GEHA - Member Web Services - Medical Plan Detail

Medical Plan Detail

	Family Deductible	Individual Deductible	In Network Out of Pocket	In And Out of Network Out of Pocket
Current Med Plan Limits	900.00	450.00	0.00	5,000.00
Accumulated To Date	0.00	0.00	0.00

2009 PLAN YEAR

Standard Option

Physician Care	You Pay - In-Network	You Pay - Out-Of-Network
Primary care physician	$10 office visit copay	35% of plan allowance, after deductible*
Specialist	$25 office visit copay	35% of plan allowance, after deductible*
Maternity care	Nothing	35% of plan allowance, after deductible*
Surgical care	15% of plan allowance, after deductible*	35% of plan allowance, after deductible*
Preventive Care/Wellness
Covered lab services	Nothing, through LabCard® program	35% of plan allowance, after deductible*
Well child care visits and immunizations	Nothing, up to age 22	Nothing, up to age 22
Adult routine screenings	Nothing	35% of plan allowance, after deductible*
Vision - annual eye exam	$5 copay at participating Avesis providers	Balance after $45 GEHA payment
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
Prescriptions
Retail pharmacy Generic	$5	$5
(30-day supply) Brand name(all)	50%	50%, plus difference between plan allowance and cost of drug
Mail order Generic	$15	N/A
(90-day supply) Brand name(all)	50%	N/A
For specialty drugs that are injected or infused, see the GEHA plan brochure.
Accidental Injury - Outpatient Care
Ambulance, physician, emergency room	Nothing, if services within 72 hours	Nothing, if services within 72 hours
Hospital/Facility Care
Hospital inpatient (you must percertify)	15% of plan allowance, after deductible*	35% of plan allowance, after deductible*
Hospital outpatient	15% of plan allowance, after deductible*	35% of plan allowance, after deductible*
Emergency room	15% of plan allowance, after deductible*	35% of plan allowance, after deductible*
Other charges	15% of plan allowance, after deductible*	35% of plan allowance, after deductible*
Maternity	Nothing	35% of plan allowance, after deductible*

Catastrophic Limits	$5,000. This is the maximum coinsurance you pay for all family members before GEHA pays all expenses.	$7,000. This is the maximum coinsurance you pay for all family members before GEHA pays all expenses.
*GEHA calendar year deductible For many services, including doctor visits and prescriptions, you pay a small copay (no deductible) and GEHA pays all remaining charges. For most other services, such as chiropractic care and surgeries, you must first meet a deductible before GEHA makes payment. GEHA's calendar year deductible is $350 for Self-Only and $700 for Self-and-Family (all family members combined). If you have Medicare A & B as your primary insurance, you pay no deductibles. See the GEHA plan brochure for information on when Medicare is primary. This is a brief description of the features of GEHA. For complete information on benefits, see the GEHA Plan Brochure, RI 71-006. All benefits are subject to the definitions, limitations and exclusions set forth in the federal brochure.