowance ($35). Plus, because there is no agreement between the out-of-network physician and us, the physician can bill you for the $50 difference between our allowance and the bill.

The following illustrates the examples of how much you have to pay out-of-pocket, under the HDHP, for services from an in-network physician vs. an out-of-network physician. The table uses our example of a service for which the physician charges $150 and our allowance is $100. The example shows the amount you pay if you have met your calendar year deductible.

EXAMPLE
In-network physician
Physician's charge: $150
Our allowance: We set it at: $100
We pay: 95% of our allowance: $95
You owe: 5% of our allowance: $5
+Difference up to charge? No: $0
TOTAL YOU PAY: $5

Out-of-network physician
Physician's charge: $150
Our allowance: We set it at: $100
We pay: 65% of our allowance: $65
You owe: 35% of our allowance: $35
+Difference up to charge? Yes: $50
TOTAL YOU PAY: $85

You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

For HDHP covered medical and surgical services with coinsurance, we pay 100% of our allowable amount for the remainder of the calendar year after out-of-pocket expenses for deductibles and coinsurance exceed:

• The HDHP out-of-pocket maximum is $6,000 for Self Only enrollment, $12,000 when enrollment is Self Plus One or Self and Family when you use in-network providers.  Only out-of-pocket expenses from in-network providers count towards those limits.
• An individual under Self Plus One and Self and Family enrollment will never have to satisfy more than what is required for the out-of-pocket maximum under a Self Only enrollment.

• The HDHP out-of-pocket maximum is $8,500 for Self Only enrollment; $17,000 when enrollment is Self Plus One or Self and Family if you use out-of-network providers.  Only out-of-pocket expenses from out-of-network providers count towards those limits.  Out-of-network coinsurance will only accumulate to the in-network maximum if meeting criteria to be reimbursed at the in-network rate (reference the No Surprise Act).
• An individual under Self Plus One and Self and Family enrollment will never have to satisfy more than what is required for the out-of-pocket maximum under a Self Only enrollment.

Out-of-pocket expenses for in-network and out-of-network benefits are the expenses you pay for covered services.

The following cannot be counted toward catastrophic protection out-of-pocket expenses:

• Expenses you pay for non-covered services;
• Expenses in excess of our allowable amount or maximum benefit limitations;
• Expenses in excess of plan limits for dental; 
• The cost for non-approved medications and drugs that we exclude;
• Any amount you pay because benefits have been reduced for non-compliance with our cost containment requirements (see Section 3); and
• The difference between the cost of generic and brand name medication.

For members enrolled in our Plan's associated PDP EGWP, we are required to accumulate all members’ actual out-of-pocket costs for covered drugs, services and supplies toward the PSHB catastrophic maximum(s), unless specifically excluded above.

If you are enrolled in our Medicare Part D Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP), the prescription drug out-of-pocket maximum is $2,000. After this maximum is met, we pay 100% of all eligible covered Part D prescription drug benefits. You will continue to pay a cost share for non-Medicare Part D drugs.

If you changed to this PSHB Plan during Open Season from a plan with a catastrophic protection benefit the effective date of the change is January 1 and covered expenses that apply to this plan’s catastrophic protection benefit starts on January 1.

Note: If you change PSHB plans during Open Season the effective date of your new PSHB plan is January 1 of the next year, and a new catastrophic protection accumulation starts on January 1. If you change plans at another time during the year, you must begin a new catastrophic protection accumulation under your new plan.

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.

We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments.

Facilities of the Department of Veteran Affairs, the Department of Defense, and the Indian Health Service are entitled to seek reimbursement from us for certain services and supplies they provide to you or a covered family member. They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges. Contact the government facility directly for more information.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services.

A surprise bill is an unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from surprise bills.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.geha.com or contact the health plan at 800-821-6136.

The Plan covers preventive care services from preferred providers, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., cancer screenings, cardiac screenings, and mammograms), well-child care, child and adult immunizations, and tobacco cessation programs. These services are covered at 100% if you use a network provider and the services are described in Section 5. Preventive care. Preventive care for children is covered at 100%. You do not have to meet the deductible before using these services.

This Plan also provides vision care benefits through EyeMed Vision Care and provides dental coverage. You do not have to meet the deductible before using these services.

The calendar year deductible does not apply to the following services:

• Supplemental vision care through EyeMed Vision Care;
• Dental benefits (100% of Plan allowance for diagnostic and preventive services twice per person per calendar year).

After you have paid the Plan’s deductible, we pay benefits under Traditional Medical Coverage described in Section 5. The Plan typically pays 95% for in-network and 65% for out-of-network care.

Covered services include:

• Medical services and supplies provided by physicians and other healthcare professionals;
• Surgical and anesthesia services provided by physicians and other healthcare professionals;
• Hospital services; other facility or ambulance services;
• Emergency services/accidents;
• Mental health and substance use disorder treatment; and
• Prescription drug benefits (covered at 75% or 60%).

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see Section 5. Savings - HSAs and HRAs for more details).

By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone else’s tax return, have not received VA (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits within the last three months or do not have other health insurance coverage other than another High Deductible Health Plan. In 2025, for each month you are eligible for an HSA premium pass through, we will contribute $83.33 per month to your HSA for a Self Only enrollment or $166.66 per month for a Self Plus One enrollment or $166.66 per month for a Self and Family enrollment. For 2025, a monthly premium pass through that is not a whole number will have any remaining balance included in the final monthly contribution. In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $4,300 for an individual and $8,550 for Self Plus One or Self and Family. See maximum contribution information in Section 5, Savings - HSAs and HRAs. You can use funds in your HSA to help pay your health plan deductible. You own your HSA, so the funds can go with you if you change plans or employment.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments (not GEHA's pass through contributions) are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying qualified medical expenses from tax-free HSA dollars or after-tax out-of-pocket dollars. If you don’t deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

• Your HSA is administered by FDIC - insured HSA Bank^tm
• Your contributions to the HSA are tax deductible.
• You may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.).
• Your HSA earns tax-free interest.
• You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents (see IRS Publication 502 for a complete list of eligible expenses).
• Your unused HSA funds and interest accumulate from year-to-year.
• It’s portable - the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire.
• When you need it, funds up to the actual HSA balance are available.

Important consideration if you want to participate in a Healthcare Flexible Spending Account (HCFSA): If you are enrolled in this HDHP with a Health Savings Account (HSA) and start or become covered by a HCFSA healthcare flexible spending account, this HDHP cannot continue to contribute to your HSA. Similarly, you cannot contribute to an HSA if your spouse enrolls in an HCFSA. Instead, when you inform us of your coverage in an HCFSA, we will establish an HRA for you.

If you are not eligible for an HSA, for example you are enrolled in Medicare or have another health plan, we will administer and provide an HRA instead. You must notify us that you are ineligible for an HSA.

In 2025, we will give you an HRA credit of $1,000 per calendar year for a Self Only enrollment and $2,000 per calendar year for a Self and Family enrollment and $2,000 for Self Plus One enrollment. You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that don’t count toward the deductible. 

HRA features include:

• For our HDHP option, the HRA is administered by GEHA.
• Entire HRA credit (prorated from your effective date to the end of the plan year) is available from your effective date of enrollment.
• Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP.
• Unused credits carryover from year-to-year.
• HRA credit does not earn interest.
• HRA credit is forfeited if you leave Federal employment or switch health insurance plans. Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan) and will forfeit their remaining HRA account balance at that time.
• An HRA does not affect your ability to participate in a Healthcare Flexible Spending Account (HCFSA). However, you must meet HCFSA eligibility requirements. 

"Net deductible after pass through" means the remaining deductible amount if you use the GEHA premium pass-through contribution to help pay your health plan deductible. By using the premium pass through to pay first dollar costs for qualified medical expenses, your out-of-pocket deductible cost on this plan is substantially reduced.

Annual In-Network Deductible: Self Only $1,650; Self Plus One/ Self and Family $3,300

GEHA's HSA/HRA premium pass-through contribution: Self Only $1,000; Self Plus One/ Self and Family $2,000

Net deductible after pass-through: Self Only $650; Self Plus One/ Self and Family $1,300

Your annual maximum for out-of-pocket expenses (deductibles and coinsurance) for covered services is limited to $6,000 per person for Self Only or $12,000 for Self Plus One (not to exceed $6,000 per person) and $12,000 when enrollment is Self and Family enrollment (any combination of family members, not to exceed $6,000 per person) when you use in-network providers.

If you use an out-of-network provider the annual maximum for out-of-pocket expenses is $8,500 for Self Only or $17,000 for Self Plus One (not to exceed $8,500 per person) and $17,000 when enrollment is Self and Family (any combination of family members, not to exceed $8,500 per person).

However, certain expenses do not count toward your out-of-pocket maximum, and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan’s allowable amount or benefit maximum). Refer to Section 4, Your catastrophic protection out-of-pocket maximum and Section 5, Traditional medical coverage subject to the deductible, for more details.

If you are enrolled in our PDP EGWP, see Section 5(f)(a) for additional information about your out-of-pocket maximum.

Section 5(h) describes the health education resources and account management tools available to you to help you manage your healthcare and your healthcare dollars.

The Plan will provide you the documents required to establish an HSA for you with HSA Bank^tm (PO Box 939, Sheboygan, WI 53082-0939, 866-471-5964, www.hsabank.com), this is the HDHP's fiduciary (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS).

GEHA is the HRA fiduciary for this Plan. (GEHA Enrollment, PO Box 21262, Eagan, MN 55121-9930, 800-821-6136, www.geha.com).

Set-up and monthly administrative fees are paid by the HDHP.

None

Eligibility for an HSA is determined on the first day of the month coincident to or following your effective date of enrollment.

You must:

• Enroll in this HDHP;
• Have no other health insurance coverage (does not apply to specific injury, accident, disability, dental, vision or long-term care coverage);
• Not be enrolled in Medicare;
• Not be claimed as a dependent on someone else's tax return;
• Not have received VA (except for veterans with a service-connected disability) benefits in the last three months;
• Not have received Indian Health Services (IHS) benefits in the last three months; and
• Complete and return all banking paperwork.

If you do not set up your health savings account with HSA Bank within 90 days, we will enroll you in the HRA.

Eligibility is determined on the first day of the month following your effective date of enrollment and will be prorated for length of enrollment.

You must enroll in this HDHP.

If you enroll in our HDHP and do not qualify for an HSA, we will establish an HRA for you.

If your eligibility changes mid-year, please contact GEHA at 800-821-6136.

If you are eligible for HSA contributions, a portion of your monthly health plan premium is deposited to your HSA each month.  Premium pass-through contributions are based on the effective date of your enrollment in the HDHP.

Note: If your effective date in the HDHP is after the 1st of the month, the earliest your HSA will be established is the 1st of the following month.  If you are new to this Plan based on an Open Season change, your first premium pass through will be made available no earlier than February as new enrollees and terminations from Open Season are still being received in January.  Your last HSA pass-through contribution for the current plan year will fund in January of the following plan year as long as you maintain eligibility through the end of the current plan year.  For 2025, a monthly premium pass through that is not a whole number will have any remaining balance included in the final monthly contribution.

In addition, you may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc).

The entire amount of your HRA will be available to you upon your enrollment.  Eligibility for the annual credit will be determined on the last day of the month following your effective date of enrollment and will be prorated for length of enrollment. 

Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan) and will forfeit their remaining HRA account balance at that time.

For 2025, a monthly premium pass through of $83.33 will be made by the HDHP directly into your HSA. 

For 2025, your HRA annual credit is $1,000 (prorated for mid-year enrollment).

Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan) and will forfeit their remaining HRA account balance at that time.

For 2025, a monthly premium pass through of $166.66 will be made by the HDHP directly into your HSA.

For 2025, your HRA annual credit is $2,000 (prorated for mid-year enrollment).

Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan) and will forfeit their remaining HRA account balance at that time.

For 2025, a monthly premium pass through of $166.66 will be made by the HDHP directly into your HSA.

For 2025, your HRA annual credit is $2,000 (prorated for mid-year enrollment).

Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan), and will forfeit their remaining HRA account balance at that time.

The maximum that can be contributed to your HSA is an annual combination of HDHP premium pass through and your contribution funds, which when combined, do not exceed the maximum contribution amount set by the IRS of $4,300 for an individual and $8,550 for Self Plus One or Self and Family.

If you enroll during Open Season, you are eligible to fund your account up to the maximum contribution limit set by the IRS.  To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum allowable contribution.

You are eligible to contribute up to the IRS limit for partial year coverage as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility.  To determine the amount you may contribute, take the IRS limit and subtract the amount the Plan will contribute to your account for the year.

If you do not meet the 12-month requirement, the maximum contribution amount is reduced by 1/12 for any month you were ineligible to contribute to an HSA. If you exceed the maximum contribution amount, a portion of your tax reduction is lost and a 10% penalty is imposed.  There is an exception for death or disability.  Contact HSA Bank^TM (PO Box 939, Sheboygan, WI 53082-0939, 866-471-5964, www.hsabank.com) for more details.

You may rollover funds you have in other HSAs to this HDHP HSA (rollover funds do not affect your annual maximum contribution under this HDHP).

HSAs earn tax-free interest (does not affect your annual maximum contribution).

Additional contributions are discussed under If you have an HSA after this section.

The full HRA credit will be available, subject to proration, on the effective date of enrollment.  The HRA does not earn interest.

Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan) and will forfeit their remaining HRA account balance at that time.

You may make an annual maximum contribution of $4,300.

You cannot contribute to the HRA.

You may make an annual maximum contribution of $8,550.

You cannot contribute to the HRA.

You may make an annual maximum contribution of $8,550.

You cannot contribute to the HRA.

You can access your HSA by the following methods:

• Debit card
• Withdrawal form
• Checks
• Online banking

For qualified medical expenses covered by your health plan, your provider is automatically reimbursed when claims are submitted through our HDHP plan. For expenses not covered by the HDHP, such as orthodontia, our Health Reimbursement Arrangement Claim Form is located online at www.geha.com or by request to Customer Service at 800-821-6136. This form is used to get reimbursement from your HRA for qualified out-of-pocket medical expenses that are not submitted to GEHA by your doctor, hospital, dentist or pharmacy. It can also be used to request reimbursement for paid Medicare premiums.

You can pay the out-of-pocket expenses for yourself, your spouse or your dependents (even if they are not covered by the HDHP) from the funds available in your HSA.  These distributions are tax-free if used for qualified medical expenses.

Note: Medical expenses are not allowable if they occur before the first full month your enrollment is effective, and they are not reimbursable from your HSA until the first of the month following the effective date of your enrollment in this HDHP and the date your HSA account is established.

You can pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the HDHP.

See IRS Publication 502 for a list of eligible medical expenses.

Non-reimbursed qualified medical expenses are allowable if they occur after the effective date of your enrollment in this Plan.

See Availability of funds below for information on when funds are available in the HRA.

See IRS Publications 502 and 969 for information on eligible medical expenses. Over-the-counter drugs and Medicare premiums are also reimbursable.  Most other types of medical insurance premiums are not reimbursable.

If you are under age 65, withdrawal of funds for non-medical expenses will create a 20% income tax penalty in addition to any other income taxes you may owe on the withdrawn funds.

When you turn age 65, distributions can be used for any reason without being subject to the 20% penalty, however they will be subject to ordinary income tax.

Not applicable - distributions will not be made for anything other than non-reimbursed qualified medical expenses.

Medicare premiums are reimbursable.

Funds are not available for withdrawal until all the following steps are completed:

• Your enrollment in this HDHP is effective (effective date is determined by your agency in accordance with the event permitting the enrollment change);
• You must complete and send the HSA application to HSA Bank^TM.  You complete the HSA application process either online or via paper forms;
• The fiduciary receives your application and sends record of the account to GEHA; and 
• GEHA contributes funds by the 15th of the month following the month of your effective date.

The entire amount of your HRA will be available to you upon your enrollment in the HDHP.

PSHB enrollee

HDHP

You can take this account with you when you change plans, separate or retire.

