High Option Benefit Summary

This is a brief description of services the GEHA Connection Dental Federal Plan's High Option will cover in 2017. To compare the High Option side by side with the Standard Option, click Choose & Compare Plans.

For 2016 benefits, see Section 5 of the 2016 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.

2017 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	In-network: Nothing Out-of-network: Any difference between the plan allowance and the billed amount.
Class B – Limited to the Calendar Year Maximum*    Fillings    Extractions    Periodontal maintenance	None	None	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*   Root canals   Bridges   Crowns   Dentures   Implants***   Periodontal surgery	None	None	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   Orthodontic services (no waiting period for High Option)	None	None	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 $35,000 per covered person. A complete list of plan limitations and exclusions may be found in the Plan Brochure.

** Plans cover two cleanings per calendar year.

*** Implants are limited to $2,500 per covered person per year, included in the Calendar Year Maximum Benefit.

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.