GEHA Benefit Plan www.geha.com 800-821-6136 2023 A Fee-for-Service (High and Standard Options) health plan with a Preferred Provider Organization IMPORTANT • Rates: Back Cover • Changes for 2023: Page 14 • Summary of Benefits: Page 128 This plan's health coverage qualifies as minimum essential coverageAs a GEHA Elevate or Elevate Plus member, ... Medical cost estimate tool 5: $10 per month, $30 max: Flu shot 4: $50: Rally Missions $50: 1 Restrictions may apply.

Provider details: This includes the provider name, date of service, date of the good faith estimate, itemized estimated cost for service, and total estimated cost of the one-time or recurring expense; a GFE covers 12 months of health services if the costs are recurring. Sometimes, each line item will have a medical or service code.Out-of-network deductible for Class B and C services is $25 Standard Self Only, $50 Standard Self Plus One and $75 Standard Self and Family.. 1 If your out-of-network dentist charges more than GEHA's agreed-upon plan allowance for a specific service, you are responsible for the difference between the plan allowance and the out-of-network dentist's charge plus regular coinsurance.GEHA Benefit Plan www.geha.com 800-821-6136 2023 A Fee-for-Service (High and Standard Options) health plan with a Preferred Provider Organization IMPORTANT • Rates: Back Cover • Changes for 2023: Page 14 • Summary of Benefits: Page 128 This plan's health coverage qualifies as minimum essential coverage

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