If you do not enroll in another HDHP, you can no longer contribute to your HSA.  See Section 1, Health Savings Account (HSA) or the beginning of this section for HSA eligibility.

If you retire and remain in this HDHP, you may continue to use and accumulate credits in your HRA.

If you terminate employment or change health plans, only eligible expenses incurred while covered under the HDHP will be eligible for reimbursement subject to timely filing requirements.  Unused funds are forfeited.

Yes, accumulates without a maximum cap.

Yes, accumulates without a maximum cap.

All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS. You may contribute your own money to your account through payroll deductions, or you may make lump sum contributions at any time, in any amount not to exceed an annual maximum limit.  If you contribute, you can claim the amount you contributed for the year as a tax deduction when you file your income taxes.  Your own HSA contributions are either tax-deductible or pre-tax (if made by payroll deduction).  You receive tax advantages in either case.  To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum contribution amount set by the IRS.  You have until April 15^th of the following year to make HSA contributions for the current year.

If you newly enroll in an HDHP during Open Season your effective date is January 1^st, or if you enroll at any time and have partial year coverage, you are eligible to fund your account up to the maximum contribution limit set by the IRS as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility.  If you do not meet this requirement, a portion of your tax reduction is lost and a 10% penalty is imposed.  There is an exception for death or disability. Contact HSA Bank^TM (PO Box 939, Sheboygan, WI 83082-0939, 866-471-5964, www.hsabank.com) for more details.

If you are age 55 or older, the IRS permits you to make additional contributions to your HSA. The allowable additional contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the IRS website at www.irs.gov or request a copy of IRS Publication 969 by calling 1-800-829-3676.

If you have not named a beneficiary and you are married, your HSA becomes your spouse’s; otherwise, your HSA becomes part of your taxable estate.

You can pay for “qualified medical expenses” as defined by IRS Code 213(d). These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, health insurance premiums if you are receiving Federal unemployment compensation, over-the-counter drugs, LASIK surgery, and some nursing services.

When you enroll in Medicare, you can use the account to pay Medicare premiums or to purchase health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you are enrolled in Medicare.

For detailed information of IRS-allowable expenses, request a copy of IRS Publications 502 and 969 by calling 800-829-3676, or visit the IRS website at www.irs.gov and click on “Forms and Instructions.” Note: Although over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA. Also, insurance premiums are reimbursable under limited circumstances.

You may withdraw money from your HSA for items other than qualified health expenses, but it will be subject to income tax and if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.

You will receive a periodic statement that shows the “premium pass through”, withdrawals, and interest earned on your account. In addition, you will receive an Explanation of Payment statement when you withdraw money from your HSA.

You can request reimbursement in any amount. Just like a normal bank account, you cannot reimburse yourself for expenses that are greater than the balance in the account.

If you don’t qualify for an HSA when you enroll in this HDHP, or later become ineligible for an HSA, we will establish an HRA for you. If you are enrolled in Medicare, you are ineligible for an HSA and we will establish an HRA for you. You must tell us if you become ineligible to contribute to an HSA.

Please review the chart at the beginning of this section, which details the differences between an HRA and an HSA. The major differences are:

• You cannot make contributions to an HRA;
• Funds in your HRA are forfeited if you leave the HDHP;
• An HRA does not earn interest; and
• HRAs can only pay for qualified medical expenses, such as deductibles and coinsurance expenses, for individuals covered by the HDHP. PSHB law does not permit qualified medical expenses to include services, drugs, or supplies related to abortions; except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.

Routine physical every year.

The following preventive services are covered at the time interval recommended at each of the links below:

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as:
  • Cancer
  • Osteoporosis
  • Depression
  • Diabetes
  • High blood pressure
  • Total blood cholesterol
  • HIV
  • Colorectal cancer
  • For a complete list of screenings, go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendationtopics/uspstf-a-and-b-recommendations
• Adult Immunizations endorsed by the Centers of Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.  For a complete list of endorsed immunizations, go to the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules/
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as:
  • Pap smears
  • Gonorrhea prophylactic medication to protect newborns
  • Annual counseling for sexually transmitted infections
  • Contraceptive methods
  • Screening for interpersonal and domestic violence
  • For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at https://www.hrsa.gov/womens-guidelines
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

In-network: Nothing

Out-of-network: Covered under Traditional medical coverage subject to deductible

Note: Aspirin, fluoride, bowel prep, generic raloxifene, generic tamoxifen, exemestane, anastrozole, folic acid, and generic statins with physician prescription are covered as preventive with the appropriate age/gender or dosage limits with no patient copay.  For more specific details see Section 5(f) Preventive care medications or visit www.geha.com/Prescriptions.

Note: Counseling for tobacco cessation for adult males, pregnant and non-pregnant females, children and adolescents is covered as preventive.  See Section 5(a) under Educational classes and programs.

Note: You must see your doctor for the specific purpose of preventive care in order to have the visit considered under this preventive care benefit.  If you have a screening or blood test done during a visit to your doctor that is for medical reasons other than prevention, you will likely have to share in some of the cost.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

• Routine mammogram - covered, including 3D mammograms.
• Ultrasound performed after inconclusive breast cancer screening exam

In-network: Nothing

Out-of-network: Covered under Traditional medical coverage subject to deductible

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy, when ordered by your physician for obesity (BMI greater than or equal to 30 kg/m²)
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider. Programs must be ordered by a physician for treatment of your own obesity, or for education and support of a family member with obesity.
• Nutritional counseling for individuals with BMI greater than or equal to 30 kg/m² is covered as outlined in Section 5(a) Educational classes and programs.
  • Note: Also see Section 5(h) for information on the Obesity screening and management program.
• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) or 5(f)(a), if applicable for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

In-network: Nothing after deductible

Out-of-network: Covered under Traditional medical coverage subject to deductible

Not covered:

• Professional fees for automated lab tests
• Physical, psychiatric, or psychological exams and testing required for obtaining or continuing employment or insurance, attending schools or camps, sports physicals, travel related to judicial or administrative proceedings or orders, or required to obtain or maintain a license of any type.
• Immunizations, boosters, and medications required for obtaining, continuing, or maintaining insurance, a license of any type, employment and/or work-related exposure, attending camps, sports physicals, or for travel; unless Section 5(a), Preventive Care coverage criteria are met.

All charges

The following preventive services are covered at the time interval recommended at each of the links below.

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Immunizations such as DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
• You may also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• To build your personalized list of preventive services, go to https://health.gov/myhealthfinder

Note: Counseling for tobacco cessation for adult males, pregnant and non-pregnant females, children and adolescents is covered as preventive.  See Section 5(a) under Educational classes and programs.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Note: Screening and Counseling for childhood obesity is covered as preventive.

In-network: Nothing

Out-of-network: Nothing, except any difference between our Plan allowance and the billed amount

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy, in children and adolescents age 6 years or older with BMI greater than or equal to 95th percentile on CDC growth charts for age and sex.
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider in children and adolescents age 6 years or older with BMI greater than or equal to 95th percentile on CDC growth charts for age and sex.
• Nutritional counseling for individuals with BMI greater than or equal to 30 kg/m² is covered as outlined in Section 5(a), Educational classes and programs.
• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

In-network: Nothing

Out-of-network: Nothing, except any difference between our Plan allowance and the billed amount

Not covered:

• Professional fees for automated lab tests
• Physical, psychiatric, or psychological exams and testing required for obtaining or continuing employment or insurance, attending schools or camps, sports physicals, or travel related to judicial or administrative proceedings or orders, or required to obtain or maintain a license of any type.
• Immunizations, boosters, and medications required for obtaining, continuing, or maintaining insurance, a license of any type, employment and/or work-related exposure, attending camps, sports physicals, or for travel; unless Section 5(a), Preventive Care coverage criteria are met.

All charges

Diagnostic and preventive services, including examination, prophylaxis (cleaning), X-rays of all types and fluoride treatment

We will pay 100% of the Plan allowance for preventive dental as follows:

• Two examinations per person per year
• Two prophylaxis (cleanings) per person per year
• Two fluoride treatments per person per year
• $150 in allowed X-ray charges per person per year

All charges in excess of the scheduled amounts listed to the left

Amalgam Restorations

Resin - Based Composite Restorations

Gold Foil Restorations

Inlay/Onlay Restorations

$21 One surface

$28 Two or more surfaces

All charges in excess of the scheduled amounts listed to the left

Simple extractions

$21 Simple extraction

All charges in excess of the scheduled amount listed to the left

Connection Vision^® Powered by EyeMed^® - Member Services: 877-808-8538

Website:  www.geha.com/HDHPvision

• You will receive a separate vision ID card from EyeMed to use for these services.
• EyeMed will process all in-network claims systematically.  Members will only be responsible for copays and amounts over allowance at the time of service.
• Out-of-network services will be paid in full at the time of service, and the member will submit an out-of-network claim form for reimbursement to the following address:

EyeMed Vision Care
Attn: OON Claims
PO Box 8504
Mason, OH 45040-7111

The following supplemental vision services are covered outside of the HDHP and are not subject to the Plan deductible.  Benefits are based on a calendar year.  The Plan allows the member to receive either contacts and frame, or frame and lens services.  Any unused portion of the funded benefit cannot be applied to offset the cost of additional services.

Reimbursement Frequency

12 months

12 months

24 months

Eye exam including dilation as necessary

Covered in full after a $5 exam copay

Reimbursed up to $45

Standard contact lens fit and follow-up

You pay no more than $55

You pay full retail price

Premium contact lens fit and follow-up

You pay no more than 90% of retail price

You pay full retail price

Any available frame at provider location

Covered in full if retail price of the frame selected is $100 or less.  For frames costing more than $100, you pay 80% of retail price over $100

Reimbursed up to $45

Standard plastic single vision

$10 materials copay

Reimbursed up to $25

Standard plastic bifocal

$10 materials copay

Reimbursed up to $40

Standard plastic trifocal

$10 materials copay

Reimbursed up to $50

Standard plastic lenticular

$10 materials copay

Reimbursed up to $80

Standard progressive lens

You pay no more than $75

Reimbursed up to $40

Premium progressive lens

Schedule 1: $95
Schedule 2: $105
Schedule 3: $120
Schedule 4: $75 copay + (80% of Retail charge) less $120 allowance

Reimbursed up to $40

UV treatment

You pay $15

You pay full retail price

Tint (solid and gradient)

You pay $15

You pay full retail price

Standard plastic scratch coating

You pay $15

You pay full retail price

Standard polycarbonate

You pay $40

You pay full retail price

Standard anti-reflective coating

You pay $45

You pay full retail price

Polarized

You pay 80% of the retail price

You pay full retail price

Photochromatic/ Transitions plastic

You pay $75

You pay full retail price

Premium anti-reflective

Price, based on manufacturer

You pay full retail price

Other add-ons

You pay 80% of the retail price

You pay full retail price

Conventional

You pay the $10 material copay for lenses costing $110 or less plus 85% on the retail price over $110

Reimbursed up to $110

Disposable

You pay the $10 material copay for lenses costing $110 or less plus the retail price over $110

Reimbursed up to $110

Medically necessary

$10 copay, paid in full, requires pre-approval by EyeMed

Reimbursed up to $250

Lasik or PRK from U.S. Laser Network

15% off retail price or 5% off promotional price

You pay full retail price

40% off the retail price for complete pair eyeglass and 15% off the retail price for conventional contact lenses after the funded benefit has been used.

You pay full retail price

The deductible applies to almost all benefits in this Section. In the You pay column, we say “no deductible” when it does not apply. When you receive covered services, you are responsible for paying the allowable charges until you meet the deductible.

100% of allowable charges until you meet the deductible of $1,650 for Self Only enrollment or $3,300 for a Self Plus One enrollment or a Self and Family enrollment when you use in-network providers.  100% of allowable charges until you meet the deductible of $3,300 for Self Only enrollment or $6,600 for a Self Plus One enrollment or a Self and Family enrollment when you use out-of-network providers.  Only plan allowance paid for services or supplies from out-of-network providers counts towards this amount.

After you meet the deductible, we pay the allowable charge (less your coinsurance) until you meet the annual catastrophic out-of-pocket maximum.

In-network: After you meet the deductible, you pay the indicated coinsurance for covered services. You may choose to pay the coinsurance from your HSA or HRA, or you can pay for them out-of-pocket.  If you have an HRA, we will withdraw the amount from your HRA if funds are available.

Out-of-network: After you meet the deductible, you pay the indicated coinsurance based on our Plan allowance and any difference between our allowance and the billed amount.

Professional services of physicians

• In physician’s office
• Office medical consultations
• Second surgical opinion
• During a hospital stay
• At home
• In an urgent care center
• Advance care planning
• Telehealth visit provided by a healthcare provider other than MDLIVE

Note: For additional telehealth benefits see Telehealth with MDLIVE below. 

In-network: 5% of the Plan Allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

MinuteClinic^®

MinuteClinic^® is available in several states and the District of Columbia.  Walk-in medical clinics are located inside select CVS Pharmacy locations and no appointment is necessary.

MinuteClinic^® is staffed by certified family nurse practitioners and physician assistants who diagnose, treat and write prescriptions for common illnesses, injuries and skin conditions. MinuteClinic^® also offers physical exams, routine vaccinations and screenings for disease monitoring. To locate a MinuteClinic^®, www.cvs.com/minuteclinic/clinic-locator or call 866-389-2727.

5% of the Plan Allowance

Telehealth with MDLIVE

Telehealth professional services for:

• Minor acute conditions (see Section 10 for definition)
• Dermatology conditions (see Section 10 for definition)

Note: For more information on telehealth benefits, please see Section 5(g). Wellness and Other Special Features.

Note: Practitioners must be licensed in the state where the patient is physically located at the time services are rendered.

Nothing

Note: HDHP members who have met their deductible will be charged by MDLIVE, but GEHA will then reimburse the member 100% of the Plan Allowance.

Tests, such as: 

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• X-rays
• Non-routine mammograms
• CT, MRI, MRA, Nuclear Cardiology and PET studies (outpatient requires preauthorization)
• Double contrast barium enemas
• Ultrasound
• Electrocardiogram and EEG
• Prostate-Specific Antigen (PSA) tests
• Specialized diagnostic genetic testing and screening (preauthorization required for genetic testing)

Note: Benefits are available for specialized diagnostic genetic testing and genetic screenings when it is medically necessary to diagnose and/or manage a patient's existing medical condition. Medical necessity is determined by the plan using evidence-based medicine. Benefits are not provided for genetic panels when some or all of the tests included in the panel are experimental or investigational or are not medically necessary.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Note: If your in-network provider uses an out-of-network lab, imaging facility or radiologist, we will pay out-of-network benefits for lab and radiology charges

In-Lab Attended Polysomnography (sleep study)

• Requires preauthorization.

Note: Refer to Section 5(c) for outpatient facility fees

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Home Polysomnography (sleep study)

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Deductible will be waived in-network for these tests and diagnoses:

• Hemoglobin A1C testing with a diagnosis of diabetes
• Low-density Lipoprotein LDL testing with a diagnosis of heart disease
• International Normalized Ratio (INR) testing with a diagnosis of liver disease and/or bleeding disorders

In-network: 5% of the Plan allowance (no deductible)

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Note: If your in-network provider uses an out-of-network lab, we will pay out-of-network benefits for lab charges.

Not covered:

• Professional fees for automated lab tests.
• Physical, psychiatric, or psychological exams and testing required for obtaining or continuing employment or insurance, attending schools or camps, sports physicals, travel related to judicial or administrative proceedings or orders, or required to obtain or maintain a license of any type.
• Immunizations, boosters, and medications required for obtaining, continuing, or maintaining insurance, a license of any type, employment and/or work-related exposure, attending camps, sports physicals, or for travel; unless Section 5(a), Preventive Care coverage criteria are met.
• Testing ordered by or on behalf of third parties (e.g., schools, courts, employers, etc.). 

