GEHA Connection Dental Federal

Standard 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: 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 12-month waiting period	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 $2,500 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.