Standard Option Benefit Summary

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Standard Option Benefit Summary

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This is a brief description of services the GEHA Connection Dental Federal Plan's Standard Option will cover in 2020. To compare the Standard Option side by side with the High Option, click Choose & Compare Plans.

For 2019 benefits, see Section 5 of the 2019 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.

2020 Plan Year Standard Option Benefit Schedule
	Waiting Period	Calendar Year Deductible	Plan Pays
Class A – Limited to the Calendar Year Maximum* Exams Cleanings** X-rays	None	None	In-network: 100% Out-of-network: Plan pays 100% of the plan allowance. Member pays 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: 55% Out-of-network: Plan pays 55% of the plan allowance. Member pays 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: 35% Out-of-network: Plan pays 35% of the plan allowance. Member pays 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	In-network: 70% Out-of-network: Plan pays 70% of the plan allowance. Member pays 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.

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

Coordination of benefits – As with all FEDVIP plans, dental benefits available from your FEHB carrier will be considered before we calculate benefits paid by GEHA.

Orthodontic services – GEHA does not cover orthodontic services previously started with another carrier, except for High Option members with orthodontics started under TRICARE.

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.