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

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

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

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

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

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

Once enrolled in your PSHB Program Plan, you should make any enrollment changes in the PSHB System located at https://health-benefits.opm.gov. If you are unable to access your PSHB account online, contact your employing office at 877-477-3273 or retirement office at 888-767-6738. If you have questions about your benefit coverage, contact us directly.

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

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

You enroll in a PSHB Program Plan and make enrollment changes in the PSHB System located at https://health-benefits.opm.gov/. If you are unable to access your PSHB account online, contact your employing office at 877-477-3273 or retirement office at 888-767-6738. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment request. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s PSHB enrollment.

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

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

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

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law 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 PSHB Program if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

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

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

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

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

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

Our PDP EGWP is only available to Postal Service annuitants who are Medicare Part D-eligible, enrolled in this plan and their covered Medicare Part D-eligible covered family members. Our PDP EGWP is not an open market Medicare Part D Plan. If you are an active Postal Service employee, or covered family member, and become eligible to enroll in Medicare Part D, you are not eligible to enroll in our PDP EGWP. Please, contact CMS for assistance at 877-267-2323.

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

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

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

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

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

Any person covered under the 31 day extension of coverage who is confined in a facility or other institution for care or treatment on the 31^st 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 60^th day after the end of the 31 day temporary extension.

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

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

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

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

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

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

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

You may not elect Temporary Continuation of Coverage (TCC) if you are fired from your Federal job due to gross misconduct.

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

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

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

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-821-6136 or write to us at:

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 provider” or “covered facility.” How much we pay - and you pay - depends on the type of covered provider or facility you use and who bills for the covered services. If you use our preferred providers, you will pay less.

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

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; (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; or (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; (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 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; (2) the person's progress; (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 PSHB Program and you enroll in another PSHB Plan (or become covered as a family member under a FEHB enrollment), or
• we terminate our contract with your PPO 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 in-network specialist based on the above circumstances, you can continue to see your specialist and your in-network benefits will continue until the end of your postpartum care, even if it is beyond the 90 days.

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 PSHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another PSHB Plan to us, 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 PSHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized person's benefits under the new plan begin on the effective date of enrollment.

The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for other services, are detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care or services. In other words, a pre-service claim for benefits (1) requires precertification, 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 if 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. 

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

• In-network:
  • We will reduce our benefits for the Inpatient Hospital, Long-Term Acute Care, Residential Treatment Center (RTC), Skilled Nursing Facility (SNF), or Rehabilitation Facility stay by $500 if precertification is not obtained prior to admission. If the stay is not medically necessary, we will only pay for any covered medical services and supplies that are otherwise payable on an outpatient basis. 

• Out-of-network:
  • We will reduce our benefits for the Inpatient Hospital, 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. If the stay is not medically necessary, we will only pay for any covered medical services and supplies that are otherwise payable on an outpatient basis.
  • Out-of-network facilities must, prior to admission, agree to abide by the terms established by the Plan for the care of the particular member and for the submission and processing of related claims.

You do not need precertification in these cases:

• You have another group health insurance policy that is the primary payor for the facility stay; or
• Medicare Part A is the primary payor for the facility stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payor, and you do need precertification.

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. Refer to the back of your member ID card under the heading Prior Authorization for the contact information. 

Services requiring preauthorization or medical necessity determination may be reviewed with guidelines as described at www.geha.com/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.

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/preauthorization are rendered. Refer to the back of your member ID card under the heading Prior Authorization for the contact information.

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

Next, provide the following information:

• enrollee’s name and Plan identification number;
• patient’s name, birth date, and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for facility 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 facility the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. 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 Postal Service Insurance Operations (PSIO) at 202-936-0002 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.

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

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

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the 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.

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

Services requiring authorization are 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 list of policies. Authorization is required on services including:

• Applied behavioral analysis (ABA) therapy;
• Arthroplasty;
• Bariatric and metabolic surgical procedures (obesity surgery);
• Behavioral health treatment programs, including outpatient programs;
• Cellular and gene therapy;
• Certain prescription drugs; 
• Durable medical equipment (DME), orthopedic, and prosthetic devices, including surgically implanted devices over $1,000;
• Facility admissions (including hospital, long term acute care, rehabilitation facilities, residential treatment centers, and skilled nursing facilities; see Covered facilities above);
• Fertility procedures and drugs;
• Genetic testing;
• Certain heart and vein surgeries;
• High tech radiology/imaging; 
• Hysterectomy except for diagnosis of cancer;
• Musculoskeletal injections, procedures, and surgeries (arthroplasty, back/spine, orthopedic, and pain management);
• Non-emergency air ambulance transportation;
• Non-surgical cancer treatment; 
• Prostate implants, destruction, and removal;
• Psychological testing and neuropsychological testing exceeding 8 hours/calendar year;
• Reconstructive procedures and treatments that may be experimental or investigational;
• Sleep studies (in-lab) attended or performed in a healthcare facility;
• Surgical treatment of airway obstructions including sleep apnea; and
• Transplants.

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 prior approval 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 prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information. You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
3. Write to you and maintain our denial.

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

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

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

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

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

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

Obtain Overseas Claim form 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 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. If you utilize an out-of-network provider, out-of-network benefits would apply.

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, 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 the Standard Option, you pay a copayment of $20 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.

Standard 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 $350. Under the Self Plus One or Self and Family enrollment, once the calendar year deductible amount of $700 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 $700. 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 $1,050. Under the Self Plus One or Self and Family enrollment, once the calendar year deductible amount of $2,100 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 $2,100. 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 PSHB Plans during Open Season, the effective date of your new PSHB Plan is January 1 of the next year, and a new deductible starts on January 1. If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change 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 calendar year deductible. We will base this percentage on either the billed charge or the Plan allowance, whichever is less.

Example: Under the Standard Option, you pay 15% of our allowance for in-network office visits.

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, under Standard Option, if your physician ordinarily charges $100 for a service but routinely waives your 15% coinsurance. The contracted rate is $65. We will pay $55.25 (85% of the actual charge of $65).

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

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 Standard Option, you pay 15% of our $100 allowance ($15). 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 Standard Option you pay 40% of our $100 allowance ($40). Plus, because there is no agreement between the out-of-network physician and us, the physician can bill you for the $50 difference between our allowance and the bill.

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

EXAMPLE:

In-network physician

Physician's charge: $150
Our allowance: We set it at: $100
We pay: 85% of our allowance: $85
You owe: 15% of our allowance: $15
+Difference up to charge?: No: $0
TOTAL YOU PAY: $15

Out-of-network physician

Physician's charge: $150
Our allowance: We set it at: $100
We pay: 60% of our allowance: $60
You owe: 40% of our allowance: $40
+Difference up to charge?: Yes: $50
TOTAL YOU PAY: $90

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.

