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. 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 www.opm.gov/healthcare-insurance/healthcare for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express, and
• Information on and links to other electronic enrollment systems.

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 FEHB 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 and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your FEHB 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 member. Family members include your spouse and your 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. 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 form. 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 FEHB enrollment.

Contact your employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member.

Your employment or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status including your marriage, divorce, annulment, or when your child reaches age 26. 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 FEHB Plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another 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 FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, Tribal Benefits Officer, retirement office or personnel/payroll 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 marriage) 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 FEHB 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 you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB 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 FEHB 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 FEHB coverage, you must continue your FEHB 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.

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2027 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan's 2026 benefits until the effective date of your coverage with your new plan. Annuitants' coverage and premiums begin January 1. If you joined at any other time during the year, your employing 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 FEHB Program. Generally, you must have been enrolled in the FEHB 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.

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (a non-FEHB individual policy).

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 contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof. In order to change enrollment type, you must contact your employing or retirement office. 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 FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (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, 
http://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 FEHB enrollment.

If you leave Federal service, Tribal employment, 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 FEHB enrollment after you retire, if you lose your Federal or Tribal 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 or Tribal 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 FEHB coverage.

If you leave Federal or Tribal 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 FEHB 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/Get-Support.

If you would like to purchase health insurance through the ACA's 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 Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

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:

G.E.H.A Enrollment
PO Box 21262
Eagan, MN 55121

You may also request replacement cards through our website: www.geha.com/My-Member-Portal.

You can get care from any "covered providers” and “covered facilities.”  How much we pay - and you pay - depends on the type of covered provider or facility you use and how the services are billed. If you use our preferred providers, you will pay less.

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and any applicable medical or payment policies. Policies may be found on our website www.geha.com/Provider-Policies. In some instances, additional services may be rendered, and additional cost shares may apply.

G.E.H.A helps you identify lower-cost healthcare options. When using the Find a Provider or Health Cost Estimator tool, you will see preferred facility designations (such as “Freestanding Facility”), on certain types of facilities such as ambulatory surgical centers or stand-alone imaging centers. Services performed at network freestanding facilities may cost less than care received in a hospital or hospital-affiliated facility.

To find providers or estimate costs, log in to www.geha.com and go to Find costs and care, here you can find a provider or use the Health Cost Estimator tool to compare providers, services, and locations before receiving care.

If you are receiving specialty medication infusions or injections, G.E.H.A may contact you to provide information on how to save costs and help you explore alternative facility options.

Benefits are applied based on how your provider bills us. You must reference all Sections in this Brochure depending on where your care is obtained. For example, but not limited to, any procedure, injection, diagnostic service, laboratory, or x-ray service done in a hospital in conjunction with a physician office examination may apply separate cost share depending on where you obtain your care.

FEHB 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.

Covered providers are medical practitioners who perform covered services when acting within the scope of their license or certification under applicable state law and who furnish, bill or are paid for their healthcare services in the normal course of business. Covered services must be provided in the state in which the practitioner is licensed or certified.

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. 

Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex, pregnancy, or genetic information.

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: You may continue seeing your specialist and receiving any PPO benefits for up to 90 days if you are undergoing treatment for a chronic or disabling condition and you lose access to your specialist because:

• we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan, or
• we terminate our contract with your specialist for reasons other than for cause.

Contact us at 800-821-6136 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 specialist based on the above circumstances, you can continue to see your specialist and your PPO benefits will continue until the end of your postpartum care, even if it is beyond the 90 days.

Note: If you lose access to your specialist because you changed your carrier or plan option enrollment, contact your new plan.

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, call our Customer Care department immediately at 800-821-6136. If you are new to the FEHB 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, 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 92^nd 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 FEHB 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, prior approval or a referral and (2) will result in a reduction of benefits if you do not obtain precertification, prior approval or a referral.

Precertification is the process by which – prior to your inpatient admission – we evaluate the medical necessity of your proposed stay, the location in which services are intended to be rendered, 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 facility 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 facility whether or not they have contacted us. 

Avoid paying providers for services prior to precertification. It is important to assure services are authorized by a covered provider or facility.

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

For out-of-network facilities on the Elevate Option, you are responsible for obtaining precertification for these services.

In-network: Network Plan physicians must provide or arrange your in-network care and get precertification or preauthorization for certain services and/or procedures, including but not limited to those noted below in Other services that require preauthorization. 

Note: Avoid paying providers for services prior to preauthorization. It is important to assure services are authorized and provided by a covered provider or facility.

Out-of-network (Elevate only):

You must get precertification for certain services prior to admission. Failure to do so will result in the following penalties, unless due to a medical emergency:

• We will reduce our benefits for the Inpatient Hospital stay, Long Term Acute Care, Residential Treatment Center (RTC), Skilled Nursing Facility (SNF), or Rehabilitation Facility stay by $500 per day for each day that is not precertified prior to admission, limited to a maximum penalty of $5,000 per 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. 

You do not need precertification in these cases:  

• You have another group health insurance policy that is the primary payor for the facility stay or other services; or
• Medicare Part A is primary payor for the facility stay. 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.

Some surgeries and procedures, drugs, tests, services and equipment require precertification or preauthorization. Specific services requiring preauthorization or precertification are indicated in Section 5, when applicable. Please note this list is subject to change, please call to verify if your procedure requires preauthorization. 

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

Transplants services require more extensive reviews. The transplant must be performed in a designated transplant facility to receive maximum 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. 

• 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. 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.

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.

• Applied behavioral analysis (ABA) therapy;
• Arthroplasty; 
• Bariatric (obesity surgery);
• Bone growth stimulators;
• Cellular and gene therapy;
• Certain prescription drugs
• Cochlear and auditory implants and implant procedures;
• Durable medical equipment (DME) over $1,000;
• Facility admissions (including hospitals, long term acute care, rehabilitation facilities, residential treatment centers, and skilled nursing facilities; see above*);
• Fertility procedures and drugs; 
• Genetic testing;
• Hysterectomy except for diagnosis of cancer;
• Neurostimulation, including devices and implantation procedures for cranial, gastric, peripheral, spinal, or vagus nerve stimulation;
• Non-emergency air ambulance transportation; 
• Orthognathic surgery (jaw), including TMJ;
• Orthopedic and prosthetic devices over $1,000;
• Prostate implants, destruction, and removal;
• Psychological testing and neuropsychological testing exceeding 8 hours/calendar year;
• Reconstructive procedures;
• Sleep studies (in-lab) attended or performed in a healthcare facility; 
• Transplants

First, you, your representative, your physician, or your facility must call to obtain preauthorization before an inpatient facility 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 or contact us at 800-821-6136.

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 facility the number of approved inpatient days and we will send written confirmation of our decision to you, your doctor, and the facility.

For non-urgent care claims, we will tell the physician and/or facilities the number of approved inpatient days, or the care that we approve for other services that must have precertification. 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 the 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 Health Insurance 2 at 202-606-3818 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 a period of 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. 

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 facility must notify us within two business days following the day of the emergency admission, even if you have been discharged from the facility.

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 facility must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the facility must contact us for precertification of additional days for your baby.

Note: When a newborn requires definitive treatment during or after the mother’s 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 facility stay - including for maternity care - needs to be extended, you, your representative, your doctor or the facility must ask us to approve the additional days. If you remain in the facility 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. 

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 844-443-4279.

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.

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:

G.E.H.A Medical Claims
PO Box 21172
Eagan, MN 55121

You may obtain overseas claim forms from www.geha.com/Health-Overseas-Access. 

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 and/or 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. Covered providers outside the United States will be paid at the in-network level of benefits, subject to the deductible, copays and/or 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/Health-Overseas-Access to locate an in-network provider. When you are seeking treatment stateside, all precertification and authorization requirements are applicable. If you utilize an out-of-network provider, out-of-network benefits would apply on the Elevate Option. The Elevate Plus Option does not provide benefits for out-of-network providers, except in cases of emergency medical care.

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

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: When you see your in-network Primary Care Provider (PCP), under Elevate Plus, you pay a copayment of $30 per visit.

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

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. Copayments and 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.

Elevate Plus Option

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 $200. Under the Self Plus One and the Self and Family enrollments, once the calendar year deductible amount of $200 is satisfied for an individual, covered benefits are payable for that individual; the calendar year deductible is met for all family members when the covered expenses accumulated to the calendar year deductible for any combination of family members reaches the Self Plus One or the Self and Family limit of $400. Only Plan allowance paid for services or supplies from in-network providers counts toward this amount.

Out-of-Network:  Elevate Plus does not provide out-of-network benefits. 

Elevate Option

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 reaches $750. Under the Self Plus One and the Self and Family enrollments, once the calendar year deductible amount of $750 is satisfied for an individual, covered benefits are payable for that individual; the calendar year deductible is met for all family members when the covered expenses accumulated to the calendar year deductible for any combination of family members reaches the Self Plus One or the Self and Family limit of $1,500. 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 $2,000. Under the Self Plus One and the Self and Family enrollments, once the calendar year deductible amount of $2,000 is satisfied for an individual, covered benefits are payable for that individual; the calendar year deductible is met for all family members when the covered expenses accumulated to the calendar year deductible for any combination of family members reaches the Self Plus One or the Self and Family limit of $4,000. Only Plan allowance paid for services or supplies from out-of-network providers counts toward 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 has been satisfied.

Note: If you change plans during Open Season and the effective date of your new plan is after January 1 of the next year, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change enrollment 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 does not 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 Elevate Option, you pay 25% (or 20% under the Elevate Plus Option) of our allowance for certain in-network services. 

If your provider routinely waives (does not require you to pay) your copayments, 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 30% coinsurance, the actual charge is $70.  We will pay $49 (70% of the actual charge of $70).

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 G.E.H.A 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. 

• 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 or copayment. 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 the Elevate Option, you pay just 25% of our $100 allowance ($25). 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 the Elevate Option you pay 50% of our $100 allowance ($50). 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. Elevate Plus Option does not provide benefits for out-of-network providers, so you would pay 100% of the provider's billed charges. 

The following illustrates the examples of how much you have to pay out-of-pocket, under the Elevate Option, for services from an in-network physician vs. an out-of-network physician. This is an 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 - Elevate Option
In-network physician
Physician’s charge: $150
Our allowance: We set it at: $100
We pay: 75% of our allowance: $75
You owe: 25% of our allowance: $25
+Difference up to charge: No: $0
TOTAL YOU PAY: $25

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

After your (deductible, copayments and coinsurance) reaches the out-of-pocket maximum you do not have to pay any more for covered services, with the exception of certain cost sharing for the services below which do not count toward your catastrophic protection out-of-pocket maximum.

