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 Standard Option Dental Plan Detail

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This is a brief description of services covered under the GEHA Connection Dental Federal Plan. Do NOT rely on this chart alone. All benefits are subject to the definitions, limitations and exclusions set forth in the dental brochure.
  Waiting Period Calendar Year Deductible You Pay
Class A - Limited to the Calendar Year Maximum*
   Exams
   Cleanings
   X-rays		 None None PPO: Nothing

Non-PPO: Any difference between the Plan allowance and the billed amount
Class B - Limited to the Calendar Year Maximum*
   Fillings
   Extractions
   Periodontal maintenance		 None None PPO: 45% of the Plan allowance

Non-PPO: 45% of the Plan allowance and any difference between our allowance and the billed amount
Class C - Limited to the Calendar Year Maximum*
    Root canals
   Crowns
   Bridges
   Dentures
   Periodontal Surgery		 None None PPO: 65% of the Plan allowance

Non-PPO: 65% of the Plan allowance and any difference between our allowance and the billed amount
Class D - Limited to a Lifetime Maximum of $1,500 per Covered Child

Age up to age 19 after a 24-month waiting period 		24 months None PPO: 50% of the Plan allowance

Non-PPO: 50% of the Plan allowance and any difference between our allowance and the billed amount
* Class A, B and C Covered Services are limited to a combined Calendar Year Maximum Benefit of $1,200 per covered person.
Predetermination of benefits – Before you receive treatment, estimate how much your care will cost. You or your provider can send in an itemized proposed treatment plan and we will send you and your dentist an explanation of how the services will be covered.
Choosing a dentist – You have the choice of provider. However, for many services, your costs are lower when you see a dentist in the CONNECTION Dental® Network. Network providers will not bill you more than the plan's maximum allowable charge for covered services.
Claim forms – No special claim forms are required. Just send in the itemized bill from your provider.
Limitations and exclusions – This plan has certain limits on dental coverage in order to keep plan rates affordable for you and your dependents. A complete list of plan limitations and exclusions may be found in the GEHA Connection Dental Federal Plan Brochure.