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|Standard Option Dental Plan Detail|
|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*
Non-PPO: Any difference between the Plan allowance and the billed amount
|Class B - Limited to the Calendar Year Maximum*
|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*
|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.