Your out-of-pocket maximum for services rendered during this calendar year is:

• For Standard Option, the out-of-pocket maximum is $6,500 for Self Only enrollment; $13,000 when enrollment is Self Plus One or Self and Family if you use in-network providers.
• Only out-of-pocket expenses from in-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.

• For Standard Option, the out-of-pocket maximum is $8,500 for Self Only enrollment; $17,000 when enrollment is Self Plus One or Self and Family if you use out-of-network providers. Only out-of-pocket expenses from out-of-network providers count towards those limits. Out-of-network coinsurance will not accumulate to the in-network maximum unless meeting criteria to be reimbursed at the in-network rate (reference the No Surprises Act).
• 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.

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

If you are enrolled in our Medicare Part D Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP), the prescription drug True Out-of-Pocket (TrOOP) cost is $2,400. After this is met, we pay 100% of all Medicare eligible covered Part D prescription drug benefits. You will continue to pay a cost share for non-Medicare Part D drugs.

See Section 9, Medicare Advantage (Part C) for further details.

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

Notes:

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

Professional services of physicians

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

Notes:

• If you have a screening or blood test done during a preventive visit to your doctor that is for medical reasons other than prevention, you will  be responsible for copays and coinsurance for additional services.
• If additional services (e.g., lab, x-ray) are provided during your office visit, separate cost shares may apply.

In-network: $20 copayment for office visits to primary care providers; $0 copay applies for the first non-preventive visit for children under 18, after which the $20 copay applies (no deductible)

$35 copayment for office visits to specialists (no deductible)

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

• During a hospital stay (services not related to your inpatient stay, may apply separate cost share)
• At home

In-network: 15% of the Plan allowance

Out-of-network: 40% 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 cvs.com/minuteclinic/clinic-locator or call 866-389-2727.

$10 copayment for office visit (no deductible)

Telehealth services 

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

Nothing (no deductible)

Tests, such as but not limited to:

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• Prostate-Specific Antigen (PSA) tests

Notes:

• See Section 5(c), for any applicable outpatient facility charges.
• If your in-network provider uses an out-of-network lab, imaging facility, or radiologist, we will pay out-of-network benefits for lab charges.

In-network: 15% of the Plan allowance (no deductible)

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Tests, such as but not limited to:

• X-rays
• Ultrasound
• Electrocardiogram and EEG
• Non-routine mammograms
• Neurological testing
• Bone density test
• Home Polysomnography (sleep study) 
  • In-Lab - requires preauthorization, see Section 3, Other services that require preauthorization.  Refer to Section 5(c), for outpatient facility fees associated with in-lab sleep studies.
• Double contrast barium enemas
• Specialized diagnostic genetic testing and screening, preauthorization required 
  • Note: Benefits are available for diagnostic genetic testing and genetic screenings when it is medically necessary to diagnose and/or manage a patient’s existing medical condition. Medical necessity is determined by the Plan using evidence-based medicine. Benefits are not provided for genetic panels when some or all of the tests included in the panel are experimental or investigational or are not medically necessary.
• Other minor diagnostic test(s)

Notes:

• See Section 5(b), Surgical Benefits and 5(c), Outpatient Facility fees for applicable charges for non-routine colonoscopy procedures.
• See Section 5(c) for any applicable outpatient facility charges.
• If your in-network provider uses an out-of-network lab, imaging center or radiologist, we will pay out-of-network benefits for lab and radiology charges.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Tests at a Free-Standing Facility, such as:

• CT, MRI, MRA, Nuclear Cardiology and PET studies - Preauthorization required
• Other major diagnostic test(s)

Notes:

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

In-network: $250 copayment (no deductible)

Out-of-network: 40% 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.
• 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.).

All charges

You may use this voluntary program for covered outpatient lab tests.

To access:

1. Tell your physician you want to go to QuestSelect;
2. Schedule your lab appointment;
3. When you arrive, either share your QuestSelect Program ID card or  your Medical ID card and verbally share you are participating in QuestSelect Program.

To find an approved collection site near you, call 800-646-7788 or visit www.geha.com/Member-Lab-Savings.

Nothing (no deductible)

Note: This benefit applies to expenses for lab tests only. Related expenses for services by a physician (or lab tests performed by an associated laboratory not participating in the QuestSelect Program) are subject to applicable deductibles and coinsurance.

Routine physical every year.

The following preventive services are covered at the time interval 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 recommended screenings such as:
  • Cancer
  • Osteoporosis
  • Depression
  • Diabetes
  • High blood pressure
  • Total blood cholesterol
  • HIV
  • Colorectal cancer
  • For a complete list of screenings, age and frequency limitations, go   to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations.

• 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.
• Individual counseling on prevention and reducing health risks. 
• For a complete list of preventive care benefits for women, go to Health Resources and Services Administration (HRSA) website at                    https://www.hrsa.gov/womens-guidelines 
  • Note: Preventive screening subject to appropriate requirements, see additional online references below.
• To build your personalized list of preventive services go to                https://health.gov/myhealthfinder.

Notes: 

• For preventive care medications and anti-obesity medications, see Prescription Drug Benefits, Section 5(f) or Section 5(f)(a), for cost share requirements or visit www.geha.com/Prescriptions-Summary. 
• See Section 5(a), Educational classes and programs, for coverage of tobacco cessation treatment. 
• 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: 40% of the Plan allowance and any difference between our allowance and the billed amount

• Routine mammogram – covered, including 3D mammograms.
  • This coverage will include breast ultrasound performed after inconclusive breast cancer screening exam.

In-network: Nothing (no deductible)

Out-of-network: 40% 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:

• Intensive nutrition and behavioral weight-loss counseling therapy when ordered by your physician for obesity (BMI greater than or equal to 30 kg/m²).
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider. Programs must be ordered by a physician for treatment of your own obesity, for education and support of a family member with obesity.
• Obesity screening for those persons below the USPSTF obesity prevention risk factor level.  
• All services reflected above are only covered when recommended and supported by a supervising physician.

Notes:

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

In-network: Nothing (no deductible)

Out-of-network: 40% 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.

All charges

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

• 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.
• Routine hearing screening performed during a child’s preventive care visit.
• You may also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations.
• To build your personalized list of preventive services, go to https://health.gov/myhealthfinder.

Notes:

• For no patient copay preventive medications for appropriate age and dosage limits, see Section 5(f), Preventive care medications, or visit www.geha.com/Prescriptions-Summary.
• For coverage of tobacco cessation treatment, see Section 5(a), Educational classes and programs. 
• 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: Nothing, except any difference between our Plan allowance and the billed amount (no deductible)

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

• Intensive nutrition and behavioral weight-loss counseling therapy in children and adolescents age 6 years or older with BMI greater than or equal to 95^th 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.
• All services reflected above are only covered when recommended and supported by a supervising physician.

