| 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 | |
| 2006 Plan Year | Standard Option |
| Benefit | Preferred Provider | Non-Preferred Provider |
| Hospitalization for Surgery/Medical | ||
| Inpatient | $450 calendar year deductible* 85% room and board 85% other hospital charges Precertification required |
$450 calendar year deductible* 65% room and board 65% other hospital charges Precertification required |
| Outpatient | $450 calendar year deductible* 85% other hospital charges |
$450 calendar year deductible* 65% other hospital charges |
| Certain specialty drugs which are injected or infused are subject to copayments. Please refer to the 2006 Plan Brochure for complete explanation. |
||
| Emergency room | $450 calendar year deductible* 85% other hospital charges |
$450 calendar year deductible* 65% other hospital charges |
| Physician Care | ||
| Inpatient medical, inpatient and outpatient surgical |
$450 calendar year deductible* 85% of plan allowance |
$450 calendar year deductible* 65% of plan allowance |
| Outpatient medical office visit |
$10 copayment primary care physician $25 copayment specialist office visit 85% preferred provider, other charges subject to $450 calendar year deductible* |
$450 calendar year deductible* 65% of plan allowance |
| Certain specialty drugs which are injected or infused are subject to copayments. Please refer to the 2006 Plan Brochure for complete explanation. |
||
| Accidental Injury | ||
| Outpatient care within 72 hours |
No deductible 100% of plan allowance |
No deductible 100% of plan allowance |
| Maternity | ||
| Standard | No deductible 100% room and board 100% other hospital charges 100% physician charges |
$450 calendar year deductible* 65% room and board 65% other hospital charges 65% of plan allowance for physician charges |
| Well-Child Care | ||
| Birth to age 22 | No deductible 100% of plan allowance for well-child visits and immunizations |
No deductible 100% of plan allowance for well-child visits and immunizations |
| Prescription Drugs | ||
| Retail pharmacy | No deductible 30-day supply $5 generic, 50% brand-name |
No deductible 30-day supply $5 generic 50% brand-name You pay any difference between our allowance and cost of drug |
| Mail order pharmacy | No deductible 90-day supply $15 generic, 50% brand-name |
Not applicable |
| Dental | ||
| Standard | No deductible 50% of plan allowance for diagnostic and preventive services twice per year |
No deductible 50% of plan allowance for diagnostic and preventive services twice per year |
| Supplemental Dental Benefits | Click here for information on CONNECTION Dental Plus | |
| Chiropractic Care | ||
| Standard | $450 calendar year deductible* $9 per adjustment, 30 per year $25 per year spinal X-rays |
$450 calendar year deductible* $9 per adjustment, 30 per year $25 per year spinal X-rays |
| Catastrophic Limits | ||
| Out-of-pocket | $5,000 self-only and self-and-family |
$7,000 self-only and self-and-family |
*You pay just one deductible for the plan year for all covered medical, outpatient professional mental health and chiropractic services. If you choose family coverage, the maximum deductible applied for all family members combined is $900.
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.