| Preventive Care/Wellness |
You Pay - PPO Provider |
You Pay - Non-PPO Provider |
| Adult preventive care |
Nothing; no calendar year limit on preventive care from PPO providers |
25% of plan allowance, after deductible* |
| Covered lab services |
5% of plan allowance, after deductible* |
25% of plan allowance, after deductible* |
| Well child care visits and immunizations |
Nothing, up to age 22 |
Nothing, up to plan allowance, up to age 22 |
Vision - annual eye exam
lenses & frame, contacts |
$10 copay at participating Avesis providers
$10 copay - see plan brochure for detail |
Balance, after reimbursement for materials |
| Dental - diagnostic/preventive |
50% of plan allowance, twice per year |
50% of plan allowance, twice per year |
| Chiropractic care |
Balance after deductible* and GEHA payment. GEHA pays $20 per visit for 12 visits per year and $25 per year for spinal X-rays |
Balance after deductible* and GEHA payment. GEHA pays $20 per visit for 12 visits per year and $25 per year for spinal X-rays |
| Physician Care |
| Physician |
5% of plan allowance, after deductible* |
25% of plan allowance, after deductible* |
| Specialist |
5% of plan allowance, after deductible* |
25% of plan allowance, after deductible* |
| Maternity care |
5% of plan allowance, after deductible* |
25% of plan allowance, after deductible* |
| Surgical care |
5% of plan allowance, after deductible* |
25% of plan allowance, after deductible* |
| Prescriptions |
Mail order Generic and brand
(90-day supply) |
25% of plan allowance, after deductible* |
N/A |
Retail pharmacy Generic and
(30-day supply) brand |
25% of plan allowance, after deductible* |
25% of plan allowance, after deductible* |
| Accidental Injury - Outpatient Care |
| Ambulance, physician, emergency room |
5% of plan allowance, after deductible* |
25% of plan allowance, after deductible* |
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| Hospital/Facility Care |
Hospital inpatient
(you must percertify) |
5% of plan allowance, after deductible* |
25% of plan allowance, after deductible* |
| Hospital outpatient |
5% of plan allowance, after deductible* |
25% of plan allowance, after deductible* |
| Emergency Room |
5% of plan allowance, after deductible* |
25% of plan allowance, after deductible* |
| Maternity |
5% of plan allowance, after deductible* |
25% of plan allowance, after deductible* |
| Other Charges |
5% of plan allowance, after deductible* |
25% of plan allowance, after deductible* |
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| Catastrophic Limits |
$5,000 single/$10,000 family. This is the maximum coinsurance and deductible you pay before GEHA pays all expenses. |
$5,000 single/$10,000 family. This is the maximum coinsurance and deductible you pay before GEHA pays all expenses. |
* GEHA calendar year deductible
Under this health plan, your deductible is $1,500 for self-only coverage and $3,000 for self-and-family coverage. With the exception of
preventive care, vision and dental, you must pay the full deductible before GEHA pays for your health care. You can use funds in your
health savings account to cover your deductible and other medical expenses.
This is a brief description of the features of GEHA. For complete information on benefits, see the GEHA Plan Brochure, RI 71-014.
All benefits are subject to the definitions, limitations and exclusions set forth in the federal brochure.
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