Coverage and benefits

Get a quick overview of your plan benefits and costs and find more detailed information about additional benefits and programs.

Important Information about your Part D Vaccine and Insulin Coverage

What You Pay for Vaccines – Our plan covers most adult Part D vaccines at no cost to you.

What You Pay for Insulin – You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan. Refer to your plan materials.

UnitedHealthcare GEHA Group Medicare Advantage (PPO) Plan

2024 materials

GEHA High Medicare Advantage Plan

GEHA Standard Medicare Advantage Plan

Preventive services

The following preventive services are covered under your plan for a $0 copay when you visit your primary care provider:

Annual Wellness Exam
Annual Routine Physical
Screenings for certain Cancers (Prostate, colorectal, breast cancer)
Screening for diabetes
Smoking and Tobacco Use Cessation

For information about these preventive services, please call the Customer Service number on your member ID card.

Benefits and costs

Plan options and costs
Benefit	GEHA High Medicare Advantage Plan (PPO)	GEHA Standard Medicare Advantage Plan (PPO)
GEHA High Medicare Advantage Plan (PPO)	GEHA Standard Medicare Advantage Plan (PPO)
Part B premium subsidy	$100	$75
Part B premium subsidy
$100	$75
Annual medical deductible	None	None
Annual medical deductible
None	None
Annual out-of-pocket maximum	None	None
Annual out-of-pocket maximum
None	None
Office and clinic visits	$0 copay primary care office visit $0 copay specialist office visit $0 copay virtual visit and telemedicine	$0 copay primary care office visit $0 copay specialist office visit $0 copay virtual visit and telemedicine
Office and clinic visits
$0 copay primary care office visit $0 copay specialist office visit $0 copay virtual visit and telemedicine	$0 copay primary care office visit $0 copay specialist office visit $0 copay virtual visit and telemedicine
Hospital services (inpatient)	$0 copay	$0 copay
Hospital services (inpatient)
$0 copay	$0 copay
Hospital services (outpatient)	$0 copay	$0 copay
Hospital services (outpatient)
$0 copay	$0 copay
Ambulance services	$0 copay	$0 copay
Ambulance services
$0 copay	$0 copay
Emergency room	$0 copay	$0 copay
Emergency room
$0 copay	$0 copay
Urgent care	$0 copay	$0 copay
Urgent care
$0 copay	$0 copay
Durable medical equipment	$0 copay	$0 copay
Durable medical equipment
$0 copay	$0 copay
Prosthetics	$0 copay	$0 copay
Prosthetics
$0 copay	$0 copay
Diabetic supplies (test strips, lancets, glucose monitors)	$0 copay	$0 copay
Diabetic supplies (test strips, lancets, glucose monitors)
$0 copay	$0 copay
Preventive services	$0 copay	$0 copay
Preventive services
$0 copay	$0 copay
Routine podiatry	6 per year / $0 copay	6 per year / $0 copay
Routine podiatry
6 per year / $0 copay	6 per year / $0 copay
Acupuncture	50 per year / $0 copay	50 per year / $0 copay
Acupuncture
50 per year / $0 copay	50 per year / $0 copay
Chiropractic	20 per year / $0 copay	20 per year / $0 copay
Chiropractic
20 per year / $0 copay	20 per year / $0 copay
Rehabilitation therapies - physical therapy, speech therapy, occupational therapy	$0 copay	$0 copay
Rehabilitation therapies - physical therapy, speech therapy, occupational therapy
$0 copay	$0 copay
Hearing aid allowance - $2,500 allowance for unlimited aids every 3 years. Allowance is combined for both ears	$0 copay You must use a UnitedHealthcare Hearing provider to utilize the hearing aid Allowance.	$0 copay You must use a UnitedHealthcare Hearing provider to utilize the hearing aid Allowance.
Hearing aid allowance - $2,500 allowance for unlimited aids every 3 years. Allowance is combined for both ears
$0 copay You must use a UnitedHealthcare Hearing provider to utilize the hearing aid Allowance.	$0 copay You must use a UnitedHealthcare Hearing provider to utilize the hearing aid Allowance.
Dental	Class 1 Preventive & Diagnostic (P&D): 100% Class 2 Minor: 80% Class 3 Major: 50% Deductible (P&D not included): $50 Annual Calendar Maximum: $1,000 Out-of-Network Reimbursement Schedule: Maximum Allowable Charge	Class 1 Preventive & Diagnostic (P&D): 100% Class 2 Minor: 80% Class 3 Major: 50% Deductible (P&D not included): $50 Annual Calendar Maximum: $1,000 Out-of-Network Reimbursement Schedule: Maximum Allowable Charge
Dental