• For the Elevate Plus Option, the out-of-pocket maximum is $7,000 for Self Only enrollment; $14,000 when enrollment is Self Plus One or Self and Family when you use in-network providers.
• For the Elevate Option, the out-of-pocket maximum is $10,600 for Self Only enrollment; $21,200 when enrollment is Self Plus One or Self and Family if you use in-network providers.
• Only eligible out-of-pocket expenses from in-network providers count toward these 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 Elevate Plus Option does not provide out-of-network benefits.
• For the Elevate Option, the out-of-pocket maximum is $17,000 for Self Only enrollment; $34,000 when enrollment is Self Plus One or Self and Family if you use out-of-network providers. Only eligible out-of-pocket expenses from out-of-network providers count toward these limits.
• An individual under Self Plus One or 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;
• Charges incurred by failure to obtain pre-certification, when using non-network facilities, and other amounts you pay because benefits have been reduced/denied for      non-compliance with the Plan's requirements (see Section 3);
• Expenses in excess of Plan limits for dental;
• The cost for non-approved medications and drugs that we exclude; and
• The difference between the cost of the generic and brand name medication.

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan's catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan's catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year's catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year's benefits; benefit changes are effective January 1.

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 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 non-participating providers with respect to patient visits to participating health care facilities, or for 
• air ambulance services furnished by non-participating providers of air ambulance services. 

Balance billing happens when you receive a bill from the non-participating provider, facility, or air ambulance service for the difference between the non-participating 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/Plan-Transparency or contact the health plan at 800-821-6136.

• Healthcare FSA (HCFSA) - Reimburses an FSA participant for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, over-the-counter drugs and medications, vision and dental expenses, and much more) for the participant and, their tax dependents, and their adult children (through the end of the calendar year in which they turn 26). 
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP Plans. This means that when you or your provider files claims with your FEHB or FEDVIP Plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

Professional services of physicians

• In physician's office
• Office medical consultations
• Second surgical opinions
• Advance care planning
• At home
• Telehealth services provided by your physician 

Note: If additional services (e.g., lab, x-ray) are provided during your office visit, separate cost shares may apply.

In-network: $30 copayment for office visits to primary care providers (no deductible); $50 copayment for office visits to specialists (no deductible)

Out-of-network: You pay all charges

In-network: $10 copayment for office visits to primary care providers (no deductible); $30 copayment for office visits to specialists (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• During a hospital stay 

Note: Services not related to your inpatient stay, may apply separate cost share.

In-network: 20% of the Plan allowance 

Out-of-network: You pay all charges

In-network: 25% of the Plan allowance

Out-of-network: 50% 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®, visit https://www.cvs.com/minuteclinic/clinic-locator or call 866-389-2727.

$10 copayment for office visit (no deductible)

Note: Other services rendered may take additional cost share

$10 copayment for office visit (no deductible)

Note: Other services rendered may take additional cost share

Telehealth professional services through the Plan's administrative partner for:

• Minor acute conditions, see Section 10, Definitions of Terms 
• Dermatology conditions, see Section 10, Definitions of Terms 

Note: For telehealth services provided by your physician, see Section 5(a), Diagnostic and treatment services.

Note:

• For more information on telehealth vendor, see Section                  5(h), Wellness and Other Special Features, or visit www.geha.com/Telehealth-Visit.

Nothing (no deductible)

Nothing (no deductible)

Tests, such as but not limited to:

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology

In-network: Nothing (no deductible)

Out-of-network: You pay all charges 

In-network: 25% of the Plan allowance 

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount 

Tests, such as but not limited to:

• X-rays
• Non-routine mammogram
• Ultrasound
• Electrocardiogram and EEG
• Neurological testing

In-network: $50 copayment (no deductible)

Out-of-network: You pay all charges 

In-network: 25% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount 

Diagnostic tests, such as but not limited to:

• Double-contrast barium enemas
• Bone density tests
• Diagnostic genetic testing and screening
• Sleep studies (Polysomnography)

Notes:

• Preauthorization may be required for these tests
• See Section 5(c) for any applicable outpatient facility charges.

In-network: 20% of the Plan allowance (deductible applies)

Out-of-network: You pay all charges

In-network: 25% of the Plan allowance (deductible applies)

Out-of-network: 50% of the Plan allowance (deductible applies) and any difference between our allowance and the billed amount

Tests such as, but not limited to:

• CT/CAT scan
• MRI
• Nuclear Cardiology
• PET scan

Notes:

• Preauthorization is required for these tests.
• See Section 5(c) for any applicable outpatient facility charges.

In-network: $100 copayment (no deductible)

Out-of-network: You pay all charges 

In-network: 25% of the Plan allowance 

Out-of-network: 50% of the Plan allowance and any difference between our 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, travel, related to judicial or administrative proceedings or orders, or required to obtain or maintain a license of any type. 
• Home test kits including but not limited to HIV and drug home test kits, except as specified by the brochure.
• Testing ordered by or on behalf of third parties (e.g., schools, courts, employers, etc.).

Routine physical every year. 

The following preventive services are covered at the time intervals recommended at each of the links below. Please consult with your healthcare provider to determine if the services below are appropriate for you:

• U.S. Preventive Services Task Force (USPSTF) A and B recommend screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. For a complete list of screenings, age and frequency limitations go to the website at www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• 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, and 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 www.hrsa.gov/womens-guidelines
• Routine mammogram - covered, including 3D mammograms
  • This coverage will include breast ultrasound performed after inconclusive breast cancer screening exam
• Routine use of adult immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) and adopted by the Centers for Disease Control and Prevention (CDC) are covered. A recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention. For the current immunization schedule, visit https://www.cdc.gov/vaccines/imz-schedules/index.html.
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder.

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.

In-network: Nothing (no deductible)

Out-of-network: You pay all charges 

In-network: Nothing (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our 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:

• Nutrition and behavioral weight-loss counseling therapy when ordered by your physician for obesity.
• 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, for education and support of a family member with obesity.
• Obesity screening for those persons below the USPSTF obesity prevention risk factor level.

Notes:

• Nutritional counseling, see Section 5(a), Educational classes and programs.
• When anti-obesity medication is prescribed, see Section 5(f).
• When Bariatric or Metabolic surgical treatment or intervention is indicated, see Section 5(b).
• For Weight management, see Section 5(a) or Wellness and Other Special Features, Section 5(h).

In-network: Nothing (no deductible)

Out-of-network: You pay all charges 

In-network: Nothing (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our 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, 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.

• 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. For preventive immunizations see guidance below.
  
• Routine use of children’s immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) schedule and adopted by the Centers for Disease Control and Prevention (CDC) are covered. A recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention. For the current immunization schedule, visit https://www.cdc.gov/vaccines/imz-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://uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations.

• Examinations, limited to:
  • Examinations for amblyopia and strabismus – limited to one screening examination (ages 3 through 5)
  • Examinations done on the day of immunizations (ages 3 up to age 22)
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder.                        

Notes:

• For preventive medications for appropriate age and dosage limits, see Section 5(f) Preventive care medications, or visit www.geha.com/Prescriptions-Summary. 
• Any procedure, injection, diagnostic service, laboratory, or          x-ray service done in conjunction with a routine examination that is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

In-network: Nothing (no deductible)

Out-of-network: You pay all charges

In-network: Nothing (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our 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:

• 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.
• Obesity screening for those persons below the USPSTF obesity prevention risk factor.

Notes:

• Nutritional counseling, see Section 5(a), Educational classes and programs.
• When anti-obesity medication is prescribed, see Section 5(f).
• When Bariatric or Metabolic surgical treatment or intervention is indicated, see Section 5(b).
• Also, for Weight Management program, see Wellness and Other Special Features, Section 5(h).

In-network: Nothing (no deductible)

Out-of-network: You pay all charges

In-network: Nothing (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our 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, travel, related to judicial or administrative proceedings or orders, or required to obtain or maintain a license of any type.
• 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

All charges

Complete maternity (obstetrical) care, such as:

• Prenatal and Postpartum care
• Screening for gestational diabetes 
• Delivery 
• Bacteriuria screening
• Screening and counseling for prenatal and postpartum depression 
• Breastfeeding and lactation support, supplies and counseling for each birth

Notes:

As part of your coverage, you have access to in-network Certified Professional Midwives (CPM) Certified Nurse Midwives (CNM), Certified Midwives (CM), and board-certified lactation specialists during the prenatal and post-partum period, where state licensing and credentialling is available. Network providers can be found online at www.geha.com/Locate-Care and in your member portal at www.mygeha.com.  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, How You Get Care/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.
• We cover routine nursery care of a newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment if we cover the infant under Self Plus One or Self and Family enrollment. 
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Section        5(b), Surgical benefits. 
• 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. 

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.

• Maternity care expenses incurred by a Plan member serving as a surrogate 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 that may be received 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.
• Refer to Section 5(a), Educational classes and programs for information on Childbirth Education classes.
• See Section 5(h), for more information on G.E.H.A's Family Planning Care Program. 
• Refer to Section 5(a), Durable medical equipment (DME), for obtaining breast pump and supplies from a contracted provider.
• See Section 5(e), for more information on Mental Health and Substance Use Disorders for treatment or call SAMHSA's National Helpline, 800-662-4357 or go to http://www.findtreatment.gov.
• For more information, visit www.geha.com/Healthy-Pregnancy.

In-network: Nothing for preventive prenatal and postpartum care (no deductible)

Out-of-network: You pay all charges 

In-network: Nothing for preventive prenatal and post-partum care (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

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 of Terms, for additional information. 

Benefits are allowable for services of a certified doula providing in person or virtual 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

All charges in excess of $1,000 (no deductible)

All charges in excess of $1,000 (no deductible) 

Not covered:

• Home uterine monitoring devices 
• Services for birth coaching or labor support, except when provided by a certified doula. See Section 10, Definitions of Terms

All charges

All charges

Contraceptive counseling on an annual basis.

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

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

For additional Family Planning and Prescription drug coverage, see Section 5(f).

Notes:

Your plan offers some type 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 contraceptive procedure that is not already available may be requested through the contraceptive exceptions process. For pharmacy related exception requests, call 855-240-0536. For medical exception requests, call 800-821-6136. Additional information is available on our website at  www.geha.com/Family-Planning-Options.

Once we have been contacted with exception request information sufficient for us to make a determination, you will receive a response within 24 hours or the next business day. Contraceptive exception requests are not subject to Section 8, The Disputed Claims Process.  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: You pay all charges 

In-network: Nothing (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Voluntary male sterilization

In-network: Nothing (no deductible)

Out-of-network: You pay all charges 

In-network: Nothing (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Reversal of voluntary surgical sterilizations
• Genetic testing and counseling 

Infertility definition can be found in Section 10, Definitions of Terms.

Diagnosis and treatment of infertility specific to:

• Artificial insemination (AI)
• Intravaginal insemination (IVI)
• Intracervical insemination (ICI)
• Intrauterine insemination (IUI)

In-network: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: 25% of the Plan allowance  

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Fertility preservation for iatrogenic infertility:

• Procurement of sperm or eggs including medical, surgical, and pharmacy claims associated with retrieval; 
• Cryopreservation of sperm and mature oocytes; and
• Cryopreservation storage costs for 12 months.