Notes:

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

In-network: Nothing (no deductible)

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

Not covered:

• Professional fees for automated lab tests.
• Physical, psychiatric, or psychological exams and testing required for obtaining or continuing employment or insurance, attending schools or camps, sports physicals, travel related to judicial or administrative proceedings or orders, or required to obtain or maintain a license of any type.
• 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

Complete maternity (obstetrical) care, such as:

• Screening for gestational diabetes
• Prenatal and Postpartum care
• Delivery professional fees
• Bacteriuria screening
• Breastfeeding and lactation support and counseling for each birth, see Durable medical equipment (DME) below for supplies.

Notes:

• Screening and counseling for prenatal and postpartum depression (see Section 5(e), Mental Health and Substance Use Disorders for treatment) or call SAMHSA's National Helpline, 800-662-4357 or go to https://www.findtreatment.samhsa.gov.
• 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, but you must precertify.
• 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 only 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).
• 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 credentialing 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.
• 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.
• 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.
• 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.

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

In-network: Nothing (no deductible)

Out-of-network: 40% 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 support for pregnancy-related care. Coverage is limited to $1,000 per pregnancy and must include in-person or virtual 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)

Not covered:

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

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

Notes:

• For contraceptive drugs and devices, see Section 5(f) or 5(f)(a), Prescription drug coverage/Contraceptive drugs and devices. 
• 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 described on   our website at www.geha.com/Family-Planning-Options or by calling Customer Care.
  • 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 any difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

In-network: Nothing (no deductible)

Out-of-network: 40% 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: 40% 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

All charges

Infertility - see Section 10, Definitions of Terms, for the definition and qualifications for these benefits.

Diagnosis and treatment of infertility specific to:

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

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.

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

Notes:

• See Section 5(a), Lab, x-ray and other diagnostic tests, for cost share associated with diagnostic testing.
• See Section 5(b), Surgical procedures, for cost share associated with covered surgical services.
• Fertility drugs, see Section 5(f), Prescription Benefits or Section 5(f)(a), PDP EGWP Prescription Drug benefits, Plan limits apply.
• See Section 5(h), for information on G.E.H.A's Family Planning Care Program.
• Refer to Professional services of physician above for applicable office visit cost shares related to diagnosis.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

In Vitro Fertilization (IVF) - see Section 10, Definitions of Terms. Preauthorization is required. See Section 3, Other services that require preauthorization.

IVF procedures and related services and supplies may be covered when medically necessary, including:

• Oocyte identification and retrieval
• Sperm preparation
• Insemination of oocytes
• Embryo culture
• Embryo biopsy and preimplantation genetic testing when determined to be medically necessary
• Intrauterine embryo transfer
• Cryopreservation of sperm and ova (gametes) and embryos for future transfer
• Storage of cryopreserved gametes and embryos for 1 year

In Vitro Fertilization is limited to $25,000 annual maximum. Dollar limits include procedures, supplies, and any related facility or anesthesia services.

• Fertility drugs
  • See Section 5(f) Prescription Drug Benefits or 5(f)(a) PDP EGWP Prescription Drug Benefits, if applicable. Plan limits apply.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• 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
• 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 sterilization.
• Reversal of voluntary surgical sterilization.
• 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.

All charges

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

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

In-network: 15% of the Plan allowance

Out-of-network: 40% 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

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

Notes:

• Most medications required for treatment therapies are available under Section 5(f) or Section 5(f)(a), 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: 15% of the Plan allowance

Out-of-network: 40% 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
• See Section 5(f), Prescription drug benefits, for available medications required for treatment therapies.

In-network: 15% of the Plan allowance

Out-of-network: 40% 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 
• Ongoing licensed/unlicensed dialysis assistance in the home after initial dialysis training
• Medical foods that do not require a prescription under Federal law even if your physician or other health care professional prescribes them
• Medical foods not provided by a DME vendor
• Nutritional supplements that are not administered by catheter or nasogastric tubes

All charges

We cover up to 60 outpatient therapy visits 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: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Exercise programs
• Long-term rehabilitative therapy
• Maintenance therapy-measurable improvement is not expected, or progress is no longer demonstrated
• Hot and cold packs
• Hippotherapy
• Rehabilitative services intended to teach or enhance Instrumental Activities of Daily Living (therapy to promote skills associated with independent living, such as shopping, using a phone, cleaning, laundry, preparing meals, managing medications, driving, or managing money/finances)
• Sensory, Auditory, or Sensory Integration Therapy
• Biofeedback, educational, recreational or milieu therapy

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: 15% of the Plan allowance

Out-of-network: 40% 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 and cochlear implants
  • For benefits for the devices, see Section 5(a), Orthopedic and prosthetic devices.

Note:

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

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

• External hearing aids
  • Benefit is payable per person every 36 months for adults and every    12 months for children up to age 22.

All charges in excess of $2,500 (no deductible) in- and out-of-network, combined

Not covered:

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

All charges

• First pair of contact lenses or standard ocular implant lenses if required to correct an impairment existing after intraocular surgery or accidental injury.
• 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: 15% of the Plan allowance

Out-of-network: 40% 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
• Vision therapy except as noted above
• Eye exercises and orthoptics

All charges

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

In-network: Office visit copay, plus 15% of the Plan allowance for other services performed during the visit and

• Primary care - $20 copayment (no deductible) 
• Specialist - $35 copayment (no deductible)

Out-of-network: 40% 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.

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)

All charges

• Artificial limbs and eyes
• Orthopedic braces
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• 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:

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

In-network: 15% of the Plan allowance

Out-of-network: 40% 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

All charges

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

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

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

Covered items include:

• Oxygen
• Rental of dialysis equipment
• Hospital beds
• 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:

• Preauthorization is required, see Section 3, Other services that require preauthorization for Durable Medical Equipment that has a cumulative rental and/or retail price of $1,000 or more. 
• See section 10, Definitions of Terms for Medical Necessity.
• Refer to Section 5(f) or Section 5(f)(a), Prescription drugs/Covered medications and supplies, to obtain glucose meter and diabetic supplies.

In-network: 15% of the Plan allowance

Out-of-network: 40% 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

Speech Generating Devices, see Section 10, Definitions of Terms 

• 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.

All charges in excess of $1,250 (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) in- and out-of-network, combined

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.

All charges

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

Services may include, but are not limited to, therapies, DME or Medical Supplies and are not payable separately.

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

Notes:

• 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: 15% of the Plan allowance

Out-of-network: 40% 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

All charges

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

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

In-network: $35 copayment (no deductible)

Out-of-network: 40% 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

All charges

Acupuncture:

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

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

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

All charges

Coverage is limited to:

• Tobacco cessation programs - We cover counseling sessions including proactive phone counseling, group counseling and individual counseling.  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 CVS Caremark Mail Service Pharmacy  or a Non-Network Retail pharmacy. (See filing instructions in Section 5(f), Prescription drug benefits).

In-network: Nothing (no deductible)

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

• Diabetes 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: Nothing up to the Plan allowance and any difference between our allowance and the billed amount (no deductible)

• Nutritional counseling – Provided by a dietitian with 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: 40% 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.