All charges

Complete maternity (obstetrical) care, such as:

• Prenatal and Postpartum care
• Screening for gestational diabetes
• Delivery professional fees
• Sonograms
• Screening and counseling for prenatal and postpartum depression (see Section 5(e), Mental Health and Substance Use Disorders for treatment)

In-network: Nothing

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Doula

A doula is a non-medical trained professional who provides emotional, physical, and informational support during pregnancy, labor/delivery, and post-partum periods.  See Section 10, Definitions for additional information.

Benefits are allowable for services of a certified doula providing support for pregnancy-related care.  Coverage is limited to $1,000 per pregnancy and must include in-person support during labor and delivery when pregnancy results in birth.

Services provided by a certified doula limited to:

• Prenatal visits
• Labor and delivery support
• Postpartum visits for up to one year following birth or cessation of pregnancy
• Support during and after miscarriage, including bereavement support

In-network: All charges in excess of $1,000 (deductible applies)

Out-of-network: All charges in excess of $1,000 (deductible applies)

Breastfeeding and lactation support, supplies and counseling for each birth

Note: Refer to Section 5(a) under Durable medical equipment (DME) for obtaining breast pump and supplies.  You can obtain the breast pump and supplies from a contracted provider.

In-network: Nothing (no deductible)

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount for support and counseling

Note: Here are some things to keep in mind:

• Hospital services are covered under Section 5(c) and Section 5(b) Surgical benefits.
• As part of your coverage, you have access to in-network certified nurse midwives and board-certified lactation specialist during the prenatal and post-partum period. Your coverage also includes services provided by a certified doula as outlined below.
• You do not need to precertify your vaginal delivery; see Section 3, Maternity care for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery.  We will cover an extended stay if medically necessary, but you must precertify.
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• We will cover other care of an infant who requires non-routine treatment if we cover the infant under a Self Plus One enrollment or Self and Family enrollment.
• Home nursing visits, intravenous/infusion therapy and injections are covered the same as other medical benefits (not maternity) for diagnostic and treatment services as outlined in Section 5(a) Home health services.
• Any maternity services considered preventive will be covered by the Plan at 100% (no deductible).  See Section 5 Preventive care for additional information.

Note: When a newborn requires definitive treatment during or after the mother's hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.  In addition, circumcision is covered at the same rate as for regular medical or surgical benefits.

In-network: Nothing

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Note: Maternity care expenses incurred by a Plan member serving as a surrogate mother are covered by the Plan subject to reimbursement from the other party according to the surrogacy contract or agreement.  The involved Plan member must execute our Reimbursement Agreement against any payment she may receive under a surrogacy contract or agreement.  Expenses of the newborn child are not covered under this or any other benefit in a surrogate mother situation.

Note: Refer to Section 5(a) Educational classes and programs for information on Childbirth Education classes.

Note: See Section 5(g) for information on GEHA's Family Planning Care Program.

In-network: Nothing

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount.

Not covered:

• Home uterine monitoring devices.
• Charges related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of rape or incest.
• Charges for services and supplies incurred after termination of coverage.
• Services for birth coaching or labor support, except when provided by a certified doula.  See Section 10, Definitions.

All charges

Contraceptive counseling on an annual basis.

In-network: Nothing (no deductible)

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the HRSA list: 

• Voluntary female sterilization
• Surgically implanted contraceptives
• Injectable contraceptive drugs 
• Intrauterine devices (IUDs)
• Diaphragms

Note: See additional Family Planning and Prescription drug coverage Section 5(f) or 5(f)(a), if applicable.

Note: Your plan offers some types of voluntary female sterilization surgery coverage at no cost to members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exceptions process described below.

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

In-network: Nothing (no deductible)

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Voluntary male sterilization

In-network: 5% of the Plan allowance (after deductible)

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount.

Not covered:

• Reversal of voluntary surgical sterilizations
• Genetic counseling

All charges

Infertility is defined as the inability to conceive pregnancy within a 12-month period for individuals under age 35 (6 months for persons aged 35 or older) through unprotected intercourse or artificial insemination.  Infertility may also be established through evidence of medical history and diagnostic testing.  Infertility includes the need for medical intervention to conceive pregnancy either as an individual or with a partner, except following voluntary sterilization.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Diagnosis and treatment of infertility is covered and is specific to procedures listed below, except as shown in the Not covered section below

• Artificial insemination (AI) is a surgical procedure for the introduction of sperm or semen into the vagina, cervix, or uterus to produce pregnancy. Artificial Insemination procedures and related services and supplies may be covered when medically necessary, including:
  • Intravaginal insemination (IVI), except if performed outside of clinical setting
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
  • Fertility drugs (See Section 5(f) Prescription Drug Benefits or 5(f)(a) PDP EGWP Prescription Drug Benefits, Plan limits apply.)

Note: See Section 5(a), Lab, X-ray and other diagnostic tests for cost share associated with diagnostic testing.

Note: See Section 5(b), Surgical procedures for cost share associated with covered surgical services.

Note: Preauthorization is required, see Section 3.

Note: See Section 5(g) for information on GEHA's Family Planning Care Program.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Iatrogenic infertility (see definition in Section 10)

• Standard fertility preservation procedures (retrieval of and freezing of eggs or sperm) for members who have been diagnosed with iatrogenic infertility include:
  • the collection of sperm
  • cryopreservation of sperm
  • cryopreservation of embryo
  • collection of oocytes
  • cryopreservation of oocyte
  • benefits limited to up to 12 months of storage of sperm, oocytes and embryo
• Also includes infertility associated with medical and surgical gender affirmation

Note: Requires Preauthorization.  See Section 3.

Note: See Section 5(c) for facility related benefits.

Note: See Section 5(g) for information on GEHA's Family Planning Care Program.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Assisted reproductive technology (ART), See Section 10, Definitions (Procedures which involve surgically removing eggs from the ovaries, combining them with sperm in the laboratory, and returning them to the birthing person's body or donating them to another person), including:
  • In vitro fertilization (IVF), See Section 10, Definitions.  (A method of assisted reproduction that involves combining an egg with sperm in a laboratory) including IVF needed due to iatrogenic infertility
  • Embryo transfer and gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT)
• Charges for gestational carrier or surrogacy, including antenatal appointments and labor/delivery services
• Charges for procedures to collect, analyze, manipulate, or otherwise treat gametes (sperm and ova) when the partner or donor who produces the gamete is not a covered patient on the plan
• Collection of unfertilized eggs/sperm and storage of fertilized and/or unfertilized eggs/sperm except in cases of iatrogenic infertility
• Cost of donor egg
• Cost of donor sperm
• Elective preservation, such as egg freezing sought due to natural aging
• Fertility drugs, provided by facilities or physicians, including ovulation induction cycles while on injectable medication to stimulate the ovaries. Fertility drugs must be obtained through the pharmacy benefit, see Section 5(f), Prescription Drug Benefits and Specialty Drug Benefits.  Medications will not be covered when dispensed by other sources, including physician offices, home health agencies and outpatient hospitals.
• Genetic counseling
• Infertility services after voluntary sterilizations
• Preimplantation diagnosis, testing, and/or screening of eggs, sperm, or embryos
• Reversal of voluntary surgical sterilizations
• Services and supplies related to non-covered ART procedures, such as in vitro fertilizations or home insemination procedures
• Treatments such as artificial insemination, assisted reproductive technology, and/or in vitro fertilization prior to establishing diagnosis of infertility.  See Section 10, Definitions.

All charges

• Testing and treatment, including materials (such as allergy serum)
• Allergy injections
• Allergy testing is limited to 100 tests per person per calendar year

Note: Each individual test performed as part of a group or panel is counted individually against the 100-test limit.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: 

• Clinical ecology and environmental medicine
• Provocative food testing
• Non-FDA approved sublingual allergy desensitization drugs

All charges

• Antibiotic therapy - Intravenous (IV)/Infusion
• Total Parenteral Nutrition (TPN)
• Enteral/Tube feeding Nutrition, including Medical Foods for Inborn Errors of Metabolism (IEM).  See Section 10 for definition.
• Outpatient cardiac and pulmonary rehabilitation 
• Chemotherapy and radiation therapy (preauthorization required)

Note: High-dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed in Section 5(b), Surgical and Anesthesia Services and Section 5(f), Prescription Drug Benefits.

• Intravenous (IV)/Infusion Therapy 
• Respiratory and inhalation therapies
• Growth hormone therapy (GHT)

Note: Growth hormone (GHT) is covered under the prescription drug benefit. We only cover GHT when we preauthorize the treatment. Call 800-821-6136 for preauthorization.  We will ask you to submit information that establishes GHT is medically necessary.  Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies.  See Other services that require preauthorization in Section 3. 

Note: Most medications required for treatment therapies are available under the Prescription drug benefit. Specialty benefits may apply. Please refer to Section 5(f).

Note: Applied Behavioral Analysis Therapy is available under the Mental Health and Substance Use Disorder Benefits in Section 5(e).

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Dialysis

• Dialysis – hemodialysis and peritoneal dialysis
• GEHA needs to be notified of the first date of your dialysis for coordination of benefits. Refer to GEHA's dialysis notification form located at www.geha.com/Dialysis.
• Home dialysis training for the member and a helper are covered

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Chelation therapy except for acute arsenic, gold or lead poisoning
• Maintenance cardiac and pulmonary rehabilitation
• Topical hyperbaric oxygen therapy
• Prolotherapy
• "Grocery" food items that can routinely be obtained online or in stores (e.g., gluten-free breads)

All charges

• Up to 60 outpatient therapy visits per person per calendar year for the combined services of the following:
  • Qualified physical therapists
  • Qualified occupational therapists
  • Qualified speech therapists

Inpatient therapy services are not applied to the 60-visit benefit.

Therapy must be therapeutic, consistent with medically-accepted standards of care, and not experimental, investigational, or solely educational in nature.

Combined therapy visits may be used for rehabilitative therapy or habilitative therapy.

• Rehabilitative: Therapy is initiated to restore bodily function when there has been a total or partial loss of bodily function due to illness, surgery, or injury.
• Habilitative: Therapy is initiated to address a genetic, congenital, or early acquired disorder resulting in significant deficit of Activities of Daily Living (ADL), fine motor, or gross motor skills. Therapy services are provided to enhance functional status and is focused on developing
  skills that were never present.

Note: When you receive therapy from a qualified therapist in the outpatient setting which is medically necessary and meets the criteria for rehabilitative or habilitative therapy, your therapy is covered up to the Plan limits.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Long-term rehabilitative therapy 
• Exercise programs
• Maintenance therapy—measurable improvement is not expected or progress is no longer demonstrated.
• Hot and cold packs
• Computers, tablets, computer programs/games used in association with communication aides, internet or phone services used in conjunction with communication devices
• Hippotherapy
• Rehabilitative services intended to teach or enhance Instrumental Activities of Daily Living (therapy to promote skills associated with independent living, such as shopping, using a phone, cleaning, laundry, preparing meals, managing medications, driving, or managing money/ finances)
• Sensory Therapy, Auditory Therapy, or Sensory Integration Therapy

All charges

Provided when medically necessary following brain injury or traumatic brain injury.

Services will only be covered when provided by:

• Speech, occupational and/or physical therapists
• Psychologists
• Physicians

while practicing within their scope of care.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist.

Note: For routine hearing screening performed during a child’s preventive care visit, see Section 5 Preventive care, children.

• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants.

Note: For benefits for the devices, see Section 5(a), Orthopedic and prosthetic devices.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: 

• Hearing services that are not shown as covered
• Over-the-counter hearing aids, enhancement devices accessories or supplies

All charges

• First pair of contact lenses or standard ocular implant lenses if required to correct an impairment existing after intraocular surgery or accidental injury.
• Outpatient vision therapy for treatment of convergence insufficiency up to a maximum of 24 visits per year for ages 5-18.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Deductible will be waived in-network for this screening and diagnosis:

• Retinopathy screening with a diagnosis of diabetes

In-network: 5% of the Plan allowance (no deductible)

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Computer programs of any type, including but not limited to those to assist with vision therapy
• Eyeglasses or contact lenses and examinations for them, except for the supplemental vision plan 
• Radial keratotomy and other refractive surgeries
• Special multifocal ocular implant lenses

All charges

Routine foot care only when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Diabetic shoes and shoe inserts individually designed and fitted to offload pressure points on the diabetic foot are limited to $150 per person per calendar year

In-network: All charges in excess of $150 (no deductible) 

Out-of-network: All charges in excess of $150 (no deductible)

Not covered:

• Cutting, trimming of toenails or removal of corns, calluses, or similar routine treatment of conditions of the foot, except as stated above

All charges

• Artificial limbs and eyes
• Orthopedic braces
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
• Bioelectric, computer programmed prosthetic devices

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical procedures.  For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services Provided by a Hospital or Other Facility, and Ambulance Services.

Note: We will pay only for the cost of the standard item. Coverage for specialty items is limited to the cost of the standard item.

Note: Preauthorization may be required for orthopedic and prosthetic devices with a retail price of $1,000 or more. Refer to the back of your member ID card for the contact information. Call Customer Care for benefit coverage questions or assistance locating a provider. Healthcare providers are encouraged to call Prior Authorization number for requirements.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Over-the-counter hearing aids, enhancement devices accessories or supplies

All charges

Durable medical equipment (DME) is equipment and supplies that:

• Are prescribed by your attending physician (i.e., the physician who is treating your illness or injury)
• Are medically necessary
• Are primarily and customarily used only for a medical purpose
• Are generally useful only to a person with an illness or injury
• Are designed for prolonged use
• Serve a specific therapeutic purpose in the treatment of an illness or injury

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment.  Covered items include:

• Oxygen
• Rental of Dialysis Equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers

Note: Preauthorization may be required for Durable Medical Equipment that has a cumulative rental and/or retail price of $1,000 or more. Refer to the back of your member ID card for contact information. Call Customer Care for benefit coverage questions or assistance locating a provider.  Healthcare providers are encouraged to call the Prior Authorization number for requirements.

Note: For items that are available for purchase we will limit our benefit for the rental of durable medical equipment to an amount no greater than the purchase price. We may contact you to recommend a provider in your area to decrease your out-of-pocket expense.

Note: Coverage for specialty equipment such as specialty wheelchairs and beds is limited to the cost of the standard care and may be subject to a home evaluation.

Note: Please see the definition for Medical Necessity, in Section 10.

Note: Refer to Section 5(f) for glucose meter and diabetic supplies.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Deductible will be waived in-network for this equipment and diagnosis:

• Blood pressure monitor with a diagnosis of hypertension

In-network: 5% of the Plan allowance (no deductible)

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Breast pump and supplies:

• One personal use, double channel electric breast pump with double suction capability is purchased for pregnant or nursing members every 12-months with birth/delivery. A prescription is required when
  requesting a pump.
  • An initial all-inclusive supply kit is provided with a new pump order. Replacement supplies and supply kits are allowed when necessary for pump operation.
  • There is no cost to the member when the designated pump is obtained through a contracted provider. For more information visit www.geha.com/Maternity.

Note: Refer to Section 5(a), Maternity Care for information on Breastfeeding support and counseling.

In-network: Nothing (no deductible)

Out-of-network: All Charges

Speech generating devices (electronic voice output communication aids, which are electronic augmentative and alternative communication systems used to supplement or replace speech or writing for individuals with severe speech impairments):

• Preauthorization required
• Used for patients suffering from severe expressive speech disorders and have a medical condition that warrants the use of such device
• Requires a formal speech and language evaluation by licensed speech therapist

In-network: All charges in excess of $1,250 per calendar year 

Out-of-network: All charges in excess of $1,250 per calendar year

Wigs/cranial hair prosthesis used for hair loss due to the treatment of cancer.

Note: One wig/cranial hair prosthesis per lifetime.