Notes:

• All Infertility and related services within this section, Preauthorization is required. See Section 3, Other services that require preauthorization.
• See Section 5(b), Surgical procedures for cost share associated with covered surgical services. 
• Fertility drugs (See Section 5(f), Prescription Drug Benefits, Plan limits apply.)

In-network: $30 copayment for office visits to primary care providers (no deductible); $50 copayment for office visits to specialists (no deductible)

Out-of-network: You pay all charges

In-network: $10 copayment for office visits to primary care providers (no deductible); $30 copayment for office visits to specialists (no deductible)

Out-of-network: 50% of the Plan allowance (deductible applies) and any difference between our allowance and the billed amount

Not covered:

• Assisted reproductive technology (ART), See Section 10, Definitions of Terms. 
  • In vitro fertilization (IVF), See Section 10, Definitions of Terms. 
  • 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 for reasons other than listed above, 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 benefits, 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 
• Treatments such as artificial insemination, assisted reproductive technology, and/or in vitro fertilization prior to establishing diagnosis of infertility. See Section 10, Definitions of Terms 

• Testing and treatment, including materials (such as allergy serum)
• Allergy injections 

In-network: $30 copayment for primary care providers (no deductible); $50 copayment for specialists (no deductible)

Out-of-network: You pay all charges

In-network: $10 copayment for primary care providers (no deductible); $30 copayment for specialists (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Clinical ecology and environmental medicine
• Provocative food testing
• Sublingual allergy desensitization drugs

All charges

All charges

• Intravenous (IV)/Infusion Therapy - Home IV/infusion and antibiotic therapy
  • See Section 5(c) for Outpatient therapy services
• Total Parenteral Nutrition (TPN)
• Intrathecal pump refills
• Enteral/Tube feeding nutrition, including Medical Foods for Inborn Errors of Metabolism (IEM). See Section 10, Definitions of Terms. 
• Chemotherapy and radiation therapy - Preauthorization is required. See Section 3, Other services that require preauthorization.

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. 

• Respiratory and inhalation therapies
• Growth hormone therapy (GHT)

Note: Growth hormone therapy (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.

Notes: 

• Most medications required for treatment therapies are available under Section 5(f), Specialty drug benefits. 
• Applied Behavioral Analysis Therapy is available under the Mental Health and Substance Use Disorder Benefits in Section       5(e).
• Outpatient therapy (including cardiac and pulmonary rehabilitation). See Section 5(c), Outpatient hospital services for applicable outpatient facility charges. 

In-network: $30 copayment for primary care providers (no deductible); $50 copayment for specialists (no deductible)

Out-of-network: You pay all charges

You pay 10% of the Plan allowance for drugs and/or medical nutrition administered or obtained in connection with your treatment (excludes drugs obtained under the Prescription drug benefit in Section 5(f)). 

Note: Specialty drugs obtained outside of the pharmacy benefit from other sources (physician offices, home health agencies, outpatient hospitals) may be subject to additional cost share as outlined in Section 5(f), Specialty drug benefits.

In-network: 25% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Dialysis

• Dialysis - hemodialysis and peritoneal dialysis 
• Initial home dialysis training for the member and a helper is covered. 

Note:

• See Section 5(f), Prescription drug benefits, for available medications required for treatment therapies. 

In-network: $30 copayment for primary care providers (no deductible); $50 copayment for specialists (no deductible)

Out-of-network: You pay all charges

In-network: 25% of the Plan allowance

Out-of-network: 50% 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
• "Grocery" food items that can routinely be obtained online or in stores (e.g., gluten-free breads)
• Maintenance cardiac and pulmonary rehabilitation
• Topical hyperbaric oxygen therapy
• Prolotherapy 
• On-going licensed/unlicensed dialysis assistance in the home after initial dialysis training

All charges

All charges

Outpatient therapy visits are covered, per person, per calendar year for the combined services when a physician:

• orders the care;
• identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• indicates the length of time the services are needed.

Notes: 

• Inpatient therapy services are not applied to the visit limits, see Section 5(c), Inpatient hospital 
• Rehabilitative and Habilitative therapy, see Section 10, Definitions of Terms

In-network: $30 copayment per visit for primary care providers (no deductible); $50 copayment per visit for specialists (no deductible), for up to 60 therapy visits

Out-of-network: You pay all charges 

In-network: $10 copayment per visit for primary care providers (no deductible); $30 copayment per visit for specialists (no deductible), for up to 30 therapy visits

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Exercise programs
• Long-term rehabilitation therapy
• Maintenance therapy-measurable improvement is not expected, or progress is no longer demonstrated
• Computers, tablets, wearable or digital devices, software or application programs (“apps”, including phone apps), and subscriptions are not covered (even if ordered by a doctor) unless explicitly stated as a covered service or as offered through participation in a clinical program.
• Hot and cold packs
• Hippotherapy
• Sensory, Auditory, or Sensory Integration Therapy
• Biofeedback, educational, recreational or milieu therapy

All charges

All charges

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

Services will only be covered when provided by the following while practicing within their scope of care:

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

In-network: $30 copayment for office visits to primary care providers (no deductible); $50 copayment for office visits to specialists (no deductible)

Out-of-network: You pay all charges 

In-network: $10 copayment for office visits to primary care providers (no deductible); $30 copayment for office visits to specialists (no deductible)

Out-of-network: 50% 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.
• Implanted hearing-related devices, such as bone anchored hearing aids

Notes:

• For routine hearing screening performed during a child's preventive care visit, see Section 5(a), Preventive care, children.
• For benefits for the devices, see Section 5(a), Orthopedic and prosthetic devices

In-network: $30 copayment for office visits to primary care providers (no deductible); $50 copayment for office visits to specialists (no deductible)

Out-of-network: You pay all charges 

In-network: $10 copayment for office visits to primary care providers (no deductible); $30 copayment for office visits to specialists (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• External hearing aids

Note: See Non-FEHB Benefits Available to Plan Members for additional hearing aid discount program information.

All charges in excess of $1,500 (no deductible)

Payable per person every 36 months for adults, and every 12 months for children up to age 22

All charges

Not covered:

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

• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)

In-network: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: 25% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• Diagnosis and treatment of diseases of the eye
• Outpatient vision therapy for treatment of convergence insufficiency up to a maximum of 24 visits per year for ages 5-18

In-network: $30 copayment for office visits to primary care providers (no deductible); $50 copayment for office visits to specialists (no deductible)

Out-of-network: You pay all charges 

In-network: $10 copayment for office visits to primary care providers (no deductible); $30 copayment for office visits to specialists (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Eyeglasses or contact lenses and examinations for them, except as shown above
• Radial keratotomy and other refractive surgeries
• Special multifocal ocular implant lenses
• Computers, tablets, wearable or digital devices, software or application programs (“apps”, including phone apps), and subscriptions are not covered (even if ordered by a doctor) unless explicitly stated as a covered service or as offered through participation in a clinical program.
• Vision therapy except as noted above
• Eye exercises and orthoptics

All charges

All charges

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

In-network: $30 copayment for office visits to primary care providers (no deductible); $50 copayment for office visits to specialists (no deductible)

Out-of-network: You pay all charges

In-network: $10 copayment for office visits to primary care providers (no deductible); $30 copayment for office visits to specialists (no deductible)

Out-of-network: 50% 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 

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

Out-of-network: You pay all charges

All charges in excess of $150 (no deductible), in- and out-of-network combined

Not covered:

• Cutting, trimming, or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (except for surgical treatment)

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

   

Notes:

• 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.
• We will pay only for the cost of the standard item. Coverage for specialty items is limited to the cost of the standard item.
• Preauthorization is required, see Section 3, Other services that require preauthorization, for orthopedic and prosthetic devices with a retail price of $1,000 or more. 

In-network: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: 25% of the Plan allowance 

Out-of-network: 50% 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 
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices 

We cover rental or purchase of prescribed durable medical equipment, at our option, including repair and adjustment.

Covered items include:

• Oxygen
• Certain medical supplies
• Rental of dialysis equipment
• Standard hospital beds
• Standard wheelchairs
• Crutches
• Walkers
• Continuous Positive Airway Pressure (CPAP) machine
• Braces including necessary adjustments to shoes to accommodate braces, which are used for the purpose of supporting a weak or deformed body part
• Braces restricting or eliminating motion in a diseased or injured part of the body
• Bone growth stimulators

Notes:

• Call us at 800-821-6136 as soon as your physician prescribes this equipment.  We arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.
• Preauthorization is required, See Section 3, Other services that require preauthorization, for Durable Medical Equipment that has a cumulative rental and/or retail purchase price of $1,000 or more. 
• See Section 10, Definitions of Terms for Medical Necessity
• Refer to Section 5(f), Prescription drugs/Covered medications and supplies, to obtain glucose meter and diabetic supplies.

In-network: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: 25% of the Plan allowance 

Out-of-network: 50% 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/Healthy-Pregnancy.

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

In-network: Nothing (no deductible)

Out-of-network: You pay all charges

In-network: Nothing (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Speech Generating Devices

Notes:

• For definition, see Definitions of Terms, Section 10.
• Preauthorization is required, See Section 3, Other services that require preauthorization
• 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 (no deductible)

Out-of-network: You pay all charges

All charges in excess of $1,250 per calendar year (no deductible), in- and out-of-network combined

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

Note: One wig/cranial hair prosthesis per lifetime.

All charges in excess of $350 (no deductible) 

All charges in excess of $350 (no deductible) 

Not covered:

• Motorized wheelchairs and other power operated vehicles unless meeting ACA requirements and medical necessity
• Deluxe or upgraded equipment and supplies
• 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, Definitions of Terms) 
• Lifts, such as seat, chair, hydraulic, or van lifts
• 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 
• 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.

Services are limited to 50 visits per calendar year as defined by service type billed by the home health agency.

Notes:

• Medically necessary part-time or intermittent skilled nursing care by a licensed Home Health agency, when ordered by an appropriate medical professional, for services such as:

  • Wound care for pressure sores or a surgical wound
  • Patient and caregiver education
  • Intravenous or nutrition therapy
  • Injections
  • Monitoring serious illness and unstable health status
• Please refer to the Specialty drug benefits in Section 5(f), Prescription Drug Benefits, for information on benefits for home infusion therapy medications.
• See Durable medical equipment (DME) above for coverage of DME benefit services received in the home.

In-network: $30 copayment (no deductible)

Out-of-network: You pay all charges 

In-network: 25% of the Plan allowance 

Out-of-network: 50% 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, Definitions of Terms)
• Long-term care (see Section 10, Definitions of Terms)
• Services or supplies furnished by immediate relatives or household members, such as spouse, parents, children, brothers or sisters by blood, marriage or adoption
• Private duty nursing

Chiropractic services 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: $30 copayment (no deductible), for up to 15 visits, per person, per calendar year

Out-of-network: You pay all charges 

In-network: $10 copayment (no deductible), for up to 12 visits, per person, per calendar year

Out-of-network: 50% 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, cold pack application, naturopathic services and rolfing 
• Maintenance therapy - measurable improvement is not expected or progress is no longer demonstrated

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: $30 copayment (no deductible)

Out-of-network: You pay all charges 

In-network: $10 copayment (no deductible)

Out-of-network: 50% 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

Participation in the Plan’s Virtual partner’s weight management program, including Intensive Behavioral Therapy (IBT) is required before and during for approval of any anti-obesity medication or surgical intervention. The program supports both adult and pediatric populations and is integrated with any current treatment to support continuity of care.