You pay 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

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
• 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 policy and criteria.

Notes:

• Post-operative care is considered to be included in the fee charged for a surgical procedure by a doctor. Any additional fees charged by a doctor are not covered unless such charge is for an unrelated condition.
• For female and male surgical family planning procedures, see Section    5(a), Family Planning.
• Assistant surgeons are covered up to 20% of our allowance for the surgeon's charge for procedures when it is medically necessary to have an assistant surgeon. Registered nurse first assistants and certified surgical assistants are covered up to 15% of our allowance for the surgeon’s charge for the procedure if medically necessary to have an assistant surgeon.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

When multiple physician(s) and/or surgical procedures performed during the same operative session add time or complexity to patient care, our allowance is reduced.  See www.geha.com/Provider-Partner-Tools for policy and criteria.

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.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Reversal of voluntary sterilization
• Services of a standby physician or surgeon
• Routine treatment of conditions of the foot (see 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 covered only if medically necessary 

All charges

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

Notes:

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

In-network: 15% of the Plan allowance

Out-of-network: 40% 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
• Surgeries to correct congenital anomalies for individuals age 18 and older unless there is a functional deficit
• Charges for photographs to document physical conditions
• Surgery for Sex-Trait Modification to treat gender dysphoria

All charges

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate, and severe functional malocclusion
• Excision of cysts and incision of abscesses unrelated to tooth structure
• Extraction of impacted (unerupted or partially erupted) teeth
• Partial or radical removal of the lower jaw with bone graft
• Excision of tori, tumors, leukoplakia, premalignant and malignant lesions, and biopsy of hard and soft oral tissues when unrelated to teeth and supporting structures
• Open reduction of dislocations and excision, manipulation, aspiration or injection of temporomandibular joints
• Removal of foreign body, skin, subcutaneous areolar tissue, reaction-producing foreign bodies in the musculoskeletal system and salivary stones and incision/excision of salivary glands and ducts.
• Repair of traumatic wounds
• Incision of the sinus and repair of oral fistulas
• Surgical treatment of trigeminal neuralgia
• Repair of accidental injury to sound natural teeth such as expenses for   x-rays, drugs, crowns, bridgework, inlays and dentures. We may review x-rays and/or treatment records in order to determine benefit coverage. 
• Orthognathic surgery for the following conditions requires preauthorization and is not covered for any other condition, see  Section 3, Other services that require preauthorization:
  • 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.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

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

All charges

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

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

In-network: 15% of the Plan allowance

Out-of-network: 40% 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: 15% of the Plan allowance

Out-of-network: 40% 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. 

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

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

In-network: 15% of the Plan allowance

Out-of-network: 40% 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: 15% of the Plan allowance

Out-of-network: 40% 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: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Transportation Benefit

• Provides up to $10,000 per covered transplant (excluding cornea) for transportation, lodging, and meals for the recipient and one other individual (or two others if the recipient is a minor) when the recipient lives more than 100 miles from the Plan designated transplant facility. Reimbursement for eligible expenses is subject to the IRS daily per diem limit. (See www.irs.gov or www.gsa.gov). 
• Reimbursement is limited to actual out of pocket expenses. Expenses paid using points, credits, miles, vouchers, or other non-cash equivalents are not eligible.
• Transportation benefits are payable only when G.E.H.A is the primary payor and apply to followup care for up to one year after the transplant. 

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

National Transplant Program (NTP)

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, 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. 
• See Sections 5(a) through 5(f) for applicable services and benefits.

Services are paid at the regular Plan 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

All charges

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: 15% of the Plan allowance

Out-of-network: 40% 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

Precertification is required in advance of admission.

Inpatient services provided and billed by a hospital or other covered facility while you are staying there.

Room and board, such as:

• Ward, semi-private, or intensive care accommodations
• General nursing care
• Meals and special diets
• Other hospital services

Notes:

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

Other hospital services and supplies, such as:

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and x-rays
• Blood or blood plasma, if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered  items billed by a hospital for use at home. 
  • See Section 5(a) for any applicable Durable Medical Equipment (DME) cost share.

Note:

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

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance plus the difference between the Plan allowance and the billed amount

Maternity care – Inpatient hospital

Here are some things to keep in mind:

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

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

In-network: Nothing (no deductible)

Out-of-network: 40% of the Plan allowance plus the difference between the Plan allowance and the billed amount 

Not covered:

• Any part of a hospital admission that is not medically necessary, see Section 10, Definitions 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

All charges

Inpatient residential treatment centers (RTC) are covered under Section 5(e), Mental Health and Substance Use Disorder Benefits.

Services are paid at regular medical Plan benefits

• 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 visits maximum each per year
• Respiratory and inhalation therapies 
• In Lab Attended Polysomnography (sleep study)
  • Requires preauthorization, see Section 3, Other services that  require preauthorization
• Non-routine colonoscopy
  • Note: See Section 5(a), Professional fees and 5(b), Surgical fees for applicable charges 
• Other minor diagnostic test(s)

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

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance plus the difference between the Plan allowance and the billed amount 

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

• Laboratory tests (blood tests, urinalysis, non-routine Pap tests, Prostate Specific Antigen (PSA) tests and pathology services

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

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance plus the difference between the Plan allowance and the billed amount 

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

• CT, MRI, MRA, Nuclear Cardiology and PET studies 
• Other major diagnostic test(s)

Notes:

• Preauthorization is required, see Section 3, Other services that   require preauthorization 
• If your in-network provider uses an out-of-network lab, imaging facility or radiologist, we will pay out-of-network benefits for lab and radiology charges.

In-network: $250 copay (no deductible)

Out-of-network: 40% of the Plan allowance plus the difference between the Plan allowance and the billed amount

Not covered:

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

All charges

Maternity care – Outpatient hospital or birth center

Here are some things to keep in mind:

• You do not need to precertify your normal delivery; see Section 3, Maternity care, for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an extended stay   if medically necessary, but you must precertify.
• We cover routine nursery care of the 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 a Self and Family or Self Plus One enrollment.
• Surgical benefits, not maternity benefits, apply to circumcision.
• Maternity care expenses incurred by a Plan member serving as a surrogate mother are covered by the Plan subject to reimbursement from the other party according to the surrogacy contract or agreement. The involved Plan member must execute our Reimbursement Agreement against any payment she may receive under a surrogacy contract or agreement. Expenses of the newborn child are not covered under this or any other benefit in a surrogate mother situation.

In-network: Nothing (no deductible)

Out-of-network: 40% of the Plan allowance plus the difference between the Plan allowance and the billed amount 

Treatment therapies (Outpatient) - Preauthorization is required, see Section 3, Other services that require preauthorization.

• Intravenous (IV)/Infusion Therapy - Outpatient IV 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
  • 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.