Class 1 Preventive & Diagnostic (P&D): 100% Class 2 Minor: 80% Class 3 Major: 50% Deductible (P&D not included): $50 Annual Calendar Maximum: $1,000 Out-of-Network Reimbursement Schedule: Maximum Allowable Charge	Class 1 Preventive & Diagnostic (P&D): 100% Class 2 Minor: 80% Class 3 Major: 50% Deductible (P&D not included): $50 Annual Calendar Maximum: $1,000 Out-of-Network Reimbursement Schedule: Maximum Allowable Charge
Vision	Routine Eye Exam Refraction: $0 copay – 1 per plan year Eyeglasses Allowance: $130 every 24 months Contact Lens Allowance (in lieu of glasses): $175 every 24 months	Routine Eye Exam Refraction: $0 copay – 1 per plan year Eyeglasses Allowance: $130 every 24 months Contact Lens Allowance (in lieu of glasses): $175 every 24 months
Vision
Routine Eye Exam Refraction: $0 copay – 1 per plan year Eyeglasses Allowance: $130 every 24 months Contact Lens Allowance (in lieu of glasses): $175 every 24 months	Routine Eye Exam Refraction: $0 copay – 1 per plan year Eyeglasses Allowance: $130 every 24 months Contact Lens Allowance (in lieu of glasses): $175 every 24 months
Prescription drug coverage	Part D Retail (Up to a 30-day supply) (Note: 90-day retail supply is available for 2x copay amount at any CVS Pharmacy, 90-day retail supply is available for 3x copay at any non-CVS Pharmacy ) Tier 1 – generic: $3 copay Tier 2 – preferred brand: $35 copay Tier 3 – non-preferred brand: $65 copay Tier 4 – specialty tier: 15% / $150 Max. Part D Preferred Mail Order* (up to a 90-day supply for Tiers 1-3; Tier 4 is limited to a 30-day supply) Tier 1 – generic: $6 copay Tier 2 – preferred brand: $70 copay Tier 3 – non-preferred brand: $130 copay Tier 4 – specialty tier: 15% / $150 Max. *UnitedHealthcare’s pharmacy benefit manager is OptumRX. Mail order prescriptions will be through OptumRX. Rx out-of-pocket maximum: $3,500 Rx Deductible: None Estimate drug costs	Part D Retail (Up to a 30-day supply) (Note: 90-day retail supply is available for 2x copay amount at any CVS Pharmacy, 90-day retail supply is available for 3x copay at any non-CVS Pharmacy ) Tier 1 – generic: $8 copay Tier 2 – preferred brand: $40 copay Tier 3 – non-preferred brand: $70 copay Tier 4 – specialty tier: 33% / $150 Max. Part D Preferred Mail Order* (up to a 90-day supply for Tiers 1-3; Tier 4 is limited to a 30-day supply) Tier 1 – generic: $16 copay Tier 2 – preferred brand: $80 copay Tier 3 – non-preferred brand: $140 copay Tier 4 – specialty tier: 33% / $150 Max. *UnitedHealthcare’s pharmacy benefit manager is OptumRX. Mail order prescriptions will be through OptumRX. Rx out-of-pocket maximum: $3,500 Rx Deductible: None Estimate drug costs
Prescription drug coverage
Part D Retail (Up to a 30-day supply) (Note: 90-day retail supply is available for 2x copay amount at any CVS Pharmacy, 90-day retail supply is available for 3x copay at any non-CVS Pharmacy ) Tier 1 – generic: $3 copay Tier 2 – preferred brand: $35 copay Tier 3 – non-preferred brand: $65 copay Tier 4 – specialty tier: 15% / $150 Max. Part D Preferred Mail Order* (up to a 90-day supply for Tiers 1-3; Tier 4 is limited to a 30-day supply) Tier 1 – generic: $6 copay Tier 2 – preferred brand: $70 copay Tier 3 – non-preferred brand: $130 copay Tier 4 – specialty tier: 15% / $150 Max. *UnitedHealthcare’s pharmacy benefit manager is OptumRX. Mail order prescriptions will be through OptumRX. Rx out-of-pocket maximum: $3,500 Rx Deductible: None Estimate drug costs	Part D Retail (Up to a 30-day supply) (Note: 90-day retail supply is available for 2x copay amount at any CVS Pharmacy, 90-day retail supply is available for 3x copay at any non-CVS Pharmacy ) Tier 1 – generic: $8 copay Tier 2 – preferred brand: $40 copay Tier 3 – non-preferred brand: $70 copay Tier 4 – specialty tier: 33% / $150 Max. Part D Preferred Mail Order* (up to a 90-day supply for Tiers 1-3; Tier 4 is limited to a 30-day supply) Tier 1 – generic: $16 copay Tier 2 – preferred brand: $80 copay Tier 3 – non-preferred brand: $140 copay Tier 4 – specialty tier: 33% / $150 Max. *UnitedHealthcare’s pharmacy benefit manager is OptumRX. Mail order prescriptions will be through OptumRX. Rx out-of-pocket maximum: $3,500 Rx Deductible: None Estimate drug costs

Disclaimer

Out-of-network/non-contracted providers are under no obligation to treat UnitedHealthcare members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the costsharing that applies to out-of-network services.