IBT program includes obesity risk stratification, nutritional (dietary) assessment and medical nutrition therapy, focused on diet, physical activity, and behavior change, including any past history of weight-loss efforts aligning with evidence-based clinical guidelines (USPSTF, OMA, AACE/ACE).

For children, IBT will include counseling, nutrition help, and family support from licensed providers aligning with CDC-recognized Family Healthy Weight Programs (FHWP) or equivalent models, with program intensity, care pathways, and delivery requirements.

Prior Authorization (See Section 3) is required for metabolic surgery or anti-obesity medications. (See Section 5(b) Surgical procedures or Section 5(f) for more information about weight-loss medications).

Note: For more information on our Weight Management administrative partner, see Section 5(h), Wellness and Other Special Features.

$0 Copayment (no deductible) for members who enroll with the Plan’s Virtual Weight Management partner

$0 Copayment (no deductible) for members who enroll with the Plan’s Virtual Weight Management partner

Coverage is limited to:

• Tobacco Cessation programs - We cover counseling sessions including, proactive phone counseling, group counseling and individual counseling. 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 to treat tobacco dependence.

Note: The quantity of drugs reimbursed will be subject to recommended courses of treatment. You may obtain tobacco cessation drugs with your Plan identification card, through a participating network retail Pharmacy or Elevate Plus members may obtain through CVS Caremark Mail Service Pharmacy. (See filing instructions in Section 5(f), Prescription drug benefits.)

In-network: Nothing (no deductible)

Out-of-network: You pay all charges 

In-network: Nothing (no deductible)

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

Diabetes self-management 

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: You pay all charges 

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  

Note: Provided by a dietitian with a state license or statutory certification. Nutritional counseling must be ordered by a physician.

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

Out-of-network: You pay all charges

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

Out-of-network: 50% 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/Plan providers. 

For more information visit www.geha.com/Healthy-Pregnancy. 

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

Out-of-network: You pay all charges

All charges in excess of $150 (no deductible), in- and out-of-network combined

Not covered:

• Weight loss programs, except as specified by the brochure.

All charges

All charges

A comprehensive range of services, such as

• Operative procedures
• Treatment of fractures, including casting
• Routine 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 deficit (see Reconstructive surgery below)
• 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 medically necessary. Registered nurse first assistants and certified surgical assistants are covered up to 15% of our allowance if medically necessary.
• Surgical treatment of severe obesity (bariatric surgery). 

Preauthorization is required, see Section 3, Other services that require preauthorization. See www.geha.com/Provider-Partner-Tools for additional information on policy and criteria.

When multiple surgical procedures performed during the same operative session add time or complexity to patient care, our benefits are available on our website at www.geha.com/Provider-Policies.

Note: Multiple 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.

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

In-network: 20% of the Plan allowance

Out-of-network: You pay all charges

In-network: $250 copayment (no deductible) per performing surgeon, for surgical procedures performed in an inpatient setting

In-network: 25% of the Plan allowance, for surgical procedures performed in all other settings

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot (see Section 5 (a), Foot care)
• Surgical treatment of hyperhidrosis unless alternative therapies such as botox injections or topical aluminum chloride and pharmacotherapy have been unsuccessful
• Removal of excess skin unless medically necessary

• 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. Examples of congenital anomalies are: cleft lip; cleft palate; birth marks; and webbed fingers and toes.
• Surgeries to correct congenital anomalies for individuals age 18 and older unless there is a functional deficit

Note: Covered for children under the age of 18 regardless of functional deficit. 

• 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)

Notes:

• 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.
• 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.
• Preauthorization is required, see Section 3, Other services that require preauthorization.

In-network: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: $250 copayment (no deductible) per performing surgeon, for surgical procedures performed in an inpatient setting

In-network: 25% of the Plan allowance, for surgical procedures performed in all other settings

Out-of-network: 50% 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, see section 5(d), Accidental injury.
• Surgeries related to sexual dysfunction
• Surgery for Sex-Trait Modification to treat gender dysphoria 

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 
• Orthognathic surgery for the following conditions only: 
  • 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
• 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

Notes: 

• Accidental dental injury benefit is covered see Section 5(g),      Dental benefits.
• Preauthorization is required, see Section 3, Other services that require preauthorization.

In-network: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: $250 copayment (no deductible) per performing surgeon, for surgical procedures performed in an inpatient setting

In-network: 25% of the Plan allowance for surgical procedures performed in all other settings

Out-of-network: 50% 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 or orthognathic surgery not specifically listed as covered 
• Apicoectomy, Alveolectomy, root canal therapy

These solid organ and tissue transplants are covered and 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 

Note: All transplants and related services within this section, Preauthorization is required. See Section 3, Refer to Other services that require preauthorization.

In-network: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: $250 copayment (no deductible) per performing surgeon, for surgical procedures performed in an inpatient setting

In-network: 25% of the Plan allowance for surgical procedures performed in all other settings

Out-of-network: 50% 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. 

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

In-network: 20% of the Plan allowance

Out-of-network: You pay all charges

In-network: $250 copayment (no deductible) per performing surgeon, for surgical procedures performed in an inpatient setting

In-network: 25% of the Plan allowance for surgical procedures performed in all other settings

Out-of-network: 50% 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. 

• 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 amendable 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, Sanfilippo’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
  • Pineoblastoma
  • Scleroderma
  • Scleroderma - SSC (severe, progressive)
  • Systemic sclerosis
  • Testicular, mediastinal, retroperitoneal and ovarian germ cell tumors
  • Waldenstrom’s macroglobulinemia

In-network: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: $250 copayment (no deductible) per performing surgeon, for surgical procedures performed in an inpatient setting

In-network: 25% of the Plan allowance for surgical procedures performed in all other settings

Out-of-network: 50% 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.

• 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, 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: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: $250 copayment (no deductible) per performing surgeon, for surgical procedures performed in an inpatient setting

In-network: 25% of the Plan allowance for surgical procedures performed in all other settings

Out-of-network: 50% 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: 20% of the Plan allowance

Out-of-network: You pay all charges 

In-network: $250 copayment (no deductible) per performing surgeon, for surgical procedures performed in an inpatient setting

In-network: 25% of the Plan allowance for surgical procedures performed in all other settings

Out-of-network: 50% 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, excluding cornea, 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 Plan-designated transplant facility.  
• Transportation benefits are only payable when we are the primary payor.
• Transportation benefits are payable for follow-up care up to one year following the transplant.
• You must contact Customer Care at 800-821-6136 for what are considered reasonable temporary living expenses.

All charges in excess of $10,000 (no deductible)

All charges in excess of $10,000 (no deductible)

National Transplant Program (NTP)

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

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 G.E.H.A'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. G.E.H.A 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.
• 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.

Services are paid at regular Plan benefits

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

Services are paid at regular Plan benefits

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

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 as listed above
• Implants for artificial organs

Professional fees for the administration of anesthesia in:

• Hospital (inpatient)
• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office 

Notes:

• 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: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: 25% of the Plan allowance 

Out-of-network: 50% 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

All charges

Room and board, such as:

• Ward, semiprivate, or intensive care accommodation
• 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.

Other hospital services and supplies, such as:

• Operating, recovery, maternity 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
  • See Section 5(a) for any applicable Durable Medical Equipment (DME) cost share.

Notes:

• Precertification is required in advance of admission, see Section 3, Other services that require preauthorization.
• We base payment on whether the facility or a healthcare professional bills 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: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: 25% of the Plan allowance

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Any part of a hospital admission that is not medically necessary, see Section 10, Definitions of Terms, 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 of Terms)
• Long-term care (see Section 10, Definitions of Terms)
• Non-covered facilities such as nursing homes or schools
• Personal comfort items such as phone, television, barber services, guest meals and beds
• Private nursing care

• Operating, recovery, observation, and other treatment rooms
• Prescribed drugs and medications
• Administration of blood, blood plasma, and other biologicals
• Blood or blood plasma, if not donated or replaced
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
• Outpatient cardiac and pulmonary rehabilitation, 36 visit maximum each per year
• Respiratory and inhalation therapies

Notes:

• Surgical benefits, not maternity benefits, apply to circumcision.
• 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.

In-network: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: 25% of the Plan allowance 

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Outpatient diagnostic and treatment services performed and billed by a facility, such as but not limited to: 

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology

In-network: Nothing (no deductible)

Out-of-network: You pay all charges

In-network: 25% of the Plan allowance 

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Outpatient diagnostic testing and treatment services performed and billed by a facility, such as but not limited to:

• X-rays 
• Non-routine mammograms 
• Ultrasound
• Electrocardiogram and EEG 

In-network: $50 copayment per day per facility (no deductible)

Out-of-Network: You pay all charges 

In-network: 25% of the Plan allowance 

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Outpatient diagnostic testing and treatment services performed and billed by a facility, such as but not limited to: 

• CT/CAT Scan
• MRI

Note: Preauthorization is required for these tests

In-network: $75 copayment per day per facility (no deductible)

Out-of-network: You pay all charges

In-network: 25% of the Plan allowance 

Out-of-network: 50% 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

All charges

Treatment Therapies - Preauthorization is required, see Section 3, Other services that require preauthorization.

• Intravenous (IV)/Infusion Therapy - Outpatient IV/infusion and antibiotic therapy
• Intrathecal pumps refills
  • Note: The per diem (daily) rate for intrathecal pump refill will only be reimbursed on the day of the refill. No daily per diems will be allowed. 
• Chemotherapy and radiation therapy - Preauthorization required for chemotherapy and radiation therapy
  • Note: High-dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed in Section 5(b), Services Provided by a Hospital or Other Facility, and Ambulance Services. 

Note:

• Medications required for treatment therapies may be available under the Prescription drug benefits in Section 5(f). 

In-network: 20% of the Plan allowance 

You pay 10% of the Plan allowance (deductible applies) for drugs administered or obtained in connection with your treatment (excludes drugs obtained under the Prescription drug benefit in Section 5(f)).

Note: Specialty drugs obtained outside of the pharmacy benefit from other sources (physician offices, home health agencies, outpatient hospitals) may be subject to additional cost share as outlined in Section 5(f), Specialty drug benefits.

Out-of-network: You pay all charges

In-network: 25% of the Plan allowance 

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount. 

Skilled nursing facility (SNF): We cover semiprivate room, board, services and supplies in a SNF for up to 50 days per confinement when:

• SNF care is medically appropriate (prior authorization is required, See Section 3).
  

In-network: 20% of the Plan allowance

Out-of-network: You pay all charges

All charges

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  re-entered (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.