Notes:

• Medications required for Treatment therapies may be available under  the Prescription drug benefits in Section 5(f).
• See Treatment therapies, Section 5(a), for cost share and requirements for office treatments.

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance plus the difference between the Plan allowance and the billed amount

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

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

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

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance plus the difference between the Plan allowance and the billed amount

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), Diagnostic treatment and services, for information on advance care planning coverage.

In-network: Nothing up to the Plan limits 

Out-of-network: Nothing up to the Plan limits 

Not covered:

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

All charges

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

• the first hospital where treated
• from the first hospital to the next nearest hospital or other medical facility 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: 15% of the Plan allowance

Out-of-network: 15% 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.

Medical Necessity review is required for all air ambulance transportation.

In-network: 15% of the Plan allowance 

Out-of-network: 15% of the Plan allowance 

Not covered:

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

All charges

If you receive care for your accidental injury within 72 hours, we cover outpatient medical services and supplies billed by a/an:

• Treatment in an outpatient facility or in the outpatient/emergency room department of a hospital
• Related outpatient physician care
• Related diagnostic services

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

Emergency room: 30% of the Plan allowance, in- and out-of-network combined

Urgent care facility: In-network: $30 copay (no deductible). Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Physician office visit: In-network: $30 copay for office visit to primary care provider (no deductible) or $35 copayment for office visit to specialists (no deductible).  Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount.

If you receive care for your accidental injury after 72 hours, we cover:

• Non-surgical physician services and supplies
• Surgical care 

Note: We pay hospital benefits if you are admitted.

Services are paid at regular medical Plan benefits.

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

Not covered:

• Oral implants and transplants; including for the treatment of accidental injury 
• Masticating (chewing) incidents are not considered to be accidental injuries

All charges

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

Notes:

• We will provide in-network benefits if you are admitted to an out-of-network hospital due to a medical emergency. 
• 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: 30% of the Plan allowance 

Out-of-network: 30% of the Plan allowance 

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:

$30 copayment;

$0 copay applies for the first two urgent care visits for children under 18, after which the $30 copay applies (no deductible)

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount 

For MinuteClinic^®: Please see Section 5(a), MinuteClinic^® for complete benefits and coverage information.

Services are paid at regular medical Plan benefits

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

Medical Necessity review is required for all air ambulance transportation.

Services are paid at regular medical Plan benefits

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

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

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

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Treatment and counseling (including individual, group, or in-home therapy visits)
• Diagnosis and treatment of substance use disorders, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
  • Preauthorization is required, see Section 3, Other services that require preauthorization

In-network:

$20 copayment per office visit;

$0 copay applies for the first primary care visit for children under 18, after which the $20 copay applies (no deductible)

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

• Electroconvulsive therapy (ETC) 
  • Facility fees may also apply
• Inpatient professional fees

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

First related 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: 40% 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 $20 copay applies (no deductible)

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Applied behavior analysis (ABA) therapy:

• For the diagnosis of autism spectrum disorder.
• Services are overseen and performed by appropriate clinicians such as Board-Certified Behavior Analyst (BCBA), Board Certified Assistant Behavior Analysts (BCaBA), Registered Behavior Technicians (RBTs) or other practitioners performing services within the scope of their state license (e.g., nurse practitioners, physician assistants).
• Services address functional deficits specific to autism spectrum disorder.
• Services provided by the school are not reimbursable by the health plan. 
• Preauthorization is required, see Section 3, Other services that require preauthorization.

In-network: 15% of the Plan allowance

Out-of-network: 40% 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 the deductible. See Section 5(a), Lab, x-ray and other diagnostic tests.
• Psychological and neuropsychological testing necessary to determine   the appropriate psychiatric treatment (requires preauthorization for testing exceeding 8 hours/calendar year).

Note: See Section 5(c), for any applicable Outpatient facility charges. 

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Behavioral health professional telehealth 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)

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

In-network:

$20 copayment per office visit;

$0 copay applies for the first primary care visit for children under 18, after which the $20 copay applies (no deductible)

Out-of-network: 40% 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 ward, semi-private, or intensive care accommodations
• General nursing care
• Meals and special diets, and other hospital services

Note:

• We limit covered facilities for medically necessary treatment to a hospital, facility, or RTC.

In-network: 15% of the Plan allowance

Out-of-network: 40% 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 partial hospitalization intensive day treatment programs

In-network: 15% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

See Section 5(d), Medical emergency, for benefit details and cost share.

Services are paid at regular medical Plan benefits

Benefits are not covered as part of any professional office, inpatient or outpatient treatment services:

• ABA therapy services provided by the school are not reimbursable by the health plan
• Pastoral, marital, educational counseling or training services
• Therapy for sexual dysfunction or inadequacy
• Services performed by a non-covered provider
• Treatment for learning and intellectual disabilities
• Travel time to the member’s home to conduct therapy
• Services rendered or billed by schools, halfway houses, sober homes,   or billed by their staff
• Marriage counseling
• Hypnotherapy
• Services that are not medically necessary
• 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

• We divide prescription drugs into categories or tiers: generic, preferred, and non-preferred medications. Please note specialty medications can be considered either preferred or non-preferred. When an approved generic equivalent is available, that is the drug you will receive, unless you or your provider specifies the prescription must be dispensed as written. When an approved generic equivalent is not available, you will pay the applicable Plan copayment/coinsurance for the medications dispensed. If an approved generic equivalent is available, but you or your provider specifies that the prescription must be dispensed as written with the brand name medication, you will pay the generic copayment plus the difference between the cost of the generic drug and the brand name drug dispensed. Your provider may request the brand name drug be reviewed, and if approved as medically necessary, you will pay the applicable brand name copayment/coinsurance.
  • Generic drugs are FDA approved prescription medications.  They are chemically and therapeutically equivalent to the corresponding brand name drug but are available at a lower price. The FDA requires that generic equivalent medications contain the same active ingredients and be equivalent in strength and dosage to brand name drugs.
  • Preferred drugs are FDA approved prescription medications included on the Preferred Drug List developed by CVS Caremark. This list is developed by an independent panel of doctors and pharmacists who ensure the medications are clinically appropriate and cost-effective. 
  • Non-Preferred drugs are FDA approved prescription medications that may or may not be covered by G.E.H.A, however they are not included on the CVS Caremark Preferred Drug List. Most commonly utilized medications have generic or preferred medications available.

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 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 medical necessity review 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 call CVS Caremark at 844-443-4279 or CVS Specialty at 800-237-2767 for specialty medications.

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

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.
• Any rebates or savings received by the Plan on the cost of drugs purchased under this Plan from drug manufacturers are credited to the health plan and are used to reduce health care costs.

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 - To receive your Medicare Part B-eligible medications by mail, send your mail-order prescriptions to CVS Caremark. The CVS Caremark Mail Service Pharmacy will review the prescriptions to determine whether it could be eligible for Medicare Part B coverage and submit to Medicare if appropriate.