In-network: All charges in excess of $350

Out-of-network: All charges in excess of $350

Not covered:

• Computers, tablets, computer programs/games used in association with communication aides, internet or phone services used in conjunction with communication devices 
• Air purifiers, air conditioners, heating pads, cold therapy units, whirlpool bathing equipment, sun and heat lamps, exercise devices (even if ordered by a doctor), and other equipment that does not meet the definition of durable medical equipment (see Section 10)
• Lifts, such as seat, chair, hydraulic, or van lifts
• Devices or programs to eliminate bed wetting
• If a member is a patient in a facility other than the member’s primary residence, or in a distinct part of a facility that provides services such as skilled nursing, rehabilitation services, or provides medical or nursing, DME will not be covered separately for rental or purchase
• Replacement of the wig/cranial hair prosthesis, maintenance and supplies
• Hair transplants or surgical procedures that involve the attachment of hair or a wig/cranial hair prosthesis to the scalp.

All charges

50 in-home intermittent visits per person per calendar year, not to exceed one visit up to six hours for specialty drug infusions or up to two hours per day for all other care when:

• A registered nurse (R.N.), a licensed practical nurse (L.P.N.) under the supervision of a registered nurse, or qualified* medical social worker (M.S.W.) provides the services;
• The attending physician orders the care;
• The physician indicates the length of time the services are needed;
• Medical social services provided by a qualified* medical social worker may be covered under the home health service benefit when the member meets the following criteria:
  • Member must be in need of home health services on an intermittent basis; home health skilled nursing, physical therapy, speech-language, or occupational therapy.
  • Member must be under the care of a physician who signs the plan of care.
  • The plan of care indicates how the services which are required necessitate the skills of a qualified* medical social worker to be performed safely and effectively.
  • In-home assessment services from a qualified* medical social worker are required to support accurate diagnosis and amelioration of social determinants of health identified as an impediment to the effective treatment of the patient’s medical condition or rate of recovery.

*Services performed by a qualified medical social worker are only eligible for reimbursement when furnished through a licensed home health agency or under the supervision of an eligible physician actively involved in the member’s care.

Note: Services are subject to review for medical necessity and appropriateness of care. 

Note: Please refer to the Specialty drug benefits in Section 5(f) Prescription Drug Benefits for information on benefits for home infusion therapy medications.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family
• Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medications
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
• Custodial care (see Section 10)
• Long-term care (see Section 10)
• Services or supplies furnished by immediate relatives or household members, such as spouse, parents, children, brothers or sisters by blood, marriage or adoption
• Hourly nursing where there is no skilled need (otherwise known as private duty nursing) or the need is beyond a two hour visit per day other than for specialty drug infusions that can require up to 6 hours of skilled nursing. Also not covered is nursing provided in the acute care
  facility, post-acute facilities (skilled nursing facilities), rehabilitation facilities, long-term acute care facilities, long term care facilities
• Ongoing licensed/unlicensed dialysis assistance in the home after initial dialysis training

All charges

Benefit for Manipulative therapy services is limited to 20 visits per person per calendar year. Services are limited to:

• Chiropractic spinal and extremities manipulative treatment.
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, and vibratory therapy.
• X-rays, used to detect and determine nerve interferences due to spinal subluxations or misalignments.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Any treatment not specifically listed as covered, including acupressure, aroma therapy, biofeedback, clinical ecology, cupping, dry needling, environmental medicine, hypnotherapy, massage therapy, naturopathic services and rolfing.
• Maintenance therapy - measurable improvement is not expected or progress is no longer demonstrated

All charges

Acupuncture:

• Benefits are limited to 20 visits per person per calendar year for medically necessary acupuncture treatments by a doctor of medicine or osteopathy, or licensed or certified acupuncture practitioner

In-network: 5% of the Plan allowance 

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Any treatment not specifically listed as covered, including acupressure, aroma therapy, biofeedback, clinical ecology, cupping, dry needling, environmental medicine, hypnotherapy, massage therapy, naturopathic services and rolfing.
• Services provided by Christian Science practitioners or facilities

All charges

Coverage is limited to:

• Tobacco cessation programs – We cover counseling sessions including proactive phone counseling, group counseling and individual counseling for adult males, pregnant and non-pregnant females, children and adolescents. Benefits are payable for up to two attempts per person per calendar year, with up to four counseling sessions per attempt.
• In addition, we cover over-the-counter (with a physician’s prescription) and prescription tobacco cessation drugs approved by the FDA. The quantity of drugs reimbursed will be subject to recommended courses of treatment. You may obtain smoking cessation drugs with your plan identification card, through the CVS Caremark Mail Service Pharmacy or a non-Network Retail pharmacy. (See filing instructions in Section 5(f), Prescription drug benefits.)

In-network: Nothing (no deductible)

Out-of-network: Nothing, except any difference between our Plan allowance and the billed amount (no deductible)

• Diabetes Education – The following program criteria needs to be met:
  • Consists of services by healthcare professionals (physicians, registered dieticians, registered nurses, registered pharmacists);
  • Designed to educate the member about medically necessary diabetes self-care upon initial diagnosis

In-network: Nothing up to the Plan allowance (no deductible)

Out-of-network: Nothing up to the Plan allowance and any difference between our allowance and the billed amount (no deductible)

• Nutritional Counseling – Provided by a dietitian with state license or statutory certification. Nutritional counseling must be ordered by a physician.

In-network: Nothing up to the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Childbirth education classes
  • One series of childbirth education classes per pregnancy, only when provided by a covered provider, see Section 3, How You Get Care.
  • Classes will be allowed up to $150, but not greater than the cost or course.

For more information visit www.geha.com/Maternity

In-network: All charges in excess of $150 (deductible applies)

Out-of-network: All charges in excess of $150 (deductible applies)

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy and non-routine colonoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies - limited to children under the age of 18 unless there is a functional defect (see Reconstructive surgery)
• Surgical treatment of severe obesity (bariatric surgery): 
  • Eligible members must be age 18 or over; or for adolescents, have achieved greater than 95% of estimated adult height and a minimum Tanner Stage of 4, and 
  • Have a minimum Body Mass Index (BMI) of 40 or greater than or equal to 35 (with at least one co-morbid condition present), and
  • Complete a multi-disciplinary surgical preparatory regimen, which includes a psychological evaluation, and
  • Have completed a 6-month plan of physician supervised diet documented within the last two years. See the clinical coverage policy at www.geha.com/Coverage-Policies for criteria of the supervised program and a complete list of preauthorization requirements, and
  • Preauthorization is required
• Insertion of internal prosthetic devices (see Section 5(a) Orthopedic and prosthetic devices for device coverage information)
• Treatment of burns
• Assistant surgeons are covered up to 20% of our allowance for the surgeon's charge for procedures when it is medically necessary to have an assistant surgeon. Registered nurse first assistants and certified surgical assistants are covered up to 15% of our allowance for the surgeon’s charge for the procedure if medically necessary to have an assistant surgeon.

Note: Post-operative care is considered to be included in the fee charged for a surgical procedure by a doctor. Any additional fees charged by a doctor are not covered unless such charge is for an unrelated condition.

Note: For female surgical family planning procedures see Section 5(a), Family Planning

Note: For male surgical family planning procedures see Section 5(a) Family Planning

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

When multiple or bilateral surgical procedures performed during the same operative session add time or complexity to patient care, our benefits are:

• For the primary procedure based on: Full Plan allowance
• For the secondary and subsequent procedure(s) based on: One-half of the Plan allowance

Note: Multiple or bilateral surgical procedures performed through the same incision are “incidental” to the primary surgery. That is, the procedure would not add time or complexity to patient care. We do not pay extra for incidental procedures.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Reversal of voluntary sterilization
• Services of a standby physician or surgeon 
• Routine treatment of conditions of the foot (see Foot care)
• Surgical treatment of hyperhidrosis unless alternative therapies such as Botox injections or topical aluminum chloride and pharmacotherapy have been unsuccessful

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance; and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm - limited to children under the age of 18 unless there is a functional defect. Examples of congenital anomalies are cleft lip, cleft palate, birth marks, and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy or lumpectomy, such as:
  • surgery to produce a symmetrical appearance of breasts
  • treatment of any physical complications, such as lymphedemas
  • breast prostheses; and surgical bras and replacements (see Section 5(a), Orthopedic and prosthetic devices for coverage)

Note: We pay for internal breast prostheses as hospital benefits if billed by a hospital. If included with the surgeon's bill, surgery benefits will apply.

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

Note: Preauthorization may be required, see Section 3.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Gender Affirming Surgery
  • Surgical treatment of gender dysphoria such as surgical change of sex characteristics including bilateral mastectomy, augmentation mammoplasty, genital reconstructive surgeries (vulvoplasty, orchiectomy, urethroplasty, penectomy, vaginoplasty, labiaplasty and clitoroplasty, hysterectomy/salpingo-oophorectomy, reconstruction of the fixed part of the urethra, metoidioplasty, phalloplasty, colpectomy/vaginectomy, colpocleisis, perineoplasty, vulvectomy, scrotoplasty, implantation of erection and/or testicular prosthesis); pectoral muscle implants; hair removal including genital electrolysis, non-genital area electrolysis or laser hair removal (e.g., face, chest); liposuction/lipofilling specific to gender affirmation; facial gender affirming surgeries such as genioplasty, jaw and/or chin reshaping, rhinoplasty, blepharoplasty, brow ptosis repair, lip shortening, scalp (hairline) advancement, hair grafts; voice modification including vocal feminization and masculinization surgery.
  • Requirements:
    • Must be 18 years of age or older, and
    • Must have documented evidence of persistent gender dysphoria, and
    • Must have evidence of well-controlled physical and mental health conditions, and
    • Must have a letter from a qualified mental health professional supporting decision for the procedure(s)
    • Preauthorization is required
  • Additional information in addition to above based on specific surgical requests:
    • Genital reconstructive surgeries require 1) 12 months of hormone therapy as appropriate for member’s gender goal, and 2) 12 months living a gender role congruent with gender identity.
    • Augmentation mammoplasty requires 1) 12 months of hormone therapy as appropriate for member’s gender goal, and 2) breast growth has concluded, and breast size has been stable for 6 months, and 3) documentation that size is not sufficient for comfort in social role.
    • Facial gender affirming surgery requires clinically significant dysphoria specifically related to the feature(s) on which procedure(s) will be performed, which causes discomfort in their social role related to gender.
    • Voice surgery (phonosurgery) requires 1) participation in a minimum of 8 weeks of voice therapy performed by a licensed speech language pathologist (See Section 5(a), Physical, occupational, and speech therapy), and 2) 12 months of appropriate hormone therapy when the desired result is a lower voice pitch.
    • Body contouring and/or liposuction/lipofilling specific to gender affirmation requires body fat redistribution and muscle mass changes related to hormone therapy have stabilized for at least 3 months.

Please refer to www.geha.com/Coverage-Policies for a complete list of criteria required for procedures.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Cosmetic Surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury if repair is initiated promptly or as soon as the member's medical condition permits
• Surgeries related to sexual dysfunction
• Surgeries to correct congenital anomalies for individuals age 18 and older unless there is a functional deficit
• Charges for photographs to document physical conditions
• Gender affirming procedures that are not medically necessary (see Section 10 for medical necessity definition).

All charges

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate, and severe functional malocclusion
• Excision of cysts and incision of abscesses unrelated to tooth structure
• Extraction of impacted (unerupted or partially erupted) teeth
• Partial or radical removal of the lower jaw with bone graft
• Excision of tori, tumors, leukoplakia, premalignant and malignant lesions, and biopsy of hard and soft oral tissues when unrelated to teeth and supporting structures
• Open reduction of dislocations and excision, manipulation, aspiration or injection of temporomandibular joints
• Removal of foreign body, skin, subcutaneous areolar tissue, reaction-producing foreign bodies in the musculoskeletal system and salivary stones and incision/excision of salivary glands and ducts
• Repair of traumatic wounds
• Incision of the sinus and repair of oral fistulas
• Surgical treatment of trigeminal neuralgia
• Repair of accidental injury to sound natural teeth such as: expenses for X-rays, drugs, crowns, bridgework, inlays and dentures. We may review X-rays and/or treatment records in order to determine benefit coverage. Masticating (biting or chewing) incidents are not considered to be accidental injuries.
• Orthognathic surgery for the following conditions:
  • Moderate or severe sleep apnea only after conservative treatment of sleep apnea has failed
  • Craniofacial congenital anomalies
  • Severe functional malocclusion not able to be corrected by conservative treatment options
  • Orthognathic procedures used for reconstruction following injury or illness causing a functional deficit
  • Orthognathic surgery requires preauthorization and is not covered for any other condition
• Frenectomy, frenotomy, or frenuloplasty when the patient has a functional deficit unrelated to teeth and their supporting structures
• Other oral surgery procedures that do not involve the teeth or their supporting structures

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Oral implants and transplants; including for the treatment of accidental injury
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone) including removal of tori for placement of dentures
• Orthodontic treatment
• Any oral or maxillofacial surgery not specifically listed as covered
• Orthognathic surgery, except as outlined above for moderate or severe sleep apnea, craniofacial congenital anomalies, severe malocclusion, or used as reconstructive procedure (even if necessary because of TMJ dysfunction or disorder)

All charges

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan.  Refer to Other services that require preauthorization in Section 3 for preauthorization procedures.

Solid organ transplants limited to:

• Allogeneic islet
• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/Lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney/Pancreas
• Liver
• Lung single/bilateral/lobar
• Pancreas

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services that require preauthorization in Section 3 for preauthorization procedures.

• Autologous tandem transplants for:
  • AL Amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below. Refer to Other services that require preauthorization in Section 3 for preauthorization procedures. 

For the diagnoses listed below, the medical necessity limitation is considered satisfied if the patient meets the staging description.

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Beta Thalassemia Major
  • Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Hemoglobinopathy
  • Immune deficiency diseases other than Severe Combined Immunodeficiency (SCID, e.g., Wiskott-Aldrich syndrome. Kostmann's syndrome, Leukocyte adhesion deficiencies) not amenable to more conservative treatments
  • Infantile malignant osteopetrosis
  • Kostmann’s syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
  • Multiple myeloma
  • Multiple sclerosis
  • Myelodysplasia/Myelodysplastic syndromes
  • Myeloproliferative disorders
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Aggressive non-Hodgkin's lymphomas (Mantle Cell lymphoma, adult T-cell leukemia lymphoma, peripheral T-cell lymphoma and aggressive Dendritic Cell neoplasms)
  • Amyloidosis
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Mantle Cell (non-Hodgkin lymphoma)
  • Medulloblastoma
  • Multiple myeloma
  • Multiple sclerosis
  • Neuroblastoma
  • Scleroderma
  • Scleroderma-SSc (Severe, progressive)
  • Systemic sclerosis
  • Testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors
  • Waldenström's macroglobulinemia

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. Refer to Other services that require preauthorization in Section 3 for preauthorization procedures:

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria (PNH), Pure Red Cell Aplasia)
  • Multiple myeloma
  • Multiple sclerosis
  • Myelodysplasia/Myelodysplastic syndromes
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell disease
• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

These blood or marrow stem cell transplants are covered in-network at a Plan-designated National Cancer Institute or National Institutes of Health approved clinical trial facility if approved by the Plan’s medical director in accordance with the Plan’s protocols. These transplants include but are not limited to the diagnoses below.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogeneic transplants for:
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle Cell anemia
• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myelodysplasia/Myelodysplastic Syndromes
  • Myeloproliferative disorders (MDDs)
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia
• Autologous Transplants for
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Aggressive non-Hodgkin lymphomas
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial Ovarian Cancer
  • Mantle Cell (Non-Hodgkin lymphoma)
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Transportation Benefit 

• We will also provide up to $10,000 per covered transplant for transportation (mileage or airfare) to a Plan-designated facility and reasonable temporary living expenses (i.e., lodging and meals) for the recipient and one other individual (or in the case of a minor, two other individuals), if the recipient lives more than 100 miles from the designated transplant facility.  
• Transportation benefits are payable for follow-up care up to one year following the transplant. The transportation benefit is not available for cornea transplants. You must contact Customer Care at 800-821-6136 for what are considered reasonable temporary living expenses. 
• Transportation benefits are only payable when GEHA is the primary payor.