Note: See Section 5(a), Medical services and supplies provided by physicians and other health care professionals, diagnostic and treatment services, professional services of physicians.

In-network: Charges in excess of $30,000 (deductible applies)

Out-of-network: You pay all charges 

Charges in excess of $30,000 (deductible applies)

Not covered:

• Charges incurred during a period of remission
• Bereavement counseling, pastoral counseling, financial or legal counseling
• Funeral arrangements
• Homemaker or caretaker services

Ambulance (Local and Air): Please see Section 5(d), Ambulance for complete ambulance benefit coverage information.

Note: Medical Necessity review is required for all air ambulance transportation.

Services are paid at the regular Plan benefits.

Services are paid at the regular Plan benefits.

If you receive care for your accidental injury within 48 hours, we cover:

• Non-surgical physician services and supplies
• Related outpatient hospital services

Note: We pay hospital benefits if you are admitted.

In-network: 25% of the Plan allowance

Note: Out-of-network emergency care is paid at the in-network level

In-network: 35% of the Plan allowance

Note: Out-of-network emergency care is paid at the in-network level

If you receive care for your accidental injury after 48 hours, we cover:

• Non-surgical physician services and supplies
• Surgical care

Note: We pay hospital benefits if you are admitted.

In-network: 25% of the Plan allowance

Note: Out-of-network emergency care is paid at the in-network level

In-network: 35% of the Plan allowance

Note: Out-of-network emergency care is paid at the in-network level

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

Notes:

• We pay hospital benefits if you are admitted.
• We will also provide in-network benefits for professionals who provide services in an out-of-network hospital, when admitted due to a medical emergency.

In-network: 25%  of the Plan allowance 

Note: Out-of-network emergency care is paid at the in-network level

In-network: 35% of the Plan allowance 

Note: Out-of-network emergency care is paid at the in-network level

Outpatient medical services and supplies billed by an urgent care facility

Note: This applies only to urgent care facilities, not providers that offer urgent care or after-hours services. 

In-network: $50 copayment (no deductible)

Out-of-network: You pay all charges 

In-network: $50 copayment (no deductible)

Out-of-network: 50% 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:

• to the first hospital where treated
• from the first hospital to the next nearest hospital or other medical facility only, if necessary, treatment is unavailable or medically 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: 20% of the Plan allowance

Note: Out-of-network emergency care and transport is paid at the in-network level

In-network: 25% of the Plan allowance

Out-of-network: 25% of the Plan allowance and any difference between our allowance and the
billed amount

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 transportation.

In-network: 20% of the Plan allowance

Note: Out-of-network emergency care and transport is paid at the in-network level

In-network: 25% of the Plan allowance

Note: Out-of-network emergency care and transport is paid at the in-network level

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 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

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.

Diagnosis or 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, or in-home therapy visits)
• Diagnosis and treatment of substance use disorders including detoxification, treatment and counseling
• Professional charges for intensive day treatment in a provider’s office or other professional setting 
  • Preauthorization is required, see Section 3, Other services that require preauthorization. 

In-network: $30 copayment per office visit (no deductible)

Out-of-network: You pay all charges

In-network: $10 copayment per office visit (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

• Electroconvulsive therapy (ECT) - facility fees may also apply
• Inpatient professional fees

In-network: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: 25% of the Plan allowance 

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

One visit to a primary care or specialist for the management of a mental health condition or substance use disorder as a follow up within 30 days of:

• Inpatient confinement
• Emergency room visit

In-network: Nothing (no deductible)

Out-of-network: You pay all charges 

In-network: Nothing (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

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 for the first 5 visits for treatment of prenatal and postpartum depression, after which the $30 copayment applies (no deductible)

Out-of-network: You pay all charges

In-network: Nothing for the first 5 visits for treatment of prenatal and postpartum depression, after which the $10 copayment applies (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Note: Here are some things to keep in mind:

• Preauthorization is required, see Section 3, Other services that require preauthorization.  
• Required diagnosis of ASD (Autism Spectrum Disorder) by a provider qualified to make the diagnosis: Board Certified Behavior Analyst (BCBA), psychiatrist, or 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 (BCBA) 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.

In-network: $30 copayment per office visit (no deductible) 

Out-of-network: You pay all charges

In-network: 25% of the Plan allowance

Out-of-network: 50% 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

Note: Certain diagnostic tests are not subject to deductible. See Section 5(a), Lab, x-ray and other diagnostic tests, for applicable cost share

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

See diagnostic tests, Section      5(a) and 5(c).

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

See diagnostic tests, Section      5(a) and 5(c).

• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment

Notes:

• Preauthorization required for testing exceeding 8 hours/calendar year
• See Section 5(c), for any applicable outpatient facility charges

In-network: 20% of the Plan allowance 

Out-of-network: You pay all charges

In-network: 25% of the Plan allowance 

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Behavioral health professional services through the Plan's administrative partner for:

• Mental health counseling
• Substance use disorder counseling

Note:

• For more information on telehealth benefits, please see Section 5(h), Wellness and Other Special Features, or visit www.geha.com/Telehealth-Visit.

Nothing (no deductible)

Nothing (no deductible)

Telehealth professional services provided by a healthcare provider other than the Plan's telehealth administrative partner. 

In-network: $30 copayment for office visits to primary care providers (no deductible)

Out-of-network: You pay all charges 

In-network: $10 copayment for office visits to primary care providers (no deductible)

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Precertification is required in advance of admission. 

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services

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

In-network: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: 25% of the Plan allowance 

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

Preauthorization required, see Section 3, Other services that require preauthorization.

Outpatient services provided and billed by a hospital or other covered facility, services such as:

• Services such as partial hospitalization, residential treatment, full-day hospitalization, or facility-based intensive outpatient treatment
• Electroconvulsive therapy
• Transcranial Magnetic Stimulation (TMS)

In-network: 20% of the Plan allowance 

Out-of-network: You pay all charges 

In-network: 25% of the Plan allowance 

Out-of-network: 50% of the Plan allowance and any difference between our allowance and the billed amount

See Section 5(d), Medical emergency

Services are paid at the regular Plan benefits.

Services are paid at the regular Plan benefits.

Not covered:

• ABA therapy services provided by the school 
• 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
• Services rendered or billed by schools, halfway houses, or sober homes
• Hypnotherapy
• Respite care, outdoor residential programs, recreational therapy, educational therapy or classes
• Outward Bound programs, including equine therapy provided during the approved stay
• Personal comfort items, such as guest meals and beds, telephone, 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.)
• 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 

All charges

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; 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 are not covered by the Plan. For these drugs, generics and/or therapeutic 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 a review for medical necessity until the formulary status is determined. Please visit our website at www.geha.com/Prescriptions-Summary to view formulary medications and the most current list of specialty drugs. You may also call CVS Specialty at 800-237-2767.

The Elevate Plus Option 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 similar to one another, with similar effectiveness and safety. The Elevate Option includes a Value Formulary. The Value Formulary is a closely managed drug list and an array of utilization management (UM) strategies, including classes largely managed with specialty medications. Both Elevate and Elevate Plus formularies incorporate step therapy, where a generic/preferred medication is used prior to a brand and/or non-preferred medication.

Notes: 

• 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.
• Please visit our website at www.geha.com/Prescriptions-Summary to view the most current list of specialty drugs. You may also call CVS Caremark at 844-443-4279 or CVS Specialty at 800-237-2767.
• 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 healthcare costs.

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 G.E.H.A.
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 G.E.H.A, 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.geha.com/Prescriptions-Summary) 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 G.E.H.A reimbursement will be based on the G.E.H.A 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 G.E.H.A, 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.geha.com/Prescriptions-Summary) 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 primary 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.geha.com/Prescriptions-Summary) or Caremark mobile app (available for Android and Apple).

In any event, if you use G.E.H.A’s plan ID card when another insurance plan is primary, you will be responsible for reimbursing      G.E.H.A 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 G.E.H.A’s retail Plan allowable benefit. Our secondary and tertiary claim payment is the lesser of:

• what G.E.H.A would have paid in the absence of other primary coverage, or
• the balance due after the primary carrier’s payment.

Note: G.E.H.A secondary and tertiary member responsibility could be higher than G.E.H.A'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 – Elevate Plus Option members also have the opportunity to receive Medicare Part B-eligible medications by mail. 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.

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

G.E.H.A 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 - G.E.H.A reserves the right to maximize your quality of care as it relates to the utilization of pharmacies.

G.E.H.A will participate in other approved managed care programs, as deemed necessary, to ensure patient safety.

You must fill your prescription at a participating network retail pharmacy. To locate participating pharmacies, call CVS Caremark at 844-443-4279 or visit www.geha.com/Prescriptions-Summary. 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.

Claims (electronic or paper) processed through a non-network pharmacy will not be paid unless they are filled outside of the United States or United States territories.

Through this service, Elevate Plus Option members may receive up to a 90-day supply per prescription of maintenance medications and/or supplies for drugs which require a prescription. 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.

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/Mail-Order-Rx; enclose your prescription and the correct copayment/coinsurance.

Under regular circumstances, you should receive your medication within approximately 14 days from the date you mail your prescription. If you have any questions or need an emergency consultation with a registered pharmacist, you may call CVS Caremark at 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.

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 844-443-4279. Have your prescription bottle with the prescription information ready.

To order by mail: Simply mail the G.E.H.A Mail Order Form and copayment/coinsurance to CVS Caremark, PO Box 659541, San Antonio, TX 78265-9541.

To order online: Go to www.geha.com/Prescriptions-Summary.

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.

Network Retail Pharmacy

You must fill your prescription at a participating network retail pharmacy. 

• 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;
• FDA approved contraceptive drugs and devices for women;
• Diabetic medications and supplies, such as:
  • Insulin;
  • Needles and syringes for the administration of covered medications;
  • Blood glucose meter to be provided at no charge by the manufacturer.
    • Elevate Plus Option members may contact CVS Caremark Mail Service Pharmacy: 877-418-4746.
    • Elevate Option members may contact their participating retail pharmacy or CVS Caremark Customer Care for specifics on how to obtain a free meter at 844-443-4279.
• Drugs associated with artificial insemination and/or drugs associated with up to three (3) cycles of in vitro fertilization (IVF) treatment. Prior authorization is required.
• Medications prescribed to treat obesity. Prior authorization is required.
• Prescription prenatal vitamins;
• Covered ostomy supplies (please include the manufacturer’s product number to ensure accurate fill of the product).

Notes:

• If there is no generic equivalent available, you will pay the brand name copay/coinsurance.
• Medications to treat some complex and chronic medical conditions are only available through CVS Specialty. See CVS Caremark formulary for the categories of drugs in this program.