Please note, the CVS Caremark Mail Service Pharmacy is not a Medicare Part B provider for diabetic supplies. You must use a retail pharmacy willing to bill Medicare as primary. 

For 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 G.E.H.A Plan and your Medicare Part D plan, and provide both plan ID cards when filling a prescription allowing the pharmacy to coordinate coverage on your behalf.

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 may fill your prescription at any participating 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.

Through this service, you may receive up to a 90-day supply per prescription of maintenance medications and/or supplies 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.

You may purchase the following medications and supplies prescribed by a physician from either a pharmacy or by mail.

• Drugs and medications (including those administered during a non-covered admission or in a non-covered facility) that by Federal Law of the United States require a physician's prescription for their purchase, except those listed as not covered.
• Diabetic medications and supplies, such as:
  • Insulin
  • Needles and syringes for the administration of covered medications
  • Blood glucose meter - provided at no charge by the manufacturer, through the CVS Caremark Mail Service Pharmacy, call 800-588-4456.
• 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. See Section 5(a), Infertility.
• Medications prescribed to treat obesity. Prior authorization is required.
• Prenatal vitamins for pregnant women.
• FDA approved contraceptive drugs and devices for women.
• Covered ostomy supplies (please include the manufacturer’s product number to ensure accurate fill of the product).

Network Retail Pharmacy

All copayments/coinsurance are for up to a 30-day supply per prescription. Copay maximums increase for fills greater than a 30-day supply.

Notes:

• A generic equivalent will be dispensed unless you or your physician specifies that the prescription be dispensed as written (DAW), when an FDA approved generic drug is available. If there is no generic   equivalent available, you pay the applicable Plan coinsurance.
• If you or your physician chooses a brand name medication when a generic is available, you will be charged the generic copay plus the difference in cost between the brand name and the generic. Your physician may call 855-240-0536, if they determine there is medical necessity for the brand therapy. If approved, your copayment/coinsurance will be the applicable brand name copayment/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: $10 or the retail pharmacy’s usual and customary cost of the drug, whichever is less

Preferred: 40% of Plan allowance up to a maximum of $350, for up to a 30-day supply

Non-Preferred: 60% of Plan allowance up to a maximum of $450, for up to a 30-day supply

ACE Inhibitors/Beta Blockers (blood pressure medication) - Network Retail Pharmacy

Benefit applies to certain generic oral medications. All copayments are for up to a 30-day supply per prescription. 

Notes:

• For preferred or non-preferred medications, please see regular Plan benefits.
• This benefit is not available at non-network retail pharmacies or CVS Caremark Mail Service.

Generic: $3 or the retail pharmacy’s usual and customary cost of the drug, whichever is less

Preferred Insulin - Network Retail Pharmacy

All coinsurances are for up to a 30-day supply per prescription. Copay maximums increase for fills greater than a 30-day supply. 

Notes:

• For generic or non-preferred medications, please see regular Plan benefits.
• If you or your physician chooses a brand name medication when a generic is available, you will be charged the generic copay plus the difference in cost between the brand name and the generic.
• This benefit is not available at non-network retail pharmacies.

Preferred: 25% of Plan allowance up to a maximum of $350, for up to a 30-day supply

Retail fills eligible for a greater than a 30-day supply will be subject to 25% of Plan allowance and the applicable copay maximum per each 30-day supply

Non-Network Retail Pharmacy

All copayments/coinsurance are for up to a 30-day supply per prescription. Copay maximums increase for fills greater than a 30-day supply.

Notes:

• If a participating pharmacy is not available where you reside or you do not use your identification card, you may submit your claim, with original drug receipts.
• Reimbursement will be based on G.E.H.A’s costs had you used a participating pharmacy. You pay the difference between our allowance and the cost of the drug.
  • You must submit original drug receipts. See Section 7, Filing a Claim for Covered Services for details.
• If you or your physician chooses a brand name medication when a generic is available, you will be charged the generic copay plus the difference in cost between the brand name and the generic. Your physician may call 855-240-0536, if they determine there is medical necessity for the brand therapy. If approved, your copay/coinsurance  will be the applicable brand name copay/coinsurance.

Generic: $10 or the retail pharmacy’s usual and customary cost of the drug whichever is less

Preferred: 40% of Plan allowance up to a maximum of $350, for up to a 30-day supply

Non-Preferred: 60% of Plan allowance up to a maximum of $450, for up to a 30-day supply

You pay the difference between our allowance and the cost of the drug.

CVS Caremark Mail Service Pharmacy

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

Notes:

• A generic equivalent will be dispensed unless you or your physician specifies the prescription be dispensed as written (DAW), when a generic drug is available. If there is no generic equivalent available, you pay the brand name copay/coinsurance.
• If you or your physician chooses a brand name medication when a generic is available, you will be charged the generic copay plus the difference in cost between the brand name and the generic. Your physician may call 855-240-0536, if they determine there is medical necessity for the brand therapy.  If approved, your copay/coinsurance will be the applicable brand name copay/coinsurance.

Generic: $25 or the cost of the drug, whichever is less

Preferred: 40% of Plan allowance up to a maximum of $700, for up to a 90-day supply

Non-Preferred: 60% of Plan allowance up to a maximum of $900, for up to a 90-day supply

Preferred Insulin - CVS Caremark Mail Service Pharmacy

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

Notes:

• For generic or non-preferred medications, please see regular Plan benefits.
• If you or your physician chooses a brand name medication when a generic is available, you will be charged the generic copay plus the difference in cost between the brand name and the generic.

Preferred: 25% of Plan allowance up to a maximum of $700, for up to a 90-day supply

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 PSHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Over the counter (prescription required) and prescription drugs approved by the FDA to prevent an unintended pregnancy are included.

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
  PO 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).

 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 PSHB Plan.
• 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.

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 coinsurance will be prorated. If you continue on this therapy, you may receive up to a 30-day supply of the medication.

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

Outpatient, non-surgical cancer treatments require preauthorization. You or your provider needs 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:

• If you or your physician chooses a brand name specialty drug for which a generic drug exists, you will pay the applicable coinsurance and the difference between the cost of the brand name drug and the cost of the generic drug. Your physician may call 855-240-0536, if they determine there is medical necessity for the brand therapy. If approved, your coinsurance will be the applicable brand name coinsurance.
• Recurring oral medications must be obtained through the pharmacy benefit.
• Specialty medications dispensed by other sources including physician offices, home health agencies, and outpatient hospitals may be paid under the medical benefit, see Section 5(a), Treatment therapies, or Section 5(c), Outpatient facility.
• If Medicare denies coverage, G.E.H.A does not waive the coinsurance.

• Generic and Preferred: 50% of Plan allowance up to a maximum of $350, for up to a 30-day supply
• Non-Preferred: 50% of Plan allowance up to a maximum of $500, for up to a 30-day supply

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

Preventive medications with USPSTF A and B recommendations are covered with no cost-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. A generic equivalent will be dispensed unless you or your physician specifies that the prescription be dispensed as written, when an FDA approved generic drug is available unless substitution is prohibited by state law.