All charges in excess of $10,000

Donor expenses

• We will cover donor screening tests and donor search expenses for up to four potential donors of organ/tissue transplants.
• We cover related medical and hospital expenses of the donor when we cover the recipient.

Note: All allowable charges incurred for a surgical transplant, whether incurred by the recipient or donor will be considered expenses of the recipient and will be covered the same as for any other illness or injury subject to the limits stated below. This benefit applies only if the recipient is covered by the Plan and if the donor’s expenses are not otherwise covered.

Notes:

• If you are a participant in a clinical trial, please see Section 9, Clinical Trials, for coverage details.
• The process for preauthorizing transplants is more extensive than the normal process. Before your initial evaluation as a potential candidate for a transplant procedure, you or your doctor must contact GEHA's Medical Management Department so we can arrange to review the clinical results of the evaluation and determine if the proposed procedure meets our definition of “medically necessary” and is on the list of covered transplants. Coverage for the transplant must be authorized in advance, in writing. 
• The transplant must be performed at a Plan-designated transplant facility to receive maximum benefits. GEHA uses a defined transplant network, which may be different than the Preferred Provider Network.
• If benefits are limited to $100,000 per transplant, included in the maximum are all charges for hospital, medical and surgical care incurred while the patient is hospitalized for a covered transplant surgery and subsequent complications related to the transplant. Outpatient expenses for chemotherapy and any process of obtaining stem cells or bone marrow associated with bone marrow transplant (stem cell support) are included in benefits limit of $100,000 per transplant. Tandem bone marrow transplants approved as one treatment protocol are limited to $100,000 when not performed at a Plan-designated facility. All treatment within 120 days following the transplant is subject to the $100,000 limit except expenses for aftercare. Outpatient prescription drugs are not a part of the $100,000 limit.
• Simultaneous transplants such as kidney/pancreas, heart/lung, heart/ liver, are considered as one transplant procedure and are limited to $100,000 when not performed at a Plan-designated transplant facility.
• Chemotherapy and procedures related to bone marrow transplantation must be performed only at a Plan-designated transplant facility to receive maximum benefits.
• We will pay for a second transplant evaluation recommended by a physician qualified to perform the transplant, if: the transplant diagnosis is covered and the physician is not associated or in practice with the physician who recommended and will perform the transplant. A third transplant evaluation is covered only if the second evaluation does not confirm the initial evaluation.

Services are paid at regular Plan benefits.

Note: See Sections 5(a) through 5(f) for applicable services and benefits.

If precertification is not obtained or a Plan-designated transplant facility is not used, our allowance will be limited for hospital and surgery expenses up to a maximum of $100,000 per transplant. If we cannot refer a member in need of a transplant to a designated facility, the $100,000 maximum will not apply.

Not covered:

• Services or supplies for or related to surgical transplant procedures (including administration of high-dose chemotherapy) for artificial or human organ/tissue transplants not listed as specifically covered
• Donor screening tests and donor search expenses, except those listed above

All charges

Professional fees for the administration of anesthesia in: 

• Hospital (inpatient)
• Hospital outpatient department
• Ambulatory surgical center
• Office

Note: We cover anesthesia services related to dental procedures when necessitated by a non-dental physical impairment and the patient qualifies for dental treatment in a hospital or outpatient facility (see Section 5(c) for facility coverage). We do not cover the dental procedures.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered

• Anesthesia related to non-covered surgeries or procedures. 

All charges

Room and board, such as:

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

Note: We only cover a private room if we determine it to be medically necessary. Otherwise, we will pay the hospital’s average charge for semiprivate accommodations. The remaining balance is not a covered expense. If the hospital only has private rooms, we will cover the private room rate.

Note: When the hospital bills a flat rate, we prorate the charges to determine how to pay them, as follows: 30% room and board and 70% other charges.

Other hospital services and supplies, such as:

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Blood or blood plasma, if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home 

Note: We base payment on whether the facility, or a healthcare professional bill for the services or supplies. For example, when the hospital bills for its nurse anesthetists’ services, we pay hospital benefits and when the anesthesiologist bills, we pay surgery benefits.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance plus the difference between the Plan allowance and the billed amount

Maternity care – Inpatient hospital

Room and board, such as:

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

Note: Here are some things to keep in mind:

• You do not need to precertify your normal delivery; see Section 3, Maternity care for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an extended stay if medically necessary, but you must precertify.

Other hospital services and supplies, such as:

• Delivery room, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Blood or blood plasma, if not donated or replaced
• Dressings and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home 

Note: We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. 

Note: We will cover other care of an infant who requires non-routine treatment if we cover the infant under a Self and Family or Self Plus One enrollment. Surgical benefits, not maternity benefits, apply to circumcision. 

Note: Maternity care expenses incurred by a Plan member serving as a surrogate mother are covered by the Plan subject to reimbursement from the other party according to the surrogacy contract or agreement. The involved Plan member must execute our Reimbursement Agreement against any payment she may receive under a surrogacy contract or agreement. Expenses of the newborn child are not covered under this or any other benefit in a surrogate mother situation.

In-network: Nothing

Out-of-network: 35% of the Plan allowance plus the difference between the Plan allowance and the billed amount

Not covered:

• Any part of a hospital admission that is not medically necessary (see Section 10, Definitions), such as when you do not need acute hospital inpatient (overnight) care but could receive care in some other setting without adversely affecting your condition or the quality of your medical care. Note: In this event, we pay benefits for services and supplies other than room and board and in-hospital physician care at the level they would have been covered if provided in an alternative setting.
• Any part of a hospital admission that is related to a non-covered surgery or procedure.
• Custodial care (See Section 10, Definitions)
• Long-term care (See Section 10, Definitions)
• Non-covered facilities such as nursing homes, schools
• Personal comfort items such as phone, television, barber services, guest meals and beds
• Private nursing care

All charges

Precertification is required in advance of admission.

Note: Out-of-network facilities must, prior to admission, agree to abide by the terms established by the Plan for the care of the particular member and for the submission and processing of related claims.

Room and board, such as:

• Ward, semiprivate, or intensive care accommodation
• General nursing care
• Meals and special diets
• Ancillary charges
• Covered therapy services when billed by the facility (see Section 5(e), Professional services for services billed by professional providers.)

Note: We only cover a private room if we determine it to be medically necessary. Otherwise, we will pay the hospital's average charge for semiprivate accommodations. The remaining balance is not a covered expense. If the hospital only has private rooms, we will cover the private room rate.

Note: When the hospital bills a flat rate, we prorate the charges to determine how to pay them, as follows: 30% room and board and 70% other charges.

Note: We limit covered facilities for medically necessary treatment to a hospital and/or RTC.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Benefits are not available for non-covered services, including:

• Pastoral, marital, educational counseling or training services
• Therapy for sexual dysfunction or inadequacy
• Services performed by a non-covered provider
• Treatment for learning and intellectual disabilities
• Travel time to the member’s home to conduct therapy
• Services rendered or billed by schools, halfway houses, sober homes, group homes, similar types of facilities or billed by their staff
• Marriage counseling
• Services that are not medically necessary
• The following services are not covered as a part of any inpatient or outpatient mental health or substance use disorder treatment services: respite care; outdoor residential programs; recreational therapy; educational therapy or classes; Outward Bound programs; equine therapy provided during the approved stay; personal comfort items, such as guest meals and beds, phone, television, beauty and barber services; custodial or long-term care.

Note: We cover professional services as described in Section 5(e), Professional services when they are provided and billed by a covered professional provider acting within the scope of his or her license.

All charges

• Operating, recovery, observation, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood or blood plasma, if not donated or replaced
• Pre-surgical testing
• Dressings, splints, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
• Outpatient cardiac and pulmonary rehabilitation
• Observation care is covered up to a maximum of 48 hours as an outpatient hospital service, see Section 10, Definitions

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

Note: Please refer to Section 5(f) for information on benefits for Specialty drug benefits medications dispensed by hospitals.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Maintenance cardiac and pulmonary rehabilitation
• Services that are related to a non-covered surgery or procedure

All charges

Maternity care – Outpatient hospital or birth center

• Delivery room, recovery, observation, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood or blood plasma, if not donated or replaced
• Pre-surgical testing
• Dressings and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia services

Note: Maternity care expenses incurred by a Plan member serving as a surrogate mother are covered by the Plan subject to reimbursement from the other party according to the surrogacy contract or agreement. The involved Plan member must execute our Reimbursement Agreement against any payment she may receive under a surrogacy contract or agreement. Expenses of the newborn child are not covered under this or any other benefit in a surrogate mother situation.

In-network: Nothing

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Inpatient confinement at a skilled nursing facility when the following criteria is met:

• Precertification is obtained prior to admission
• Benefits are limited to 50 days per calendar year.

Note: When Medicare Part A is primary, the initial days paid in full by Medicare are considered part of the 50 days per calendar year benefit.

In-network: 5% of the Plan allowance (calendar year deductible applies)

Out-of-network: 35% of the Plan allowance plus the difference between the Plan allowance and the billed amount (calendar year deductible applies)

Hospice is a coordinated program of maintenance and supportive care for the terminally ill provided by a medically supervised team under the direction of a plan approved independent hospice administration.

• We pay up to $30,000 for hospice care provided in an outpatient setting or for room, board, and care while receiving hospice care in an inpatient setting. Services may include a combination of inpatient and outpatient care up to a maximum of $30,000.

These benefits will be paid if the hospice care program begins after a person’s primary doctor certifies terminal illness and life expectancy of six months or less and any services or inpatient hospice stay that is part of the program is:

• Provided while the person is covered by this Plan
• Ordered by the supervising doctor
• Charged by the hospice care program
• Provided within six months from the date the person entered or reentered (after a period of remission) a hospice care program

Remission is the halt or actual reduction in the progression of illness resulting in discharge from a hospice care program with no further expenses incurred. A readmission within three months of a prior discharge is considered as the same period of care. A new period begins after three months from a prior discharge with maximum benefits available.

In-network: 5% up to the Plan limits

Out-of-network: 35% up to the Plan limits

Not covered: 

• Charges incurred during a period of remission, charges incurred for treatment of a sickness or injury of a family member that are covered under another plan provision, charges incurred for services rendered by a close relative, bereavement counseling, funeral arrangements, pastoral counseling, financial or legal counseling, homemaker or caretaker services

All charges

Local ambulance service, within 100 miles*, only when medically necessary and the patient cannot be transported by other means to:

• the first hospital where treated
• from the first hospital to the next nearest hospital or other medical facility with medically necessary treatment, only if necessary, treatment is unavailable or unsuitable at the first hospital
• the home, only when the patient requires the assistance of medically trained personnel during transportation

*Member is responsible for all charges for 100 miles or greater when medically necessary treatment is available within 100 miles.

In-network: 5% of the Plan allowance within 100 miles*

Out-of-network: 5% of the Plan allowance and any difference between our allowance and the billed amount, within 100 miles*

Air ambulance to nearest hospital is only covered when medically necessary, and the severity of the member's condition warrants immediate evacuation, and:

• the pick-up location is inaccessible by other means, or 
• the transportation by any other means could further endanger the member's health, and
• the patient is transported to the nearest facility where medically necessary treatment is available.

Note: Medical Necessity review is required for all air ambulance

In-network: 5% of the Plan allowance

Out-of-network: 5% of the Plan allowance

Not covered:

• Ambulance transportation when the patient does not require the assistance of medically trained personnel and can be safely transferred (or transported) by other means
• All ground ambulance charges for 100 miles or greater when medically necessary treatment is available within 100 miles
• Non-ambulance transportation including wheelchair van, gurney van, commercial air flights, or any other vehicle not licensed as ambulance
• Air ambulance will not be covered if transport is beyond the nearest available medically suitable facility, but is requested by patient or physician for continuity of care or other reasons

All charges

• Non-surgical physician services and supplies
• Related outpatient physician care
• Surgical care
• Treatment outside a hospital or in the outpatient/emergency room department of a hospital or urgent care facility

Note: Emergency room charges associated directly with an inpatient admission are considered “Other charges” under Inpatient Hospital Benefits in Section 5(c) and are not part of this benefit, even though an accidental injury may be involved. This provision also applies to dental care required as a result of accidental injury to sound natural teeth. Masticating (chewing) incidents are not considered to be accidental injuries.

In-network: 5% of the Plan allowance

Out-of-network: 5% of the Plan allowance, plus the difference between the billed amount and the Plan allowance

Outpatient medical or surgical services and supplies billed by a hospital for emergency room treatment.

Note: We will provide in-network benefits if you are admitted to an out-of-network hospital due to a medical emergency.

In-network: 5% of the Plan allowance

Out-of-network: 5% of the Plan allowance

Outpatient medical services and supplies billed by an urgent care facility, except in cases of Accidental Injury.

In-network: 5% of the Plan allowance 

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Local ambulance service within 100 miles*, only when medically necessary and the patient cannot be transported by other means to:

• the first hospital where treated
• from the first hospital to the next nearest hospital or other medical facility with medically necessary treatment, only if necessary treatment is unavailable or unsuitable at the first hospital
• the home, only when the patient requires the assistance of medically trained personnel during transportation

*Member is responsible for all charges for 100 miles or greater when medically necessary treatment is available within 100 miles.

Note: See 5(c) for non-emergency service.

In-network: 5% of the Plan allowance within 100 miles*

Out-of-network: 5% of the Plan allowance and any difference between our allowance and the billed amount, within 100 miles*

Air ambulance to nearest hospital is only covered when medically necessary, and the severity of the member's condition warrants immediate evacuation, and: 

• the pick-up location is inaccessible by other means, or 
• transportation by any other means could further endanger the member's health, and
• the patient is transported to the nearest facility where medically necessary treatment is available.

Note: Medical Necessity review is required for all air ambulance

In-network: 5% of the Plan allowance

Out-of-network: 5% of the Plan allowance

Not covered:

• Ambulance transportation when the patient does not require the assistance of medically trained personnel and can be safely transferred (or transported) by other means
• All ground ambulance charges for 100 miles or greater when medically necessary treatment is available within 100 miles
• Non-ambulance transportation including wheelchair van, gurney van, commercial air flights, or any other vehicle not licensed as ambulance
• Air ambulance will not be covered if transport is beyond the nearest available medically suitable facility, but is requested by patient or physician for continuity of care or other reasons

All charges

We cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of behavioral health conditions including psychiatric conditions, mental illness or disorders, and substance use disorders. Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Treatment and counseling (including individual, group therapy or in-home therapy visits)
• Diagnosis and treatment of substance use disorders, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting (requires preauthorization)
• Electroconvulsive therapy (ECT)
• Inpatient professional fees
• Telehealth visit provided by a healthcare provider other than MDLIVE.

Note: For additional telehealth benefits see Telehealth with MDLIVE below.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

First primary care or specialist visit for the management of a mental health condition as a follow up within 30 days of a mental health inpatient confinement.

In-network: Nothing

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Telehealth with MDLIVE

Behavioral health professional telehealth services for:

• Mental health counseling
• Substance use disorder counseling

Note: For more information on telehealth benefits, please see Section 5(g), Wellness and Other Special Features.

Note: Practitioners must be licensed in the state where the patient is physically located at the time services are rendered.

Nothing

Note: HDHP members who have met their deductible will be charged by MDLIVE, but GEHA will then reimburse the member 100% of the Plan Allowance.

Professional Services for the first 5 visits per year, per pregnancy for office-based treatment of prenatal and postpartum depression. Services include:

• Diagnostic evaluation
• Medication evaluation and management (pharmacotherapy)
• Treatment and counseling (including individual, group, or in-home therapy visits)

In-network: Nothing after deductible for the first 5 visits for treatment of prenatal and postpartum depression; after 5 visits, 5% of the plan allowance.

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount.

