High Option Benefit Summary

This is a brief description of services the GEHA Connection Dental Federal Plan's High Option will cover in 2014. To compare the High Option side by side with the Standard Option, click Choose & Compare Plans.

For 2013 benefits, see Section 5 of the 2013 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.

2014 Plan Year High Option Benefit Schedule
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 person
  Orthodontic services
  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 $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 any of the more than 123,000 dentist locations that are now accessible through the Connection Dental® and Cigna networks. 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.