Generic:

• $15 for up to a 30-day supply
• $30 for a 31-60 day supply
• $45 for a 61-90 day supply 

or the retail pharmacy’s usual and customary cost of the drug, whichever is less

Preferred:

• $100 for up to a 30-day supply 
• $200 for a 31-60 day supply
• $300 for a 61-90 day supply

or the retail pharmacy’s usual and customary cost of the drug, whichever is less

Non-Preferred: 50% of Plan allowance for up to a 90-day supply

Generic:

• $10 for up to a 30-day supply
• $20 for a 31–60 day supply
• $30 for a 61-90 day supply 

or the retail pharmacy’s usual and customary cost of the drug, whichever is less 

Preferred:

50% of Plan allowance up to a maximum of:

• $500 for up to a 30-day supply
• $1,000 for a 31-60 day supply
• $1,500 for a 61-90 day supply 

or the retail pharmacy’s usual and customary cost of the drug, whichever is less 

Non-Preferred: You pay 100% of all charges

Non-Network Retail Pharmacy

You pay 100% of all charges

You pay 100% of all charges

CVS Caremark Mail Service Pharmacy

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

• 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.
• FDA approved contraceptive drugs and devices for women;
• Diabetic medications and supplies, such as:
  • Insulin;
  • Needles and syringes for the administration of covered medications;
  • Blood glucose meter to be provided at no charge by the manufacturer.
    • Elevate Plus Option members may contact CVS Caremark Mail Service Pharmacy: 877-418-4746.
    • Elevate Option members may contact their participating retail pharmacy or CVS Caremark Customer Care for specifics on how to obtain a free meter at 844-443-4279.
• Prescription prenatal vitamins;
• Covered ostomy supplies (please include the manufacturer’s product number to ensure accurate fill of the product).

Generic:  $20 or the cost of the drug, whichever is less

Preferred: $200 or the cost of the drug, whichever is less

Non-Preferred: 50% of Plan allowance

Not available

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

Network and Non-Network Retail
CVS Caremark Mail Service Pharmacy

Contraceptive coverage is available at no cost to FEHB 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.

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

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

CVS Caremark
P.O. Box 52136
Phoenix, AZ 85072-2136

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

Once we have been contacted with exception request information sufficient for us to make a determination, you will receive a response within 24 hours or the next business day. Contraceptive exception requests are not subject to Section 8. The Disputed Claims Process.  If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

Notes:

• For more information regarding prescription contraceptives, please refer to Preventive care medications in this section. Some contraceptives and services are covered under the medical benefit; see Section 5(a), Family planning. 
• 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 FEHB plan.

Nothing (no deductible)

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.geha.com/Prescriptions-Summary 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, growth hormone therapy, 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 copayment/coinsurance will be prorated. If you continue on this therapy, you may receive up to a 30-day supply of the medication. 

Your benefits may include 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 will need to call us at 800-821-6136 or visit www.geha.com/Provider-Partner-Tools.

*Your specialty benefit is limited to a 30-day supply. However, some specialty medications may not be available in a 30-day supply. Your coinsurance/copayment will be based on days of therapy (length of time medication remains in your system). 

CVS Specialty Pharmacy

All coinsurances are for up to a 30-day supply per prescription. Copay maximums apply per each 30-day supply. 

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

Notes:

• Recurring oral medications must be obtained through the pharmacy benefit.
• If Medicare denies coverage, G.E.H.A does not waive the coinsurance.

Generic and Preferred: 40% of Plan allowance up to a maximum of: 

• $700 for up to a 30-day supply
• $1,400 for up to a 60-day supply*
• $2,100 for up to a 90-day supply*

Non-preferred: 50% of Plan allowance, for up to a 30-day supply*

Generic and Preferred: 50% of Plan allowance up to a maximum of: 

• $500 for up to a 30-day supply
• $1,000 for up to a 60-day supply*
• $1,500 for up to a 90-day supply*

Non-preferred: You pay 100% of all charges

Specialty medications dispensed  by other sources including physician offices, home health agencies, outpatient hospitals may be paid under the medical benefit. If Medicare denies coverage your cost share is not waived. Recurring oral medications must be obtained through the pharmacy benefit.

You pay after the calendar year deductible:

• Generic and Preferred:      $500 copayment applies per prescription fill and 40% of the Plan allowance, up to a 30-day supply.
• Non-Preferred: $500 copayment applies per prescription fill and 60% of the Plan allowance, up to a 30-day supply.

You pay after the calendar year deductible:

• Generic and Preferred: $500 copayment applies per prescription fill and 50% of the Plan allowance, up to a 30-day supply. 
• Non-Preferred: You pay 100% of all charges.

Non-CVS Specialty Pharmacy retail purchase

You pay 100% of all charges 

You pay 100% of all charges 

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-share 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.

To receive preventive care benefits, a prescription from a doctor must be presented to the pharmacy. 

• Aspirin - All single ingredient generic oral dosage forms less than or equal to 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 less than 0.5mg for children 5 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 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 G.E.H.A's exclusive Specialty Pharmacy. 
• Iron supplements - Single ingredient pediatric oral liquids (requires a prescription) for children age 6-12 months. 
• Opioid rescue agent under this Plan with no cost share 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: www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose. Or call SAMHSA's National Helpline at 800-662-4357 or go to www.findtreatment.samhsa.gov. Prior authorization may be required on some formulations.
• 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)

Nothing (no deductible) 

• Immunizations: Vaccines; childhood and adult, Rx only
  • Coverage dependent on vaccine type.
  • G.E.H.A 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.

Note: Members may call CVS Caremark at 844-443-4279 to identify a participating vaccine pharmacy or go to www.geha.com/Prescriptions-Summary. G.E.H.A 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. G.E.H.A members should also ask retail pharmacies if there is an age requirement for vaccines that can be administered at that pharmacy.

Nothing (no deductible) 

Nothing (no deductible)

• 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 G.E.H.A ID card, through a participating network retail pharmacy or CVS Caremark Mail Service Pharmacy (Elevate Plus only), (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

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

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• 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 nutrition available without a prescription.  See Section 5(a), Treatment therapies for more information
• Nonprescription medications unless specifically indicated elsewhere
• Services or supplies for the administration of a non-covered medication
• 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

All charges

All charges

We cover restorative services and supplies necessary to promptly repair but not replace sound natural teeth. The need for these services must result from an accidental injury.

• Repair to sound natural teeth such as expenses for x-rays, drugs, crowns, bridgework, inlays and dentures.

Notes:

• We may review x-rays and/or treatment records in order to determine benefit coverage.
• See sections 5(a) through 5(f) for applicable services and benefits.

Services are paid at regular medical plan benefits.

Services are paid at regular medical plan benefits.

Not covered:

• Oral implants and transplants
• Masticating (biting or chewing) incidents are not considered to be accidental injuries. 

All charges

All charges

We have no other dental benefits.

N/A

N/A

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.

Earn rewards for healthy actions with G.E.H.A's Wellness Pays program. Total annual rewards are limited to $500 each for the subscriber and covered spouse. Maximum reward amounts are not guaranteed. Rewardable activities include, but may 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 medical expenses.

For detailed information about eligibility requirements, how to access the health assessment and all available rewards, visit www.geha.com/Reward-My-Health.

Call the G.E.H.A 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 the Plan's administrative partner. Go to 
www.geha.com/Telehealth-Visit 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, Definitions of Terms), dermatology conditions (see Section 10, Definitions of Terms), and counseling for mental health and substance use disorder.

Notes:

• This benefit is available at a reduced cost only through the Plan's administrative partner.
• Practitioners must be licensed in the state where the patient is physically located at the time services are rendered.

Your family’s healthcare resources, in your hands whether at home or on the go. The online member portal provides instant access to your family’s critical health information – anytime and anywhere. Whether you want to find a physician near you, check the status of a claim or speak directly with a healthcare professional, the portal is your go-to resource. Key features include:

• Search for physicians or facilities by location or specialty
• Store favorite physicians and facilities
• View and share health plan ID card information
• Access the Plan's telehealth administrative partner at  www.geha.com/Telehealth-Visit
• Check reward program status and activities
• Can be personalized with individual member avatar, notes and reminders
• Complete confidentiality
• Check health-related financial account balance
• Locate nearby convenience clinics, urgent care facilities, and emergency rooms
• Check status of deductible and out-of-pocket spending

For more information, visit www.geha.com/My-Member-Portal.

G.E.H.A 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 5(a))
• Behavioral change programs with coaching for members who qualify (see also Weight Management, Section 5(a))
• Discounts for gym memberships and other services through G.E.H.A Member Discount Program 
  

Visit www.geha.com/Your-Health-Journey for a list of programs, program criteria, and contact information. Please note that eligibility for these services may vary, and not all members will qualify.

G.E.H.A makes various maternity resources available to you or your covered dependent. Visit www.geha.com/Healthy-Pregnancy to order your packet on pregnancy and prenatal care and to learn more about the maternity program.   

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

G.E.H.A Care Management resources, and guidance are available to assist members or covered dependents through the infertility process. Visit www.geha.com/Family-Planning-Support. 

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

G.E.H.A 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/Pregnancy-Prep. 

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

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/My-Member-Portal.

In most cases, providers and facilities file HIPAA compliant electronic claims for you. In cases where a paper claim must be used, the provider must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form.

Note: The Elevate Plus Option does not provide out-of-network benefits except in cases of emergency. 

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

G.E.H.A 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:

G.E.H.A 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 a claim form that includes the information shown below or visit 
www.geha.com/UM-Care-Form. 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 codes such as ADA, CPT, HCPCS (including NDC numbers for all Drug type charges); and
• The charge for each service or supply
• 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.
• If your claim is for the rental or purchase of durable medical equipment; private duty nursing; and physical therapy, occupational therapy, or speech therapy, you must provide a written statement from the provider specifying the medical necessity for the service or supply and the length of time needed.
• 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 separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to each person. 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 facilities outside the United States and Puerto Rico, send a completed Overseas Claim Form and the itemized bills to: G.E.H.A, Medical Claims, PO Box 21172, Eagan, MN 55121. Obtain Overseas Claim Forms from www.geha.com/Health-Overseas-Access.

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 go to
www.geha.com/My-Member-Portal. Covered providers outside the United States will be paid at the in-network level of benefits, subject to the Plan deductible, copayments and/or 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. 

You may be required to pay for the services at the time you receive them and then submit a claim to us for reimbursement. Proof of payment is required to be submitted with Overseas Claim Form. Canceled checks, cash register receipts, or balance due statements are not acceptable. All foreign claim payments will be made directly to the enrollee.

When members living abroad are stateside and seeking medical care, contact us at 800-821-6136, or visit www.geha.com/Locate-Care to locate an in-network provider. When you are seeking treatment stateside, all precertification and authorization requirements are applicable. If you utilize an out-of-network provider, out-of-network benefits would apply on the Elevate Option. The Elevate Plus Option does not provide out-of-network benefits except in cases of emergency. 

Note: It is recommended that any member traveling outside the United States or territories purchase Travel Insurance.

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.

The Secretary of Health and Human Services has identified counties where at least 10% of the population is literate only in certain non-English languages. The non-English languages meeting this threshold in certain counties are Spanish, Chinese, Navajo and Tagalog. If you live in one of these counties, we will provide language assistance in the applicable non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes and its corresponding meaning, and the treatment code and its corresponding meaning.

