GEHA High Option offers a comprehensive plan with low copayments and low coinsurance on both medical care and prescription drugs. Here are the 2016 highlights:
- Within the provider network, 100% coverage for hospital room and board and 90% for other charges after per admission deductible.
- Nationwide network with more than a million providers – yours is probably one of them.
- Lab Card® program pays 100% of covered lab services.
- 24-hour health advice line.
- Vision coverage for no additional premium, plus discounts on glasses and contact lenses.*
- Freedom to choose a provider outside the network and still receive benefits.
- Prescription coverage with no annual deductible and $10 copay for a 30-day supply of generic prescription drugs.
- No referral needed to see a specialist. (However, you might need prior plan approval for certain services.)
- Special savings on hearing and dental care at no additional cost.
- Your health coverage goes wherever you travel, even overseas.
High Option Premium Rates for 2016
||Postal Premium Biweekly
Click to find out how to enroll in any GEHA health plan. Our free How to Choose a Health Plan can help you select the federal health plan that's right for you and your family.
High Option Prescription Benefits
In 2016, the High Option plan will use a Preferred Drug List that divides prescription drugs into three tiers: generic, preferred and non-preferred medications. When an approved generic equivalent is available, that is the drug you will receive, unless you or your physician specifies the prescription must be dispensed as written. When an approved generic equivalent is not available, you will pay the preferred or non-preferred applicable plan coinsurance. If an approved generic equivalent is available, but you or your physician specifies that the prescription must be dispensed as written with the brand medication, you will pay the generic copay plus the difference between the cost of the generic drug and the brand drug unless your physician has provided clinical necessity for the drug. When brand-name drugs are approved over generic, your coinsurance will be the applicable brand coinsurance.
Your physician may request the brand-name drug be approved through a medical necessity review. If your brand-name drug is approved as medically necessary, your coinsurance will be the applicable brand-name coinsurance.
- Generic drugs are chemically and therapeutically equivalent to the corresponding brand-name drug, but are available at a lower price. Information About Generics can help you learn more about the safety and effectiveness of generic 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 that the medications are clinically appropriate and cost-effective.
- Non-Preferred drugs are FDA-approved prescription medications that are covered by GEHA but are not included on the CVS/caremark Preferred Drug List. Most commonly utilized medications have generic or preferred medications available.
The chart below shows a summary of your cost for prescription drugs with GEHA High Option. Health plan members with Medicare Parts A & B primary pay a reduced copayment for prescription drugs. For complete benefit information, including details on specialty drugs that are injected or infused, refer to the GEHA Plan Brochure.
High Option Prescription Benefits for 2016
||You Pay – In-Network
||You Pay – Out-of-Network
|Retail pharmacy – 30-day supply
||$10 copay‡# plus difference between plan and drug cost
|Preferred brand medication
||25%, up to $150 max‡¤
||25%, up to $150 max‡¤#
|Non-preferred brand medication
||40%, up to $200 max‡¤
|40%, up to $200 max‡¤#
|Mail-order pharmacy – 90-day supply and CVS Maintenance Choice
Preferred brand medication
|25%, up to $350 max¤
Non-preferred brand medication
|40%, up to $500 max¤
CVS Maintenance Choice
GEHA and CVS/caremark can help you save on prescriptions through the Maintenance Choice program. High Option members can only receive 90-day supplies from either a CVS/pharmacy location or the CVS/caremark Mail Service Pharmacy. All you have to do is choose the savings option that is best for you.
Choose from two 90-day refill options for the same low price.
Option 1: Refill at any CVS/pharmacy.
Fill your 90-day supply at any CVS/pharmacy location and pick up your prescriptions
at your convenience.
Option 2: Refill with CVS Caremark Mail Service Pharmacy.
Have a 90-day supply of your long-term prescriptions shipped to your home or office. Save on your long-term prescriptions.
To learn more about your prescription benefits, call (844) 443-4279.
Other GEHA Health Plans
To learn more about other GEHA health plan benefits, click on the plan you'd like to read about:
Health Savings Advantage HDHP ♦ Standard Option ♦ Medicare and GEHA
*Connection Vision benefits are not part of the FEHB contract or premium.
‡Costs for initial prescription and first refill. You pay 50% for additional refills at retail. For long-term prescriptions, use mail order or your local retail CVS/pharmacy store (90-day supplies) for greater cost savings.
¤If you choose a brand medication when a generic is available, you will be charged the generic copay plus the difference in cost between the brand and the generic.
#Your claim will be calculated on the coinsurance or the appropriate copayments. Reimbursement will be based on GEHA’s costs had you used a participating pharmacy. You must submit original drug receipts.