• Aspirin - All single ingredient generic oral dosage forms 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 five years of age and younger.
• Folic acid supplements - Single ingredient generic 0.4mg and 0.8mg tabs. OTC only (requires a prescription) for women 55 years of age and younger. Limit of 100 units per fill.
• Generic metformin - 850mg tablets for individuals age 35-70 years with no prior use of anti-diabetic medications.
• Generic 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 https://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 https://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)

• 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) for most vaccines. Please check with CVS Caremark at 844-443-4279 for coverage benefits.

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

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

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

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

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at non-Plan pharmacy; except for out-of-area emergencies
• Nonprescription medications unless specifically indicated elsewhere
• 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.
• 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

True Out-of-Pocket Cost (TrOOP) of $2,400 per person annually. Once you have reached $2,400, all covered Part D drugs will be $0 copay.

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

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

Notes:

• This prescription drug Plan offers a formulary which covers Part D drugs required by CMS and additional drug coverage as outlined below:
  • Non-Part D Supplemental Benefit including but not limited to:
    • Agents when used for the symptomatic relief of cough and colds.
    • Agents when used for weight loss (Prior Authorization applies)
    • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.
• For access to our formulary, please visit: www.geha.com/Rx-Plan
• Prior authorization may be required for certain drugs, call us at 833-250-3241 if you have any questions regarding preauthorization, quantity limits, or other issues.

Retail pharmacy, up to a 30-day supply:

• Generic (preferred pharmacy): $9 copay
• Generic (non-preferred pharmacy): $10 copay
• Preferred brand: 25% of Plan allowance; limited to $200 maximum
• Non-Preferred brand: 50% of Plan allowance; limited to $300 maximum

Mail order pharmacy, up to 90-day supply:

• Generic (preferred pharmacy): $20 copay
• Generic (non-preferred pharmacy): $30 copay
• Preferred brand (preferred pharmacy): 25% of Plan allowance; limited to $500 maximum
• Preferred brand (non-preferred pharmacy): 25% of Plan allowance; limited to $600 maximum
• Non-Preferred brand (preferred pharmacy): 50% of Plan allowance; limited to $600 maximum
• Non-Preferred brand (non-preferred pharmacy): 50% of Plan allowance; limited to $900 maximum

Specialty drugs, up to 30-day supply:

• 33% of Plan allowance; limited to $250 maximum

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

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

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

Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described on Our website at www.geha.com/Family-Planning-Options or by calling SilverScript at 833-250-3241. Exception requests for contraceptive coverage will be processed within 24 hours of receiving complete information.

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

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

Notes:

• Contraceptive exception requests are not subject to Section 8(a), The Medicare Part D MAPD/PDP EGWP Plan Sponsored Disputed Claims Process. If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.
• For additional Family Planning benefits, see Section 5(a).

Nothing (no deductible)

Insulin, one-month supply

$35 copay

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

$3 copay

Preventive medications with USPSTF A and B recommendations 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.

Notes:

• To receive preventive care benefits, a prescription from your doctor must be presented to the pharmacy for these preventive services to be covered by the Plan, even if they are listed as over the counter. Changes can occur  throughout the year. 
• Over the counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation Educational Classes and Programs in Section 5(a).

Preferred retail pharmacy: Nothing (no deductible)

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

Physician prescribed over the counter and prescription naloxone, opioid rescue agents, available as nasal sprays are covered under this Plan at no cost. Prior authorization may be required on some formulations.

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

Preferred retail pharmacy: Nothing (no deductible)

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

The following medications and supplies are not covered under the G.E.H.A prescription drug benefit:

• Drugs and supplies for cosmetic purposes
• Prescriptions written by a non-covered provider
• 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.
• Continuous glucose monitors (CGMs) and supplies, except as noted under Section 5(a), Durable Medical Equipment
• Over-the-counter medications even if prescribed by a physician, unless otherwise stated in this section
• Nonprescription medications unless specifically indicated elsewhere
• Topical analgesics, including patches, lotions and creams
• Drugs to treat impotency
• Drugs and supplies when Medicare Part B is the primary payor. For Part B diabetic continuous glucose meters, see Section 5(a), Durable medical equipment. For Medicare Part B covered drugs and diabetic supplies, see Section 5(f), Coordinating with other drug coverage
• Any amount in excess of the cost of the generic drug when a generic is available, and a brand exception has not been obtained by the prescribing physician
• Drugs obtained from a retail pharmacy in excess of a 30-day supply, except maintenance medication obtained at a CVS retail pharmacy
• Drugs obtained from a foreign pharmacy in excess of a 90-day supply

All charges

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

50% up to the Plan allowance for diagnostic and preventive services per year as follows:

• Two examinations per person per year
• Two prophylaxis (cleanings) per person per year
• Two fluoride treatments per person per year
• X-ray services are limited to $75/year in- and out-of-network combined.

50% up to the Plan allowance and all charges in excess of the Plan allowance for diagnostic and preventive services

Amalgam Restorations

Resin-Based
   Composite
   Restorations

Gold Foil Restorations

Inlay/Onlay Restorations

$21 One surface
$28 Two or more surfaces

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

Simple Extractions

$21 Simple extraction

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

Not covered:

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

Nothing

All charges

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

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

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

Earn rewards for healthy actions with G.E.H.A’s Wellness Incentives program. Total annual rewards are limited to $250 each for the subscriber and covered spouse. Maximum reward amounts are not guaranteed. Rewardable activities include, but may not be limited to, the following:

• Health assessment (must complete to be eligible for additional rewards)
• Preventive cancer screenings 
• 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.

Please note that if you enroll in the G.E.H.A Medicare Advantage Plan with UnitedHealthcare, you are not eligible for the G.E.H.A Wellness incentives program.

The QuestSelect Program gives you and your covered dependents the option of receiving 100% covered outpatient laboratory testing.

QuestSelect is an optional program for members enrolled in the Standard Option. If you choose not to use QuestSelect, you will not be penalized. You will simply pay the deductible, coinsurance or copay portion of your lab work.

QuestSelect does not replace your current healthcare benefits; it simply gives you and your dependents the option of receiving 100% coverage for outpatient laboratory testing.

Please Note: You must show your QuestSelect card each time you obtain lab work whether in the physician’s office or collection site. This benefit applies to expenses for lab tests only. Related expenses for services by a physician (or lab tests performed by an associated laboratory not participating in the QuestSelect Program) are subject to applicable deductibles and coinsurance.

QuestSelect covers most outpatient laboratory testing included in your health insurance Plan, provided the tests have been ordered by a physician and you have asked for the QuestSelect benefit and shown your QuestSelect card. Outpatient lab work includes blood testing (e.g., cholesterol, CBC), urine testing (e.g., urinalysis), cytology and pathology   (e.g., pap smears, biopsies), and cultures (e.g., throat culture).

