High Option benefit summary   2013 Plan Year GEHA Connection Dental Federal     Benefit Schedule 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: 20% of the Plan allowance Non-PPO: 20% 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: 50% of the Plan allowance Non-PPO: 50% of the Plan allowance and any difference between our allowance and the billed amount Class D - Limited to a Lifetime Maximum of $2,500 per Covered Child under age 19, after a 12-month waiting period    Orthodontic services 12 months None PPO: 30% of the Plan allowance Non-PPO: 30% 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 $12,000 per covered person. ** Plans cover two cleanings per calendar year. Pretreatment estimate – 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.   © 2012 Government Employees Health Association, Inc. All rights reserved.