• Required Diagnosis of ASD (Autism Spectrum Disorder) by a provider qualified to make the diagnosis: Board Certified Behavior Analyst (BCBA), psychiatrist, pediatrician. 
• Initiation of treatment and on-going treatment and intensity of treatment must be medically necessary and appropriate for the child.
• A Functional Behavioral Assessment must be submitted prior to treatment and must demonstrate appropriateness of ABA Therapy.
• Services must be directed by a Board Certified Behavior Analyst and services may be provided by Board Certified Assistant Behavior Analysts (BCaBA) or Registered Behavior Technicians (RBTs).
• Approval of on-going services requires demonstrated involvement by family. 
• Services provided by the school are not reimbursable by the health plan.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment (requires preauthorization for testing exceeding 8 hours/calendar year)

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Room and board, such as:

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets 
• Ancillary charges

Note: We only cover a private room if we determine it to be medically necessary. Otherwise, we will pay the hospital's average charge for semiprivate accommodations. The remaining balance is not a covered expense.  If the hospital only has private rooms we will cover the private room rate.

Note: When the facility bills a flat rate, we prorate the charges to determine how to pay them, as follows: 30% room and board and 70% other charges.

Note: We limit covered facilities for medically necessary substance use disorder treatment to a hospital and/or RTC.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Precertification is required in advance of admission. 

Note: Out-of-network facilities must, prior to admission, agree to abide by the terms established by the Plan for the care of the particular member and for the submission and processing of related claims. 

Room and board, such as:

• Ward, semiprivate, or intensive care accommodations 
• General nursing care
• Meals and special diets
• Ancillary charges
• Covered therapy services when billed by the facility (see Professional services for services billed by professional providers.) 

Note: We only cover a private room if we determine it to be medically necessary. Otherwise, we will pay the hospital's average charge for semiprivate accommodations. The remaining balance is not a  covered expense. If the hospital only has private rooms, we will cover the private room rate.  

Note: When the facility bills a flat rate, we prorate the charges to determine how to pay them, as follows: 30% room and board and 70% other charges. 

Note: We limit covered facilities for medically necessary treatment to a hospital and/or RTC.

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Services such as partial hospitalization or intensive day treatment programs

In-network: 5% of the Plan allowance

Out-of-network: 35% of the Plan allowance and any difference between our allowance and the billed amount

Outpatient services and supplies billed by a hospital for emergency room treatment

Note: We pay hospital benefits if you are admitted.

In-network: 5% of the Plan allowance

Out-of-network: 5% of the Plan allowance and any difference between our allowance and the billed amount

Benefits are not available for non-covered services, including:

• Pastoral, marital, educational counseling or training services
• Therapy for sexual dysfunction or inadequacy
• Services performed by a non-covered provider
• Treatment for learning and intellectual disabilities
• Travel time to the member's home to conduct therapy
• Services rendered or billed by schools, halfway houses, sober homes, or billed by their staff
• Marriage counseling
• Services that are not medically necessary
• The following services are not covered as a part of any inpatient or outpatient mental health or substance use disorder services: respite care; outdoor residential programs; recreational therapy; educational therapy or classes; Outward Bound programs; equine therapy provided during the approved stay; personal comfort items, such as guest meals and beds, phone, television, beauty and barber services; custodial or long-term care.
• Testing ordered by or on behalf of third parties (e.g., schools, courts, employers, etc.).
• Hypnotherapy
• Physical, psychiatric, or psychological exams and testing required for obtaining or continuing employment or insurance, attending schools or camps, sports physicals, travel related to judicial or administrative proceedings or orders, or required to obtain or maintain a license of any type.

Note: We cover professional services as described in Section 5(f) Professional services when they are provided and billed by a covered professional provider acting within the scope of his or her license.

All charges

There are important features you should be aware of. These include:

• Drug coupon/copay cards: We do not honor or coordinate benefits with drug coupon/copay cards. You are responsible for your copay or coinsurance as indicated in this brochure.
• Who can write your prescription: A licensed physician or dentist, and in states allowing it, licensed or certified Physician Assistant, Nurse Practitioner or Psychologist must prescribe your medication. In addition, your mailing address must be within the United States or include an APO address.
• Where you can obtain them: You may fill the prescription at a participating network retail pharmacy, CVS Caremark Mail Service Pharmacy, or through a non-network pharmacy. We pay a higher level of benefits when you use a network pharmacy.
• How to obtain preauthorization: If you are filling a medication requiring a preauthorization for medical necessity, please call 855-240-0536. At Mail, CVS Caremark will conduct the preauthorization for medical necessity review.
• Your benefit includes the Advanced Control Specialty Formulary (ACSF); please see CVS Caremark Formulary for additional information.
• Our prescription benefit may include step therapy. GEHA’s preauthorization process may include step therapy which requires you to use a generic/preferred medication(s) before a non-preferred medication is covered. If you are filling a non-preferred medication and have already tried the generic/preferred medication(s), the non-preferred medication will be dispensed for the applicable plan copayment. When you try to fill a non-preferred medication and you have not tried the generic/preferred medication(s), the pharmacist will contact your physician to notify them of the generic/preferred alternative. If the physician approves, a generic/preferred medication will be dispensed for the applicable plan copayment. If the physician does not approve, a preauthorization review will be initiated to determine the medical necessity of the non-preferred drug. Unless there are documented clinical reasons why you cannot take the generic/preferred drug, you may still obtain the non-preferred drug but you will be responsible for 100% of the cost, which will not apply to your annual out-of-pocket maximum. If the preauthorization for the non- referred medication is approved, you will be responsible for the applicable plan copayment.

• Compound Medication: A compound drug is a medication made by combining, mixing or altering ingredients in response to a prescription, to create a customized drug that is not otherwise commercially available. Some ingredients often found in compounds including, but not limited to, over-the-counter (OTC) products, experimental or investigational agents, bulk powders, bulk chemicals, and certain bases, are not covered through the prescription benefit. Coverage for other ingredients commonly found in compound prescriptions may also require preauthorization before coverage is allowed.
  • CVS Caremark Mail Service Pharmacy can compound some medications. When a claim is submitted for online processing or direct reimbursement of a compound medication, the pricing is based on the contractual discounts plus a professional fee and any applicable sales tax. Pharmacies must submit all ingredients in a compound prescription as part of the claim for both online claims and paper claim submissions. At least one of the ingredients in the compound prescription claim must require a physician’s prescription in order to be covered by the Plan. You are responsible for the appropriate brand name or generic copay or coinsurance based on the compound ingredients. Preauthorization may be required. Experimental or investigational drugs are not FDA approved and are not covered by GEHA. If the compound includes an investigational drug, the compound will not be covered.
  • If the mail order pharmacy cannot accommodate your prescription, please consult a participating retail pharmacy. Ask the pharmacist to submit your claim electronically or online. If the retail pharmacy is unable to submit the compound medication claim electronically to CVS Caremark, you will pay the full cost of the medication and submit the claim for reimbursement. Make sure the pharmacy provides a list of the National Drug Codes (NDCs), quantity and cost for every ingredient in the compound medication and include this information on your claim. Compound medications are limited to a 30-day supply. The only exceptions for filling greater than a 30-day supply are through CVS Caremark Mail Service Pharmacy, CVS Pharmacy or a CVS Caremark Extended Day Supply (EDS) network pharmacy. Please confirm your compounding pharmacy meets this requirement or contact CVS Caremark at 844-443-4279 prior to filling the prescription. Mail the claim to CVS Caremark, PO Box 52136, Phoenix, AZ 85072-2136 or submit for reimbursement online via Caremark web portal (www.caremark.com) or Caremark mobile app (available for Android and Apple). Claim calculations, copayments, and reimbursement for direct claims is performed using an industry standard reimbursement method for compounds.

You may purchase the following medications and supplies prescribed by a physician from either a pharmacy or by mail.  Drugs and medications (including those administered during a non-covered admission or in a non-covered facility) that by Federal Law of the United States require a physician's prescription for their purchase, except those listed as not covered;

• Diabetic medications and supplies, such as:
  • Insulin;
  • Needles and syringes for the administration of covered medications;
  • Blood glucose meter - provided at no charge by the manufacturer, through the CVS Caremark Mail Service Pharmacy, call 877-418-4746;
• Drugs to treat gender dysphoria (gonadotropin-releasing hormone (GnRH) antagonists and testosterones);
• Drugs associated with artificial insemination and/or drugs associated with up to 3 cycles of in vitro fertilization (IVF) treatment. Prior authorization is required; 
• Medications prescribed to treat obesity. Prior authorization is required; 
• Prenatal vitamins for pregnant women;
• FDA approved contraceptive drugs and devices for women; and
• Covered ostomy supplies (please include the manufacturer’s product number to ensure accurate fill of the product).

Your prescription drug program includes use of the CVS Caremark Formulary which is developed by an independent panel of doctors and pharmacists who ensure the medications are clinically appropriate and cost-effective. Formularies are reviewed quarterly, and medications may change formulary status. You will receive notification if your cost share increases due to a formulary change. In an effort to continue to help promote affordable and clinically appropriate products, there are a select number of drugs that are excluded from the formulary and not covered by the Plan. For these drugs, generics and/or alternative medications in the same drug class are readily available. If one of these excluded drugs is medically necessary, a preauthorization for medical necessity is required. We do not cover excluded drugs unless we determine the medical necessity to treat a medical condition based on objective clinical data. New drugs and supplies may be added to the list as they are introduced and may require medical necessity review until the formulary status is determined. Please refer to our website at www.geha.com or call CVS Caremark at 844-4-GEHARX or 844-443-4279 for a list of excluded medications and/or formulary alternatives covered by the Plan.

Our benefit includes the Advanced Control Specialty Formulary (ACSF). The ACSF may reduce your out-of-pocket costs yet may limit your options due to a strict formulary. The ACSF focuses on specialty medications that are very similar to one another, with similar effectiveness and safety. The formulary incorporates step therapy, where a generic/preferred medication is used prior to a non-preferred medication. The ACSF is reviewed quarterly and medications may change formulary status including preferred to non-preferred and non-preferred to preferred. Impacted members will be notified of the change at least 60 days in advance. If the formulary change will lower your cost share for the medication(s), you have the option to speak with your doctor about a prescription for the lower cost alternative. Please visit our website at www.geha.com to view the most current list of specialty drugs. You may also call CVS Specialty at 800-237-2767.

Specialty category examples include: Acromegaly, Alcohol/Opioid Dependency, Allergic Asthma, Alpha-1 Antitrypsin Deficiency, Anemia, Cardiac Disorders, Central Precocious Puberty (CPP), Cryopyrin-Associated Periodic Syndromes, Cushing’s Syndrome, Cystic Fibrosis, Dupuytren’s Contracture, Electrolyte Disorder, Gastrointestinal Disorders-Other, Gout, Growth Hormone and Related Disorders, Hematopoietics, Hemophilia, Von Willebrand Disease and Related Bleeding Disorders, Hepatitis, Hereditary Angioedema, HIV Medications, Hormonal Therapies, Immune Deficiencies and Related Disorders, Immune (Idiopathic) Thrombocytopenic Purpura, Infectious Disease, Inflammatory Bowel Disease, Iron Overload, Lipid Disorders, Lysosomal Storage Disorders, Movement Disorders, Multiple Sclerosis, Muscular Dystrophy, Neuromuscular Disorders, Neutropenia, Oncology— Injectable, Oncology—Oral/Topical, Osteoporosis, Paroxysmal Nocturnal Hemoglobinuria, Phenylketonuria, Pre-Term Birth, Psoriasis, Pulmonary Arterial Hypertension, Renal Disease, Respiratory Syncytial Virus, Retinal Disorders, Rheumatoid Arthritis, Seizure Disorders, Systemic Lupus Erythematosus, Transplant and Urea Cycle Disorders

Changes to the formulary are not considered benefit changes.

Your physician may be contacted to discuss your prescriptions for drugs that are excluded by the Plan’s formulary. No change in the medication prescribed will be made without your physician’s approval.

Any rebates or savings received by the Plan on the cost of drugs purchased under this Plan from drug manufacturers are credited to the health plan and are used to reduce health care costs. Changes to the formulary are not considered benefit changes.

For other commercial coverage: If you also have drug coverage through another group health insurance plan and we are your secondary insurance, follow these procedures:

If you obtain your prescription from a retail pharmacy using your primary insurance plan:

1. Present prescription ID cards from both your primary insurance plan and GEHA.
2. If able, the pharmacy will electronically process both your primary and secondary claims and the pharmacist will tell you if you have any remaining copay/coinsurance to pay.
3. If the pharmacy cannot electronically process the secondary claim, purchase your prescription using the prescription ID card issued by your primary insurance carrier and pay any copay/coinsurance required by the primary insurance. Then, mail your pharmacy receipt and primary Explanation of Benefits (EOB) to CVS Caremark for consideration of possible reimbursement through your GEHA, secondary benefit. Submit these claims to CVS Caremark, PO Box 52136, Phoenix, AZ 85072-2136 or submit for reimbursement online via Caremark web portal (www.caremark.com) or Caremark mobile app (available for Android and Apple).

If you obtain your prescription from a mail service pharmacy using your primary insurance plan, your GEHA reimbursement will be based on the GEHA retail Plan Benefit:

1. Purchase your prescription using the prescription ID card issued by your primary insurance carrier and pay any copay/coinsurance required by the primary insurance.
2. Then, mail your pharmacy receipt and primary EOB to CVS Caremark for consideration of possible reimbursement through your GEHA, secondary benefit. Submit these claims to CVS Caremark, PO Box 52136, Phoenix, AZ 85072-2136 or submit for reimbursement online via Caremark web portal (www.caremark.com) or Caremark mobile app (available for Android and Apple).

If your primary insurance does not provide a prescription ID card:

1. Purchase your drug from the pharmacy and submit the bill to your primary insurance.
2. When the primary insurance has made payment, file the claims and the EOB with CVS Caremark for consideration of possible reimbursement using your secondary benefit. Submit these claims to CVS Caremark, PO Box 52136, Phoenix, AZ 85072-2136 or submit for reimbursement online via Caremark web portal (www.caremark.com) or Caremark mobile app (available for Android and Apple).

In any event, if you use GEHA’s plan ID card when another insurance plan is primary, you will be responsible for reimbursing GEHA any amount in excess of our secondary benefit. If another insurance plan is primary, you should use their drug benefit.

When coordination of benefits apply, reimbursement is based on GEHA’s retail Plan allowable benefit. Our secondary and tertiary claim payment is the lesser of:

• what GEHA would have paid in the absence of other primary coverage or
• the balance due after the primary carrier’s payment.

Note: GEHA secondary and tertiary member responsibility could be higher than GEHA's primary copay/coinsurance, depending upon the primary plan's allowable and the primary payment.

Should Medicare rules change on prescription drug coverage, we reserve the right to require you to use your Medicare coverage as the primary insurance for these drugs.

For Medicare Part B insurance coverage: If Medicare Part B is primary, discuss with the retail pharmacy and/or CVS Caremark the options to submit Medicare covered medications and supplies to allow Medicare to pay as the primary carrier. Prescriptions typically covered by Medicare Part B include diabetes supplies (test strips, meters), specific medications used to aid tissue acceptance from organ transplants, certain oral medications used to treat cancer, and ostomy supplies. 

Retail - When using a retail pharmacy for eligible Medicare Part B medication or supplies, present the Medicare ID card. Request the retail pharmacy bill Medicare as primary. Most independent pharmacies and national chains are Medicare providers. To locate a retail pharmacy that is a Medicare Part B participating provider, visit the Medicare website at www.medicare.gov/supplier/home.asp or call Medicare Customer Service at 800-633-4227.

Mail Order - To receive your Medicare Part B-eligible medications by mail, send your mail-order prescriptions to CVS Caremark. The CVS Caremark Mail Service Pharmacy will review the prescriptions to determine whether it could be eligible for Medicare Part B coverage and submit to Medicare if appropriate. Please note, the CVS Caremark Mail Service Pharmacy is not a Medicare Part B provider for diabetic supplies. You must use a retail pharmacy willing to bill Medicare as primary for diabetic supplies. 