To learn more, go to www.geha.com/Member-Lab-Savings.

QuestSelect does not cover: Lab work ordered during hospitalization, lab work needed on an emergency (STAT) basis and time sensitive, esoteric outpatient laboratory testing such as fertility testing, bone marrow studies and spinal fluid tests, non-laboratory work such as mammography, x-ray, imaging and dental work.

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 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.

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)).
• Behavior change programs with coaching for members who qualify.
• Discounts for gym memberships and other services through the G.E.H.A Member Discount Program.
• Bariatric surgery, when medically necessary. Bariatric surgery must be preauthorized.

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.

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 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 ER’s
• Check status of deductible and out-of-pocket spending

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

G.E.H.A offers several programs to support and partner with you during your healthcare journey. When you are experiencing a new diagnosis or struggling with managing your health, G.E.H.A is here to support you by offering various programs. You may find out more about our programs at www.geha.com/Your-Health-Journey. A nurse case manager may contact you to participate in one of these programs and provide assistance with the coordination of your care, education and clinical support. Please note that eligibility for these services may vary, and not all members will qualify.

Visit our website at www.geha.com/Provider-Partner-Tools for information on:

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

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

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. Your provider must file on the form CMS-1500, Health Insurance Claim Form.  In cases where a paper claim must be used, the facility will file on the UB-04 form.

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

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

• CVS Caremark, PO Box 52136, Phoenix, AZ 85072-2136;
• You may also submit prescription reimbursement requests online via Caremark web portal (www.geha.com/Prescriptions-Summary); or Caremark mobile app (available for Android and Apple).

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 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 (EOBs) 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 medical claim forms from www.geha.com/Health-Overseas-Access and overseas dental claim forms from                              www.geha.com/Dental-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, copayment, 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.

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 (EOBs) 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;

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

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, Postal Service Insurance Operations (PSIO), 1900 E Street NW, Room 5478, Washington, DC 20415.

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 https://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 payor.

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 PSHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant, you can suspend your PSHB coverage to enroll in one of these programs, eliminating your PSHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your PSHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the PSHB 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 PSHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant, you can suspend your PSHB coverage to enroll in one of these state programs, eliminating your PSHB premium. For information on suspending your PSHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the PSHB 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.

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.

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

Requires preauthorization.

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. These costs are covered by this Plan.
• 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. This Plan does not cover these costs.
• 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.

Important Note: Subject to limited exceptions, Postal Service annuitants entitled to Medicare Part A and their eligible family members who are entitled to Medicare Part A are required to enroll in Medicare Part B to maintain eligibility for the PSHB Program in retirement.

If you are required to enroll in Medicare Part B and fail to do so at your first opportunity, you may be disenrolled (annuitants) and/or your family members removed from coverage.

For more information on these requirements, please contact 800-821-6136.

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 Standard 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 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 in-network providers and MinuteClinic^® (where available): If you are enrolled in Medicare Part B, we waive the copayments for in-network office visits.
• Prescription drugs: If you have Medicare Parts A and B, you will pay a copayment or coinsurance for drugs through CVS Caremark and at retail pharmacies as shown in Section 5(f), Covered medications and supplies.
• Manipulative Therapy benefits: There is no change in benefit limits for manipulative therapy care when Medicare is primary. See Section 5(a), Chiropractic services for benefits.
• Physical, speech and occupational therapy benefits: There is no change in benefit limits or maximums for therapy when Medicare is primary.

We will NOT waive out-of-pocket costs as follows:

• Services obtained from a non-Medicare provider: We will limit our payment to the cost share amount we would have paid after Original Medicare’s payment based on our Plan allowable and the type of service you receive.
• Services not covered by Medicare but covered by Us will apply appropriate cost share, see Section 5.

We offer a Medicare Advantage plan, the G.E.H.A Standard Medicare Advantage Plan for Standard Option PSHB Plan members in partnership with UnitedHealthcare. Please review the benefit information for these options under Medicare Advantage (Part C) below.

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 for you:

This Plan and our Medicare Advantage plan: You may enroll in G.E.H.A's Medicare Advantage plan and also remain enrolled in our PSHB Plan. For more information on our Medicare Advantage plan, please contact 844-491-9898, TTY: 711 or visit our website: www.geha.com/Retiree-Coverage. Enrollment in the G.E.H.A Medicare Advantage Plan is voluntary. Members must complete an application for enrollment. Eligible enrollees voluntarily opt into the G.E.H.A Medicare Advantage Plan and may opt out at any time. You may enroll in the G.E.H.A Medicare Advantage Plan if:

• You are a retiree or annuitant enrolled in G.E.H.A's Standard Option and have both Medicare Part A and Part B.
• You are a United States citizen or are lawfully present in the United States, and you reside in the United States, the District of Columbia or a United States territory.
• You do NOT have End-Stage Renal Disease (ESRD). Enrollees who have ESRD cannot enroll until after the 30-month grace period has expired. Members diagnosed with ESRD while enrolled in the G.E.H.A Medicare Advantage Plan may remain enrolled and ESRD services will be covered.
• You complete an application for enrollment in the G.E.H.A Medicare Advantage Plan (see contact information above).

To learn more about benefit enhancements offered for the G.E.H.A Medicare Advantage Plan through UnitedHealthcare, please contact 844-491-9898 (TTY: 711) or go to www.geha.com/Retiree-Coverage.

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 PSHB 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 PSHB coverage to enroll in another plan's Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your PSHB coverage to enroll in a Medicare Advantage plan, eliminating your PSHB premium. (OPM does not contribute to your Medicare Advantage plan premium). For information on suspending your PSHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the PSHB 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.

Members will be eligible for Part D coverage if they meet the eligibility criteria below:

1. The individual is entitled to Medicare Part A and/or enrolled in Part B.
2. The individual has current Part D eligibility in the CMS system.
3. The individual permanently resides in a service area.
4. The individual is a US citizen or lawfully present in the United States.

Who pays: When we are the primary payor, we process the claim first. If you (as an active employee eligible for Medicare Part D or their covered Medicare Part D-eligible family member) enroll in any open market Medicare Part D plan and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by that Medicare Part D plan and consider them for payment under the PSHB Plan.

Note: If you are a Postal Service annuitant or their covered Medicare-eligible family member enrolled in our Medicare Part D PDP EGWP, this does not apply to you because you may not be enrolled in more than one Medicare Part D plan at the same time. If you opt out of or disenroll from our PDP EGWP you do not have our PSHB Program prescription drug coverage and we are not a secondary payor for prescription drug benefits.

Individual Medicare Part D coverage: You cannot be covered under two Part D plans at the same time. If you elect to opt out of G.E.H.A SilverScript PDP or G.E.H.A Medicare Advantage Part C plan, you WILL NOT be eligible for PSHB pharmacy benefits.