High Option Benefit Summary
This is a brief description of services the GEHA Connection Dental Federal Plan's High Option will cover in 2015. To compare the High Option side by side with the Standard Option, click Choose & Compare Plans.
For 2014 benefits, see Section 5 of the 2014 plan brochure (PDF).
Do NOT rely on this chart alone. All benefits are subject to the definitions, limitations and exclusions set forth in the Plan Brochure.
2015 Plan Year High Option Benefit Schedule
||Calendar Year Deductible
|Class A – Limited to the Calendar Year Maximum*
Out-of-network: Any difference between the Plan allowance and the billed amount.
|Class B – Limited to the Calendar Year Maximum*
||In-network: 20% of the Plan allowance
Out-of-network: 20% of the Plan allowance and any difference between our allowance and the billed amount.
|Class C – Limited to the Calendar Year Maximum*
||In-network: 50% of the Plan allowance
Out-of-network: 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 person
after a 12-month waiting period
||In-network: 30% of the Plan allowance
Out-of-network: 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 $15,000 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 providers. However, for many services, your out-of-pocket costs may be lower when you visit in-network locations. 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 Plan Brochure.