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision.

b) To do so you may log in at www.geha.com/My-Member-Portal and complete the online appeal submission form or send your request to us at:

Pre-Service Appeals: G.E.H.A, PO Box 64, Huntingdon Valley, PA 19006 

or

Post-Service Appeals: G.E.H.A, PO Box 21324, Eagan, MN 55121

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and Explanation of Benefits (EOB) forms.

e) Include your email address (optional for member), if you would like to receive our decision via email. Please note that by giving us your email, we may be able to provide our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim; or

b) Write to you and maintain our denial; or

c) 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.

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us - if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employees Insurance Operations, FEHB 2, 1900 E Street NW, Washington, DC 20415-3620.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and Explanation of Benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim;
• Your daytime phone number and the best time to call; and
• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email address, you may receive OPM’s decision more quickly.

Notes:

• If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.
• You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.
• The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision or notify you of the status of OPM's review within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to file a lawsuit. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or preauthorization. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault. This is called “double coverage”.

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit www.naic.org or www.geha.com/Multiple-Plans.

When we are the primary payor, we will pay benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan processes the benefit, we will pay what is left of our allowance, minus any cost share you may owe, up to our regular benefit, or up to the member’s responsibility as determined by the primary plan, whichever is less. We will not pay more than what we would have paid if we were primary. When applicable, authorization must be given to Us to obtain information about benefits or services available from the other coverage, or to recover overpayments if this Plan previously paid as primary. All terms and conditions of this Plan, as secondary payor, remain in force.

If your primary payor requires preauthorization or requires you use designated facilities or provider for benefits to be approved, it is your responsibility to comply with these requirements. In addition, you must file the claim to your primary payor within the required time period. If you fail to comply with any of these requirements and benefits are denied by the primary payor, we will pay secondary benefits based on an estimate of what the primary carrier would have paid if you followed their requirements.

Please see Section 4, Your Costs for Covered Services, for more information about how we pay claims.

This Plan always pays secondary to:

• Any medical payment, PIP or No-Fault coverage under any automobile policy available to you.
• Any plan or program which is required by law.

You should review your automobile insurance policy to ensure that uncoordinated medical benefits have been chosen so that the automobile insurance policy is the primary payer.

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If  TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

Every job-related injury or illness should be reported as soon as possible to your supervisor. Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices. If you are a federal or postal employee, ask your supervisor to authorize medical treatment by use of form CA-16 before you obtain treatment. If your medical treatment is accepted by the Dept. of Labor Office of Workers' Compensation (OWCP), the provider will be compensated by OWCP. If your treatment is determined not job-related, we will process your benefit according to the terms of this Plan, including use of in-network providers. Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send it to your provider as soon as possible after treatment, to avoid complications about whether your treatment is covered by this Plan or by OWCP. 

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of  Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

If G.E.H.A pays benefits for an illness or injury for which you accrue a right of action, are entitled to compensation, or receive a settlement, judgment, or recovery from another party, you must agree to the provisions below. All G.E.H.A benefit payments in these circumstances are a condition of and a limitation on the nature, provision, or extent of coverage or benefits under the Plan, and remain subject to all of our contractual benefit limitations, exclusions, and maximums. By accepting these conditional benefits, you agree to the following:

• You or your representative must contact G.E.H.A’s Subrogation Vendor, The Rawlings Company, LLC, at 855-967-6609 as soon as possible after the event(s) that resulted in the illness or injury, and provide all requested information, including prompt disclosure of the terms of all settlements, judgments, or other recoveries. You must sign any releases G.E.H.A requires to obtain information about any claim(s) for compensation from other sources you may have.
• You must include all benefits paid by G.E.H.A in any claim for compensation you or your representative assert against any tortfeasor, insurer, or other party for the injury or illness, and assign all proceeds recovered from any party, including your own and/or other insurance, to G.E.H.A for up to the amount of the benefits paid.
• When benefits are payable under the Plan in relation to the illness or injury, G.E.H.A may, at its option:
  • Enforce its right of subrogation, that is, take over your right to receive payments from other parties. You will transfer to G.E.H.A any rights you or your representative may have to take legal action arising from the illness or injury, and to recover any sums paid on your behalf as a result of that action; or
  • Enforce its right of reimbursement, that is, recover any sums paid on your behalf from any payment(s) you or your representative obtain from other parties. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

You must cooperate in doing what is reasonably necessary to assist us, and you must not take any action that may prejudice these rights of recovery. It is your duty to notify the Plan within 30 days of the date when notice is given to any party, including an insurance company or attorney, of your intention to pursue or investigate a claim to recover damages or obtain compensation due to your injury, illness or condition. You and your agents or representatives shall provide all information requested by the Plan or its representatives. You shall do nothing to prejudice your FEHB plan’s subrogation or recovery interest or to prejudice the plan’s ability to enforce the terms of this provision. This includes, but is not limited to, refraining from making any settlement or recovery that attempts to reduce or exclude the full cost of all benefits provided by the Plan.

• To reimburse G.E.H.A on a first priority basis (i.e., before any other party) in full, up to the amount of benefits paid, out of any and all settlements, judgments, or other recoveries that you or your representative obtain from any source and no matter how characterized, designated, or apportioned (for example, as “pain and suffering only”). G.E.H.A enforces this right of reimbursement by asserting a lien against any and all recoveries obtained, including, but not limited to, first party Medpay, Personal Injury Protection, No-Fault coverage, Third-Party liability coverage, Uninsured and Underinsured coverage, personal liability umbrella coverage, and a workers compensation program or insurance policy. G.E.H.A’s lien consists of the total benefits paid to diagnose or treat the illness or injury. G.E.H.A’s lien applies first, regardless of the “make whole” and “common fund” doctrines. Your plan is not required to participate in or pay court costs or attorney fees to any attorney hired by you to pursue your damage claims.

G.E.H.A’s lien extends to all expenses incurred prior to the settlement or judgment date, even if those expenses were not submitted to G.E.H.A for payment at the time you reimbursed G.E.H.A. The lien remains your obligation until it is satisfied in full. Failure to refund G.E.H.A or cooperate with our recovery efforts may result in an overpayment that can be collected from you.

The provisions of this section apply to all current or former Plan participants and also to the parents, guardian, or other representative of a dependent child who incurs claims and is or has been covered by the Plan. The Plan’s right to recover (whether by subrogation or reimbursement) shall apply to the personal representative of your estate, heirs or beneficiaries, administrators, legal representatives, successors, assignees, minors, and incompetent or disabled persons. “You” or “your” includes anyone on whose behalf the plan pays benefits. No adult covered person hereunder may assign any rights that it may have to recover medical expenses from any tortfeasor or other person or entity to any minor child or children of said adult covered person without the prior express written consent of the Plan.

Some FEHB Plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB Plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on www.BENEFEDS.gov or by phone at 1-877-888-3337, (TTY 1-877-889-5680), you will be asked to provide information on your Plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally-funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application. 

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy. 
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. 
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This Plan does not cover these costs.

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" please contact Medicare at 800-633-4227, (TTY 877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share, and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan - You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor and you are an annuitant/ retiree, Medicare processes your claim first. In most cases, your claim will be coordinated automatically, and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-821-6136 or see our website at
www.geha.com/Medicare-Options.

For members enrolled in the Elevate Option, we do NOT waive deductibles, coinsurance, or copayments for Medicare members. 

For members enrolled in the Elevate Plus Option we waive some costs if the Original Medicare Plan is your primary payor as follows:

• Inpatient hospital benefits: If you are enrolled in Medicare Part A, we waive the copayment or the deductible and coinsurance.
• Outpatient facility benefits: If you are enrolled in Medicare Part B, we waive the copayment or the deductible and coinsurance.
• Medical services and supplies provided by physicians and other healthcare professionals: If you are enrolled in Medicare Part B, we waive the copayment or the deductible and coinsurance.
• Office visits providers and MinuteClinic^® (where available): If you are enrolled in Medicare Part B, we waive the copayment or the deductible and coinsurance for office visits.

Please review the following examples which illustrates your cost share if you are enrolled in Medicare Part B and the Elevate Plus Option. If you purchase Medicare Part B, then we waive some costs because Medicare will be the primary payor.

Elevate Plus Option

Benefit Description: Deductible
You Pay without Medicare: In-Network: $200
You Pay without Medicare: Out-of-Network: N/A
You Pay without Medicare Part B: In-Network: $0
You Pay without Medicare Part B: Out-of-Network: $0

Benefit Description: Catastrophic Protection Out-of-Pocket Maximum
You Pay without Medicare: In-Network: $7,000 self only/$14,000 family
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: $7,000 self only/$14,000 family
You Pay with Medicare Part B: Out-of-Network: N/A

Benefit Description: Part B Premium Reimbursement Offered
You Pay without Medicare: In-Network: N/A
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: N/A
You Pay with Medicare Part B: Out-of-Network: N/A

Benefit Description: Primary Care Provider
You Pay without Medicare: In-Network: $30
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: $0
You Pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Specialist
You Pay without Medicare: In-Network: $50
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: $0
You Pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Inpatient Hospital
You Pay without Medicare: In-Network: 20% of Plan allowance
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: $0
You Pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Outpatient Hospital
You Pay without Medicare: In-Network: 20% of Plan allowance
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: $0
You Pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Incentives Offered
You Pay without Medicare: In-Network: N/A
You Pay without Medicare: Out-of-Network: N/A
You Pay with Medicare Part B: In Network: N/A
You Pay with Medicare Part B: Out-of-Network: N/A

You can find more information about how our Plan coordinates benefits with Medicare as outlined in our Medicare Benefits Guide at www.geha.com/Medicare-Options.

You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

If you are enrolled in Medicare Part B, a physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. Regardless of whether the physician requires you to sign an agreement, we will still limit our payment to the coinsurance amount we would have paid after Original Medicare’s payment based on our Plan allowable and the type of service you receive. You may be responsible for paying the difference between the billed amount and the amount we paid.

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-633-4227, TTY: 877-486-2048 or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you;

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB Plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers). However, if you do go outside the Medicare Advantage plan's network and/or service area, we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season, unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB Plan.

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

We limit our payment to an amount that supplements the benefits that Medicare would pay under Medicare Part A (Hospital insurance) and Medicare Part B (Medical insurance), regardless of whether Medicare pays. Note: We pay our regular benefits for emergency services to an institutional provider, such as a hospital, that does not participate with Medicare and is not reimbursed by Medicare.

We use the Department of Veterans Affairs (VA) Medicare-equivalent Remittance Advice (MRA) when the statement is submitted to determine our payment for covered services provided to you if Medicare is primary, when Medicare does not pay the VA facility.

If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend on whether your physician accepts Medicare assignment for the claim.

For Elevate Plus, if your physician accepts Medicare assignment, we waive some of your deductibles, copayments and coinsurance for covered charges.

If your physician does not accept Medicare assignment, you pay the difference between the “limiting charge” or the physician’s charge (whichever is less) and our payment combined with Medicare’s payment.