For Medicare Part D insurance coverage: GEHA supplements the coverage you get with your Medicare Part D prescription drug plan. Your Medicare drug plan provides your primary prescription drug benefit. GEHA provides your secondary prescription drug benefit. To ensure that you maximize your benefits, use a pharmacy in network for both the GEHA Plan and your Medicare Part D plan, and provide both plan ID cards when filling a prescription allowing the pharmacy to coordinate coverage on your behalf.

GEHA has several programs to promote patient safety. Through these programs, we work to ensure safe and appropriate quantities of medication are being dispensed. The result is improved care and safety for our members. Patient safety programs include:

• Preauthorization - Approval must be obtained for certain prescription drugs and supplies before providing benefits for them.
• Quantity allowances - Specific allowances are in place for certain medications, based on manufacturer and FDA recommended guidelines.
• Pharmacy utilization - GEHA reserves the right to maximize your quality of care as it relates to the utilization of pharmacies.

GEHA will participate in other approved managed care programs, as deemed necessary, to ensure patient safety.

You may fill your prescription at any participating retail pharmacy. To locate participating pharmacies, call CVS Caremark at 844-4-GEHARX or 844-443-4279 or visit www.caremark.com. To receive maximum savings you must present your plan ID card at the time of each purchase, and your enrollment information must be current and correct. In most cases, you simply present the plan ID card together with the prescription to the pharmacist.

Through this service, you may receive up to a 90-day supply per prescription of maintenance medications for drugs which require a prescription, ostomy supplies, diabetic supplies and insulin, syringes and needles for covered injectable medications, and oral contraceptives. Some medications may not be available in a 90-day supply from CVS Caremark Mail Service Pharmacy even though the prescription is for 90 days. Although insulin, syringes, diabetic supplies and ostomy supplies do not require a physician’s prescription, to obtain through CVS Caremark Mail Service Pharmacy you should obtain a prescription (including the product number for ostomy and insulin pump supplies) from your physician for a 90-day supply.

Some medications may require approval by CVS Caremark or GEHA. Not all drugs are available through CVS Caremark. In order to use CVS Caremark Mail Service Pharmacy, your prescriptions must be written by a licensed prescriber in the United States. In addition, your mailing address must be within the United States or include an APO address.

To order new prescriptions, ask your physician to prescribe needed medication for up to a 90-day supply, plus refills, if appropriate. Complete the information on the Ordering Medication Form found at www.geha.com/Medication; enclose your prescription and the correct copayment.

Under regular circumstances, you should receive your medication within approximately 14 days from the date you mail your prescription. You will also receive reorder instructions. If you have any questions or need an emergency consultation with a registered pharmacist, you may call CVS Caremark at 844-4-GEHARX or 844-443-4279 available 24 hours a day, 7 days a week. Forms necessary for refills will be provided each time you receive a supply of medication.

Mail to:

CVS Caremark
PO Box 659541
San Antonio, TX 78265-9541

Fax: You can ask your physician to fax your prescriptions to CVS Caremark Mail Service Pharmacy. To do this, provide your physician with your ID number (located on your ID card) and ask him or her to fax the prescription to the CVS Caremark Mail Service Pharmacy fax number: 800-378-0323.

Electronic transmission: You can ask your physician to transmit your prescriptions electronically to CVS Caremark Mail Service Pharmacy.

Refilling your medication: To be sure you never run short of your prescription medication, you should re-order on or after the estimated refill date or when you have approximately 18 days of medication left.

To order by phone: Call Member Services at 844-4-GEHARX or 844-443-4279. Have your prescription bottle with the prescription information ready.

To order by mail: Simply mail the GEHA Mail Order Form and copayment to CVS Caremark, PO Box 659541, San Antonio, TX 78265-9541.

To order online: Go to www.caremark.com

Network Retail Pharmacy 

All coinsurance is for up to a 30-day supply per prescription. 

A generic equivalent will be dispensed unless you or your physician specifies that the prescription be dispensed as written (DAW), when an FDA approved generic drug is available. If there is no generic equivalent available, you pay the applicable plan coinsurance. 

If you or your physician 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. Your physician may call 855-240-0536, if they determine there is medical necessity for the brand therapy. If approved, your coinsurance will be the applicable brand name coinsurance.

Generic/Preferred: 25% of Plan allowance

Non-Preferred: 40% of Plan allowance

Non-Network Retail Pharmacy 

If a participating pharmacy is not available where you reside or you do not use your identification card, you may submit your claim, with original drug receipts to:

CVS Caremark
PO Box 52136
Phoenix, AZ 85072-2136

You may also submit prescription reimbursement requests online via Caremark web portal (www.caremark.com) or Caremark mobile app (available for Android and Apple.)

Your claim will be calculated on the 25%/ 40% coinsurance and the appropriate deductible. Reimbursement will be based on GEHA's costs had you used a participating pharmacy. You must submit original drug receipts.

All coinsurance is for up to a 30-day supply per prescription.

If you or your physician 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. Your physician may call 855-240-0536, if they determine there is medical necessity for the brand therapy. If approved, your coinsurance will be the applicable brand name coinsurance.

Generic/Preferred: 25% of network price and any difference between our allowance and the cost of the drug

Non-Preferred: 40% of network price and any difference between our allowance and the cost of the drug

CVS Caremark Mail Service Pharmacy

All coinsurance is for up to a 90-day supply per prescription. 

A generic equivalent will be dispensed unless you or your physician specifies that the prescription be dispensed as written (DAW), when a FDA approved generic drug is available. If there is no generic equivalent available, you pay the applicable plan coinsurance.

If you or your physician 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. Your physician may call 855-240-0536, if they determine there is medical necessity for the brand therapy. If approved, your coinsurance will be the applicable brand name coinsurance.

Generic/Preferred: 25% of Plan allowance

Non-Preferred: 40% of Plan allowance

Preferred Insulin - Network Retail Pharmacy 

All copayments are for up to a 30-day supply per prescription. 

If you or your physician 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. 

Note: This benefit is not available at non-network retail pharmacies.

Preferred: 15% of the Plan allowance (no deductible)

For generic or non-preferred medications, please see regular Plan benefits.

Preferred Insulin - CVS Caremark Mail Service Pharmacy

All copayments are for up to a 90-day supply per prescription.

If you or your physician 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.

Preferred: 15% of the Plan allowance (no deductible)

For generic or non-preferred medications, please see regular Plan benefits.

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site www.hrsa.gov/womens-guidelines.

Network and Non-Network Retail
CVS Caremark Mail Service Pharmacy

Contraceptive coverage is available at no cost to PSHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Over-the-counter (prescription required) and prescription drugs approved by the FDA to prevent an unintended pregnancy are included.

Reimbursement for covered over-the-counter contraceptives (prescription required) can be submitted by sending in your original prescription receipt obtained from your pharmacy to:

CVS Caremark
PO Box 52136
Phoenix, AZ 85072-2136

You may also submit prescription reimbursement requests online via Caremark web portal (www.caremark.com) or Caremark mobile app (available for Android and Apple). 

Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described on GEHA’s website at www.geha.com/Contraception or by calling CVS Caremark at 844-4GEHARX or 844-443-4279. Exception requests for contraception coverage will be processed within 24 hours of receiving complete information.

Note: Members are encouraged not to use an HSA, health FSA, or HRA (including any related debit card) to purchase contraception for which the individual intends to seek reimbursement from their PSHB plan.

Note: For more information regarding prescription contraceptives, please refer to Preventive care medications above. Some contraceptives and services are covered under the medical benefit; see Section 5(a), Family Planning.

Nothing (no deductible)

CVS Specialty Pharmacy is the exclusive provider for specialty medications. CVS Specialty Pharmacy provides not only your specialty medications, but also personalized pharmacy care management services. If you have questions, visit www.CVSSpecialty.com or call Specialty Customer Care at 800-237-2767.

Specialty medications are certain pharmaceuticals which may be biotech or biological drugs. Specialty medications are oral, injectable or infused, and/or may require special handling. To maximize patient safety, most specialty medications require preauthorization. These drugs are used in the treatment of complex, chronic medical conditions which include but are not limited to hemophilia, multiple sclerosis, hepatitis, cancer, rheumatoid arthritis, pulmonary hypertension, transplant, HIV, osteoarthritis, and immune deficiency. If you are new to select specialty therapies (i.e.: oral oncology, hepatitis B, Parkinson’s disease psychosis and hematological disorders), you will receive a 14 or 15-day supply for the first 2 months of therapy. Your coinsurance will be prorated. If you continue on this therapy, you may receive up to a 30-day supply of the medication.

Your benefit includes the Advanced Control Specialty Formulary (ACSF); please see CVS Caremark Formulary for additional information. Most specialty drugs require preauthorization. See “How to obtain preauthorization” under Prescription drug benefits. For certain specialty therapies, you are required to use the generic unless your physician demonstrates medical necessity for the brand. 

Outpatient, non-surgical cancer treatments require preauthorization. You or your provider need to call us at 800-821-6136 or visit www.geha.com.

CVS Specialty Pharmacy

All copayments are for up to a 30-day supply per prescription.

If you or your physician choose a brand name specialty drug for which a generic drug exists, you will pay the applicable coinsurance and the difference between the cost of the brand name drug and the cost of the generic drug. Your physician may call 855-240-0536, if they determine there is medical necessity for the brand therapy. If approved, your coinsurance will be the applicable brand name coinsurance.

Specialty Plan benefits apply to limited distribution specialty medications when CVS Specialty Pharmacy does not have access to dispense.

Generic and Preferred: 25% of Plan allowance, up to a 30-day supply

Non-Preferred: 40% of Plan allowance, up to a 30-day supply

Specialty medications dispensed by other sources including physician offices, home health agencies, outpatient hospitals may be paid under the medical benefit.

Recurring oral medication must be obtained through the pharmacy benefit.

Generic and Preferred: $300 copayment applies per prescription fill and 25% of the Plan allowance, up to a 30-day supply

Non-Preferred: $500 copayment applies per prescription fill and 40% of the Plan allowance, up to a 30-day supply

Preventive Care: The following preventive medications are covered as recommended under the Patient Protection and Affordable Care Act (ACA).

Preventive medications with USPSTF A and B recommendations are covered with no cost-sharing at a participating pharmacy. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations, go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/Browse-recommendations. Age restrictions apply.

Note: To receive preventive care benefits a prescription from a doctor must be presented to the pharmacy. A generic equivalent will be dispensed unless you or your physician specifies that the prescription be dispensed as written, when an FDA approved generic drug is available unless substitution is prohibited by state law.

• Aspirin - All single ingredient generic oral dosage forms <81mg OTC only (requires a prescription) for the prevention of pre-eclampsia after 12 weeks of gestation. Limit of 100 units per fill.
• Colorectal Cancer Prevention - Bowel prep products - generic Rx, and brand name only when generic or over the counter (OTC) equivalent is not available, requires a prescription, age 45-75 years.
• Fluoride supplements (not toothpaste or rinses) - Single ingredient brand name and generic prescription products in an oral dosage form < 0.5mg for children five years of age and younger.
• Folic acid supplements - Single ingredient generic 0.4mg and 0.8mg tabs. OTC only (requires a prescription) for women 55 years of age and younger. Limit of 100 units per fill.
• Generic metformin 850mg tablets for individuals age 35-70 years with no prior use of anti-diabetic medications.
• Generic Naloxone is offered as an opioid rescue agent under this Plan with no cost sharing when obtained from a network pharmacy with a prescription. Limited to three doses annually (requires a prescription). For more information, consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose or call SAMHSA's National Helpline 800-662-HELP (4357) or go to www.findtreatment.samhsa.gov/
• Generic tamoxifen, raloxifene, exemestane and anastrozole - with prescription for women ages 35 and over for the prevention of breast cancer.
• HIV Pre-Exposure Prophylaxis – Prior authorization may be required for coverage. CVS Specialty Pharmacy is GEHA's exclusive Specialty Pharmacy.
• Iron supplements - Single ingredient pediatric oral liquids (requires a prescription) for children age 6-12 months.
• Statins - Certain statins for individuals age 40-75 years.
• Women’s Preventive Service - Contraceptives - oral, emergency, injectable, patch, barrier, and misc. - generic Rx or OTC (requires a prescription) and brand name only when generic is not available. If the brand name is medically necessary, a preauthorization for medical necessity is required. Women only and limits may apply.

Nothing (no deductible)

• Immunizations: Vaccines; childhood and adult, Rx only, coverage dependent on vaccine type
  • GEHA members can go to a participating retail pharmacy to receive certain vaccinations. Influenza vaccine is commonly administered by retail pharmacies. Other vaccines, such as those for pneumococcal pneumonia (Pneumovax), varicella/shingles (Shingrix) and hepatitis B may also be available through retail pharmacies.
  • Members may call CVS Caremark at 844-4GEHARX or 844-443-4279 to identify a participating vaccine pharmacy or go to www.caremark.com. GEHA members should check with the retail pharmacy to ensure availability of a pharmacist who can inject vaccines and availability of the vaccine product before going to the pharmacy. GEHA members should also ask retail pharmacies if there is an age requirement for vaccines that can be administered at that pharmacy.

Nothing (no deductible) for most vaccines. Please check with CVS Caremark at 844-4GEHARX or 844-443-4279 for coverage benefits.

• Tobacco cessation
  • Gum, lozenge, patch, inhaler, spray and oral therapy, brand name and generic coverage, Rx and OTC (requires a prescription).
  • We will cover over-the-counter (with a physician’s prescription) and prescription tobacco cessation drugs approved by the FDA. The quantity of drugs reimbursed will be subject to recommended courses of treatment. You may obtain tobacco cessation drugs with your GEHA ID card, through a participating network retail pharmacy, CVS Caremark Mail Service Pharmacy, or a non-network retail pharmacy (see previous section Covered medications and supplies for filing instructions).

Note: For additional information on Tobacco Cessation Educational Classes and Programs, see Section 5(a).

Nothing (no deductible), day supply limits apply depending on therapy

The following medications and supplies are not covered under the GEHA prescription drug benefit:

• Drugs and supplies for cosmetic purposes
• Vitamins, nutrients and food supplements (alone or in combination) not listed as a covered benefit or that do not require a prescription are not covered, including enteral formula/tube feeding available without a prescription
• Nonprescription medications not shown as covered
• Medical devices, or supplies such as dressings and antiseptics
• Drugs which are investigational
• Drugs to treat impotency
• Certain prescription drugs that have an over-the-counter (OTC) equivalent drug or treatment are not covered 
• Certain compounding chemicals, including but not limited to, OTC products, experimental, investigational, bulk powders, bulk chemicals and certain bases.
• Drugs to enhance athletic performance
• Services or supplies for the administration of a non-covered medication.

All charges

There are important features you should be aware of. These include:

• Materials you will receive: Each new enrollee will receive a description of our PDP EGWP Summary of Benefits, a prescription drug card, Confirmation of Enrollment, online documents notice (where to find the EOC, Formulary, and Pharmacy Directory), a mail order form, Multi Language/ Non-Discrimination notice and Notice of Privacy Practices.
• Drug coupon/copay cards: We do not honor or coordinate benefits with drug coupon/ copay cards. You are responsible for your copay or coinsurance as indicated in this brochure.
• Who can write your prescription: A licensed physician or dentist, and in the states allowing it, licensed or certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication.  Your prescribers must have Medicare-approved prescriptive authority.

• Where you can obtain them: You may fill the prescription at a preferred pharmacy, a non-preferred pharmacy, or by mail for certain drugs. We pay a higher level of benefits when you use a preferred network pharmacy.
  • Preferred pharmacy – Present your Plan identification card at a preferred pharmacy to purchase your prescriptions and have the claim be filed electronically for you.
  • Non-preferred pharmacy –You pay the full cost and manually file a claim for reimbursement by sending in your original prescription receipt obtained by your pharmacy to:

SilverScript Insurance Company
Prescription Drug Plans
Medicare Part D Paper Claim
PO Box 52066
Phoenix, AZ 85072-2066

• • Mail order – To obtain more information about the mail order drug program, order refills, check order status and request additional mail service envelopes and claim forms, or to ask questions call SilverScript at 1-833-250-3241 or visit our website, www.caremark.com.

Note: Remember to use a preferred pharmacy whenever possible and show your SilverScript ID card to receive the maximum benefits and the convenience of having your claims filed for you. For assistance locating a PDP EGWP preferred pharmacy, visit our website at www.caremark.com or call us at 833-250-3241 / TTY 711.

• We use a managed formulary. A formulary is a list of generic and preferred drugs (see below) that are available through this plan. It places all FDA approved drugs into categories based on their clinical effectiveness, safety and cost and is designed to control costs for you and the Plan. Your provider may prescribe drugs that are subject to additional review to determine they are medically necessary. The categories include:
  • Tier 1: Generic drug category includes primarily generic drugs;
  • Tier 2: Preferred drug category (also called "formulary") includes preferred brand name drugs;
  • Tier 3: Non-Preferred drug category (also called "non-formulary") includes non-preferred brand name drugs;
  • Tier 4: Specialty drug category (see description of Specialty drugs below).

Occasionally, drugs may change from one category to another category, which can affect your cost-share amount. We will attempt to notify you when this occurs.  While all FDA-approved drugs are available to you, we may have formulary restrictions on certain drugs, including but not limited to, quantity limits, age limits, dosage limits, brand exception and preauthorization. To request a copy of our current formulary, call us at 1-833-250-3241 or visit our website, https://info.caremark.com/oe/gehapdp.

• Utilization Management strategies: Preauthorization, trial and step therapy: We require preauthorization (PA) for certain drugs to ensure safety, clinical appropriateness and cost effectiveness. PA criteria are designed to determine coverage and help to promote safe and appropriate use of medications. Drugs subject to PA are screened at the point of service and the dispensing pharmacy is advised to have the prescriber contact the SilverScript PA department. SilverScript will obtain the relevant information from the prescriber to determine whether the drug use meets the established criteria for the requested drug. In certain circumstances, a preauthorization may require the trial or step of a more appropriate first line agent before the drug being requested is approved.
• A generic equivalent will be dispensed if it is available unless your physician specifically requires a brand name drug.  If you receive a brand name drug when an FDA approved generic drug is available, and your physician has not specified Dispense as Written for the brand name drug, you have to pay the difference in cost between the brand name drug and the generic.
• Why use generic drugs:  By choosing Generic or Preferred category drugs, you may decrease your out-of-pocket expenses. 
• You may request a Formulary Exception:
  • Asking for coverage of a drug that is not on the Drug List is sometimes called asking for a formulary exception.
  • Asking for removal of a restriction on coverage for a drug is sometimes called asking for a formulary exception.
  • Asking to pay a lower price for a covered non-preferred drug is sometimes called asking for a tiering exception.
  • Start by calling, writing or faxing SilverScript to make your request for us to authorize or provide coverage for the prescription you want. You can also access the coverage decision process through caremark.com website.  We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request form.  You, your doctor, (or other prescriber), or your representative can do this.  You can also have a lawyer act on your behalf.
• When you do have to file a claim. Please be sure to include your name, contact information, and information identifying which denied claim is being appealed.
• If we deny your claim and you want to appeal: You, your representative, or your prescriber must request an appeal following the process described in Section 8(a). Medicare PDP EGWP Disputed Claims process.  The PDP EGWP appeals process has 5 levels.  If you disagree with the decision made at any level of the process, you can generally go to the next level.  At each level, you'll get instructions in the decision letter on how to move to the next level of appeal.
  • A standard appeal is usually made within 7 days.  A fast appeal is generally made within 72 hours. If your health requires it, ask for a fast appeal.

You may purchase the following medications and supplies prescribed by a physician from SilverScript network pharmacies or through the mail order program:

• Drugs and medications (including those administered during a non-covered admission or in a non-covered facility) that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not Covered.
• Diabetic supplies limited to:
  • Disposable needles and syringes for the administration of covered medications
• Drugs to treat gender dysphoria: such as Estradiol; Testosterone

Note: This prescription drug plan offers a formulary which covers Part D drugs required by CMS and additional drug coverage as outlined below:

• Non-Part D Supplemental Benefit including but not limited to:
  • Agents when used for the symptomatic relief of cough and colds.
  • Agents when used for weight loss (Prior Authorization applies)
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.

Note: For access to our formulary, please visit: https://info.caremark.com/oe/gehapdp

Note: Prior authorization may be required for certain drugs, call us at 833-250-3241 if you have any questions regarding preauthorization, quantity limits, or other issues.

Retail pharmacy, up to a 30-day supply:

• Generic (Preferred Pharmacy): 20% of Plan allowance
• Generic (Non-preferred) Pharmacy: 25% of Plan allowance
• Preferred brand: 25% of Plan allowance
• Non-Preferred brand: 40% of Plan allowance

Mail order pharmacy, up to 90-day supply:

• Generic (Preferred Pharmacy): 20% of Plan allowance
• Generic (Non-preferred Pharmacy): 25% of Plan allowance
• Preferred brand (Preferred Pharmacy): 25% of Plan allowance
• Preferred (Non-preferred Pharmacy): 25% of Plan allowance
• Non-Preferred brand (Preferred Pharmacy): 40% of Plan allowance
• Non-Preferred brand (Non-preferred Pharmacy): 40% of Plan allowance

Specialty drugs, up to 30-day supply:

• 25% of Plan allowance

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines. 

Contraceptive coverage is available at no cost to PSHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below.

Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.

Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described on GEHA’s website at www.geha.com/Contraception or by calling SilverScript at 833-250-3241. Exception requests for contraception coverage will be processed within 24 hours of receiving complete information. If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

Reimbursement for covered over-the-counter contraceptives can be submitted by sending in your original prescription receipt obtained by your pharmacy to:

SilverScript Insurance Company
Prescription Drug Plans
Medicare Part D Paper Claim
PO Box 52066
Phoenix, AZ 85072-2066

Note: For additional Family Planning benefits see Section 5(a).

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation Educational Classes and Programs in Section 5(a).

Nothing (no deductible)

Insulin, one-month supply

$35 copay

Tier 1 ACE Inhibitors/Beta Blockers (blood pressure medications), 30-day supply

$3 copay

Preventive medications with USPSTF A and B recommendations. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to: www.uspreventiveservicetaskforce.org.

Note: Your doctor must write a prescription for these preventive services to be covered by the plan, even if they are listed as over the counter. Changes can occur throughout the year.

Preferred pharmacy: Nothing (no deductible)

Member is responsible for charges above allowable when using a non-preferred pharmacy.

Physician prescribed over-the-counter and prescription naloxone, opioid rescue agents, available as nasal sprays are covered under this Plan at no cost.

For more information consult the FDA guidance at: www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to www.findtreatment.samhsa.gov/.

Preferred pharmacy: Nothing (no deductible)

Member is responsible for charges above allowable when using a non-preferred pharmacy.

Not covered:

• Drugs and supplies for cosmetic purposes
• Prescriptions written by a non-covered provider
• Vitamins, nutrients and food supplements that do not require a physician's prescription, even if a physician prescribes or administers them, except as indicated
• Total parenteral nutrition (TPN) products and related services, except as noted under Section 5(a), Treatment therapies
• Continuous glucose monitors (CGMs) and supplies, except as noted under Section 5(a), Durable Medical Equipment
• Over-the-counter medications even if prescribed by a physician, unless otherwise stated in this section
• Nonprescription medications unless specifically indicated elsewhere
• Topical analgesics, including patches, lotions and creams
• Erectile dysfunction drugs
• Drugs and supplies when Medicare Part B is primary payor. For Part B diabetic continuous glucose meters, see Section 5(a), Durable medical equipment. For Medicare Part B covered drugs and diabetic supplies, see Section 5(f), Coordinating with Other Drug Coverage
• Any amount in excess of the cost of the generic drug when a generic is available, and a brand exception has not been obtained by the prescribing physician
• Drugs obtained from a retail pharmacy in excess of a 30-day supply, except maintenance medication obtained at a CVS retail pharmacy
• Drugs obtained from a foreign pharmacy in excess of a 90-day supply

All charges

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

TTY service is available at 800-821-4833 for members who are hearing impaired.

GEHA makes various maternity resources available to you or your covered dependent. Visit www.geha.com/Maternity to order your packet on pregnancy and prenatal care.

Call the GEHA 24-hour Nurse Advice Line number 888-257-4342 and speak with a registered nurse – any time, 24 hours a day. The nurse can help you understand your symptoms and determine appropriate care for your needs.

The 24-hour Nurse Advice Line allows you to conveniently manage your symptoms and treatment anywhere you have access to a phone.

Telehealth is available at a reduced cost through MDLIVE. Go to https://members.mdlive.com/geha-callmd/ or call 888-912-1183 to access on demand, affordable, high-quality care for adults and children experiencing non-emergency medical issues, including treatment of minor acute conditions (see Section 10 for definition), dermatology conditions (see Section 10 for definition) and counseling for mental health and substance use disorder. 

Note: This benefit is available at reduced cost only through the MDLIVE contracted telehealth provider network. 

Note: Practitioners must be licensed in the state where the patient is physically located at the time services are rendered.

Earn rewards for healthy actions with GEHA’s Health Rewards program. Total annual rewards are limited to $250 each for the subscriber and covered spouse. Maximum reward amounts are not guaranteed. Rewardable activities include, but not be limited to, the following:

• Health assessment (must complete to be eligible for additional rewards)
• Preventive cancer screenings (Cervical, Colorectal, and Breast)
• Annual physical
• Health and Wellness Webinars

Members will be issued a rewards account with a reloadable debit card, which can be used for eligible dental and/or vision expenses and, once they have satisfied their deductible, can be used for eligible medical expenses.

For detailed information about eligibility requirements, how to access the health assessment and all available rewards, visit: www.geha.com/HealthRewards.

GEHA offers a number of services and tools for weight management.

• BMI calculation through on-line health risk assessment
• Nutrition counseling (see Educational Classes and Programs, Section 5a)
• Behavior change programs with coaching for members who qualify
• Discounts for gym memberships and other services through Connection Fitness
• Bariatric surgery, when medically necessary. Bariatric surgery must be precertified

Our Personal Health Record helps you track health conditions, allergies, medications and more. This program is voluntary and confidential. 

GEHA offers a number of programs and services to members to assist with special conditions and needs. Members with these conditions or needs can work with health professionals, such as a nurse or health coach. Visit www.geha.com for a list of programs, program criteria, and contact information.

GEHA Care Management resources and guidance are available to assist members or covered dependents through the infertility process. Visit www.geha.com/FamilyPlanning.

Note: Infertility coverage is limited. See Section 5(a), Infertility services for covered services.

GEHA Care Management resources and guidance are available to members or covered dependents who are considering a future pregnancy and want to optimize their own health and well-being prior to conception.

Visit www.geha.com/Preconception

Visit www.geha.com/Blog for information on:

• General health topics
• Links to health care news
• Cancer and other specific diseases
• Drugs/medication interactions
• Children's health
• Patient safety information
• Helpful website links

If you have an HDHP (with either the HSA or HRA): 

• Complete claims payment history is available online through www.geha.com; and
• You will also receive an Explanation of Benefits (EOB) after every claim.

If you have an HSA under the HDHP:

• You will receive a monthly statement from the HSA Bank™ outlining your HSA account balance and activity for the month; and
• You may also access your HSA account on-line at www.hsabank.com.

If you have an HRA under the HDHP:

• Your HRA account balance will be available on-line through your Member Account at www.geha.com; and
• To request reimbursement from your HRA account for qualified out-of-pocket medical expenses that are not submitted to GEHA by your doctor, hospital, dentist or pharmacy, call GEHA’s Customer Service at 800-821-6136 or go to www.geha.com to obtain our Health Reimbursement Arrangement Claim Form. This form is also used to request reimbursement from your HRA for Medicare premiums.

• If you have our HDHP, you may choose any provider. However, you will receive discounts when you see a network provider. You can find network providers online at www.geha.com.
• Pricing information for prescription drugs is available at www.caremark.com.
• Link to online pharmacy through CVS Caremark at www.caremark.com.
• Educational materials on the topics of HSAs, HRAs and HDHPs are available at www.geha.com.

• GEHA has a strong patient safety program. Pharmacy initiatives help ensure that members have fewer health complications related to prescription drugs. Disease management programs help our members with specific health conditions such as heart disease and diabetes. Medical case managers assist patients with high-risk pregnancies, durable medical equipment, transplants and other special needs.
• Patient safety information is available online at www.geha.com.

To obtain claim forms, claims questions or assistance, or answers about our benefits, contact us at 800-821-6136, or at our website at www.geha.com.

In most cases, providers and facilities file claims for you. Your provider must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. Submit claims to the network address on the back of the GEHA ID card, for both in- and out-of-network claims.

Submit dental claims, or out-of-network charges that you have paid in full to:

GEHA Dental Claims
PO Box 21191
Eagan, MN 55121

Submit medical and Medicare primary claims, or out-of-network charges that you have paid in full to:

GEHA Medical Claims
PO Box 21172
Eagan, MN 55121

When you must file a claim – such as for services you received overseas or when another group health plan is primary – submit it on the CMS-1500 or ADA form, a claim form that includes the information shown below, or visit www.geha.com/Claim. Bills and receipts should be itemized and show:

• Patient’s name, date of birth, address, phone number and relationship to enrollee;
• Patient’s Plan identification number;
• Name and address of person or company providing the service or supply;
• Dates that services or supplies were furnished;
• Diagnosis;
• Type of each service or supply: itemized bill including valid ADA, CPT, HCPCS (including NDC numbers for all Drug type charges);
• The charge for each service or supply; and
• We will provide translation and currency conversion for claims for overseas (foreign) services. The conversion rate will be based on the date services were rendered.

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills. Many direct-to-consumer program models do not support claim submissions to insurance carriers. They do not provide enough detailed, itemized, information to meet this claim submission criteria.

In addition:

• If another health plan is your primary payor, you must send a copy of the Explanation of Benefits (EOB) form you received from any primary payor (such as the Medicare Summary Notice (MSN)) with your claim.
• Bills for home nursing care must show that the nurse is a registered or licensed practical nurse and should include nursing notes.
• Claims for prescription drugs and supplies must include receipts that show the prescription number, name of drug or supply, prescribing provider's name, date, and charge. A copy of the provider's script must be included with prescription drugs purchased outside the United States. 

We will notify you of our decision within 30 days after we receive your post-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

Keep a record of the medical expenses of all covered family members as deductibles and maximum allowances apply. Save copies of all medical bills, including those you accumulate to satisfy a deductible. In most instances they will serve as evidence of your claim. We will not provide duplicate or year-end statements.

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service. If you could not file on time because of Government administrative operations or legal incapacity, you must submit your claim as soon as reasonably possible. Once we pay benefits, there is a three-year limitation on the re-issuance of uncashed checks.

For covered services you receive by providers and hospitals outside the United States and Puerto Rico, send a completed Overseas Claim Form and the itemized bills to: GEHA, Medical Claims, PO Box 21172, Eagan, MN 55121. Obtain Overseas Claim Forms from www.geha.com.

Eligibility and/or medical necessity review is required when procedures are performed or you are admitted to a hospital outside of the United States. Review includes the procedure/service to be performed, the number of days required to treat your condition, and any other applicable benefit criteria.

If you have questions about the processing of overseas claims, contact us at 800-821-6136 or by email overseas@geha.com. Covered providers outside the United States will be paid at the in-network level of benefits, subject to deductible and coinsurance. We will provide translation and currency conversion for claims for overseas (foreign) services. The conversion rate will be based on the date services were rendered.

When members living abroad are stateside and seeking medical care, contact us at 800-821-6136, or visit www.geha.com to locate an in-network provider. If you utilize an out-of-network provider, out-of-network benefits would apply.

Please reply promptly when we ask for additional information. We may delay processing or deny benefits for your claim if you do not respond. Our deadline for responding to your claim is stayed while we await all of the additional information needed to process your claim.

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, a healthcare professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent. For the purposes of this section, we are also referring to your authorized representative when we refer to you.