It is important to know that a physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its payment on, called the “limiting charge.” The Medicare Summary Notice (MSN) that Medicare will send you will have more information about the limiting charge. If your physician tries to collect more than allowed by law, ask the physician to reduce the charges. If the physician does not, report the physician to the Medicare carrier that sent you the MSN form. Call us if you need further assistance.

An injury caused by an external force or element such as a blow or fall that requires immediate medical attention. Also included are animal bites, poisonings, and dental care required to repair injuries to sound natural teeth as a result of an accidental injury, not from biting or chewing.

The process of making decisions about future healthcare options in the event of a medical crisis. This might involve the appointment of a substitute decision maker or the completion of an advance care directive or similar document. 

Artificial insemination is a surgical procedure for the introduction of sperm or semen into the vagina, cervix, or uterus to produce pregnancy. 

An authorization by you (the enrollee or covered family member) that is approved by us (the Carrier), for us to issue payment of benefits directly to the provider.

• We reserve the right to pay you directly for all covered services. Benefits payable under the contract are not assignable by you to any person without express written approval from us, and in the absence of such approval, any assignment shall be void.
• Your specific written consent for a designated authorized representative to act on your behalf to request reconsideration of a claim decision (or, for an urgent care claim, for a representative to act on your behalf without designation) does not constitute an Assignment.
• OPM’s contract with us, based on federal statute and regulation, gives you a right to seek judicial review of OPM's final action on the denial of a health benefits claim but it does not provide you with authority to assign your right to file such a lawsuit to any other person or entity. Any agreement you enter into with another person or entity (such as a provider, or other individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf, does not constitute an Assignment, is not a valid authorization under this contract, and is void.

Assisted reproductive technology (ART) includes all fertility treatments in which either eggs or embryos are handled. In general, ART procedures involve surgically removing the 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. They do NOT include treatments in which only sperm are handled (i.e., intrauterine - or artificial - insemination) or procedures in which a birthing person takes medicine only to stimulate egg production without the intention of having eggs retrieved.

There is an in-network deductible and an out-of-network deductible for the entire Plan year for covered services - medical, prescription, inpatient, outpatient, mental health and chiropractic services - you must incur for almost all covered services and supplies before we start paying benefits.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either federally-funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application. 

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy. 
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. 
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes are generally covered by the clinical trials. 

See Section 4, Your Costs for Covered Services. 

A compound medication includes more than one ingredient and is custom made by a pharmacist according to your doctor's instructions. Compound prescriptions must contain a federal legend drug and the ingredients must be covered by the G.E.H.A benefit. 

See Section 4, Your Costs for Covered Services.  

See Section 4, Your Costs for Covered Services.  

We do not provide benefits for custodial care, regardless of who recommends the care or where it is provided. The Carrier or its delegated medical professionals determine which services are custodial care. 

Custodial care includes treatment, supplies or services, that are provided to a patient mainly to help with activities of daily living. These activities include but are not limited to:

• Service, supplies, and treatment that are designed mainly to train or assist the patient in personal hygiene or other activities of daily living rather than provide therapeutic treatment; or 
• Personal care such as help ambulating, getting in and out of bed, eating by spoon, tube or gastrostomy, exercise, and dressing;
• Homemaking, such as preparing meals or special diets;
• Acting as companion or sitter;
• Supervising medication that can usually be self-administered; 
• Physical, emotional, or behavioral treatment or services that can be provided by non-licensed caregivers with minimal instruction, including but not limited to recording temperature, pulse, and respirations, or administration and monitoring of feeding systems; and
• Services or treatment where further medical professional intervention is not expected to result in significant improvement in the member's condition. The member's condition is no longer demonstrating measurable progress towards established treatment goals that have been documented in the patient's treatment record. 

See Section 4, Your Costs for Covered Services.  

Under the telehealth benefit, dermatologic conditions seen and treated include but are not limited to acne, rashes, eczema, suspicious spots/moles, warts and other abnormal bumps, rosacea, inflamed or enlarged hair follicles, psoriasis, cold sore, alopecia, insect bites.

A doula is a non-medical trained professional who provides emotional, physical, and informational support during pregnancy, labor/delivery, and post-partum periods. 

Doulas must be certified to provide doula services to meet the Plan requirements of a covered provider. Doulas eligible to provide services for any state Medicaid program in the United States, or certified by any organization recognized as providing acceptable training by any state Medicaid program will be considered a certified doula and eligible for reimbursement for services from the Plan. Training organizations include, but are not limited to: 

• Childbirth and Postpartum Professional Association (CAPPA)
• Childbirth International 
• Commonsense Childbirth Institute
• Doulas of North America (DONA)
• Doula Trainings International (DTI)
• International Childbirth Education Association
• National Black Doulas Association

Doula services do not include diagnosis of medical conditions, provision of medical advice, or any type of clinical assessment, exam, or procedure. 

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.

The date the benefits described in this brochure are effective:

• January 1 for continuing enrollments and for all annuitant enrollments;
• The first day of the first full pay period of the new year for enrollees who change
  plans or options or elect FEHB coverage during the open season for the first time; and
• For new enrollees during the calendar year, but not during the open season, the effective date of enrollment as determined by the employing office or retirement system.

A medical, surgical, diagnostic, psychiatric, mental health, substance use disorder, or other health care service, technology, supply, treatment, procedure, drug, medication, device, or biological product (referred to as “service”) is experimental or investigational if the Plan determines any of the following to apply:

1. A service which cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA) and approval for marketing has not been given for the proposed use or patient-specific diagnosis or condition at the time it is furnished.
2. Reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis for the proposed use or patient-specific diagnosis or condition.
3. Reliable evidence shows that the consensus of opinion among experts is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.
4. Reliable evidence shows that the healthcare service does not improve health outcome, is not more beneficial as established alternative(s) for the proposed use or patient specific condition or diagnosis, service does not produce improvement outside of the research setting or is otherwise not consistent with generally accepted standards of medical practice in the United States.
5. Reliable evidence shall mean credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, nationally recognized evidence-based clinical guidelines and criteria from independent sources, national physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas, and any other relevant factors. Please refer to www.geha.com/Coverage-Criteria for details on the literature used in medical decision making.

Determination of experimental/investigational status may require review of appropriate government publications such as those of the National Institute of Health, National Cancer Institute, Agency for Healthcare Policy and Research, Food and Drug Administration, National Library of Medicine, the American Hospital Formulary Service, or the United States American Hospital Pharmacopoeia Dispensing Information. We reserve the right to consult expert opinion in determining whether healthcare services are Experimental or Investigational.

Healthcare coverage that a member or covered dependent is eligible for because of employment by, membership in, or connection with, a particular organization or group that provides payment for hospital, medical, dental or other healthcare services or supplies, including extension of any of these benefits through COBRA.

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.

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

Medically necessary part-time or intermittent skilled nursing care by a licensed Home Health agency, when ordered by an appropriate medical professional, for services such as:

• Wound care for pressure sores or a surgical wound
• Patient and caregiver education
• Intravenous or nutrition therapy
• Injections
• Monitoring serious illness and unstable health status

An impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs including gonadotoxic therapies, or ovary or testicle removal for treatment of disease.

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. 

Inpatient care is care rendered to a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as an inpatient with the expectation that he or she will remain at least overnight and occupy a bed even if it later develops that the patient can be safely discharged or transferred to another hospital and not actually use a hospital bed overnight. See Section 3, How You Get Care, Covered facilities, for the definition of an Acute Inpatient and Residential Treatment Center.

In vitro fertilization (IVF) is a method of assisted reproduction that involves combining an egg with sperm in a laboratory dish. If the egg fertilizes and begins cell division, the resulting embryo may be transferred into the uterus where it may implant in the uterine lining and further develop, or be cryopreserved for later transfer. A cycle of IVF is defined as stimulation of ovaries, oocyte retrieval, and embryo transfer or preservation.

Often referred to as LTCH or LTAC, these facilities provide services for patients who need extended intensive or critical, hospital-level of care beyond that of the traditional short hospital stay. LTCH's specialize in treating patients who have more than one serious condition yet have the potential to improve with time and care and return to their previous health status. Generally, services are focused on respiratory therapy, head trauma treatment, and pain management.

We do not provide benefits for long-term care, regardless of who recommends the care or where it is provided. The Carrier or its delegated medical professionals determine which services are long-term care.

A range of services and support provided to meet personal care needs on a long-term basis. While some medical care may be necessary, most of the care provided is not and does not require a licensed caregiver. This encompasses a spectrum of services provided in a variety of settings for people who do not have full independence because of a medical condition, injury, or chronic and/or behavioral illness.

Long-term care is often used to provide custodial care as well as instrumental activities of daily living necessary for safety and health.

Long-term care is usually custodial care that has lasted for 90 days or more yet can begin prior to 90 days dependent on the member's response to professional intervention.

Long-term care and long-term acute care are not one and the same. See the definition of long-term acute care for more information about those services.

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability and requires immediate medical, surgical, or behavioral health care (includes mental health and substance use disorders).

Inborn errors of metabolism are rare genetic (inherited) disorders in which the body cannot properly turn food into energy. The disorders are usually caused by defects in specific proteins (enzymes) that help break down (metabolize) parts of food. G.E.H.A will cover medical food for a diagnosis of IEM. Medical Food is defined as a food which is recommended by a physician after an evaluation and is intended to provide for the dietary management of a disease or condition that has specific nutritional requirements. G.E.H.A will not cover "grocery" food items that can routinely be obtained online or in stores (e.g., gluten-free breads).

Healthcare services, drugs, supplies or equipment provided by a hospital or covered provider of the healthcare services for the purpose of preventing, evaluating, diagnosing, or treating a Medical or Behavioral Health Condition, that the Plan determines are all of the following:

• Are clinically appropriate to diagnose or treat the patient’s condition, illness or injury in terms of type, frequency, extent, site and duration of treatment, and treatment setting are considered effective for your condition;
• Are consistent with generally accepted standards of medical practice in the United States.
• Generally accepted standards of medical practice are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, nationally recognized evidence-based clinical guidelines and criteria from independent sources, national physician specialty society recommendations and the views of medical practitioners practicing in relevant clinical areas, and any other relevant factors. Please refer to www.geha.com/Coverage-Criteria for details on the literature used in medical decision making.
• Are not primarily for the personal comfort or convenience of the patient, the family, or the provider;
• Are not a part of or associated with the scholastic education or vocational training of the patient;
• Are not more costly than an alternate drug, service(s), or supply that is at least as likely to produce equivalent therapeutic or diagnostic results for the diagnosis or treatment of your condition;
• In the case of inpatient care, cannot be provided safely as observation or on an outpatient basis;
• Is not custodial or long-term care (see the Plan's definition).

The fact that a covered provider has prescribed, recommended, or approved a service, supply, drug or equipment does not, in itself, make it medically necessary. We reserve the right to consult expert opinion in determining whether healthcare services are Medically Necessary.