2021 GEHA Dental Benefits Guide

1 | GEHAC hoose from two comprehensive Dental offers two Dental plan options our High Option and Standard Option. Both plans include: XComprehensive Dental services, from preventive care to crowns, bridges and dentures. XNo deductibles and no waiting periods for most services. XBenefit levels are the same for in-network and out-of-network XIncludes an unlimited annual maximum benefit per person. XPays a higher percentage for your covered services. XNo waiting period for orthodontic XGEHA s lowest premium Dental plan. XIncludes a $2,500 annual maximum benefit per person. X12-month waiting period for orthodontic No waiting period for Class A, Class B or Class C services. 12-month waiting period for Class D orthodontic services, Standard Option plan to enrollTo sign up for a GEHA Dental plan, visit the prompts to enroll in GEHA Connection Dental Federal.

2 You can also call BENEFEDS toll-free at TTY: s new in premiums on averageNationally, on average, GEHA Dental premiums have been reduced slightly for the 2021 plan year. Members in some areas will see a premium increase to more accurately reflect the cost of services for those on adult cleaningsHigh Option plan members with certain health conditions, such as pregnancy, diabetes and heart disease, can be eligible for a third cleaning in a calendar year if considered medically new CDT Dental procedure codesWe have added 37 new codes. For a full list of new codes, see the plan brochure at plan yearHigh OptionStandard OptionWhat the plan paysIn-network or out-of-network2In-network or out-of-network2 Basic Class ATwo exams, two cleanings3 and one X-ray per calendar year100%100%Intermediate Class BFillings, extractions and periodontal maintenance80%55%Major Class CRoot canals, crowns, bridges, dentures, periodontal surgery (implants limited to $2,500 per person/year)50%35%Orthodontics Class DAdults and children70%No waiting period$3,500 lifetime maximum70% 12-month waiting period$2,500 lifetime maximumCalendar year maximumfor Class A, B and C servicesUnlimited per person$2,500 per personCompare plan deductibles.

3 No waiting to enrollTo sign up for a plan, visit and follow the prompts to enroll in GEHA Connection Dental Federal. You can also call BENEFEDS toll-free at TTY: is a brief description of services covered under the GEHA Connection Dental Federal plan. For a complete list of plan limitations and exclusions, please refer to the GEHA Connection Dental Federal Plan Brochure available online at preventive care covered 100%.1 There is no waiting period for Class A, Class B or Class C services. There is a 12-month waiting period for Class D orthodontic services on the Standard Option plan only. 2 If your out-of-network dentist charges more than GEHA s agreed-upon plan allowance for a specific service, you are responsible for the difference between the plan allowance and the out-of-network dentist s charge plus regular High Option plan members with certain health conditions can be eligible for a third cleaning in a calendar year if considered medically Dental plan members get access to more than 388,000 in-network locations nationwide and enjoy worldwide get the greatest value from your GEHA plan, you are encouraged to use in-network providers.

4 All in-network preventive care is covered at 100% with any GEHA Dental plan. For other services, network providers will not bill you more than the agreed-upon fees for covered services. To find a provider, or to see if your provider is in-network, visit servicesIf your out-of-network dentist charges more than GEHA s agreed-upon plan allowance for a specific service, you are responsible for the difference between the plan allowance and the out-of-network dentist s charge plus regular FEHB medical plansIf you have a FEHB medical plan with Dental coverage, your medical plan will be considered the primary payer for some preventive, restorative and other services before any Benefits are paid by any FEDVIP Dental plan. This includes GEHA s FEDVIP orthodontic servicesGEHA does not cover cosmetic treatment or orthodontic work in progress (except for High Option members with orthodontics started under TRICARE).

5 3 digits of ZIP codeRate codeAL, AR, FM, GU, IA, MH, MP, MS, ND, NE, PR, PW, VIEntire state or territory1ID, LA, MO, MT, NC, OK, SC, SD, TN, UT, VTEntire state2AS, DE, HI, NM, OREntire state or territory3CO, DC, NH, RIEntire state4 AKEntire state5AZ850-853, 8643 AZRest of state2CA900-931, 933-935, 939-952, 954, 956-9595 CARest of state4CT064-0695 CTRest of state4FL329-334, 3493 FLRest of state2GA300-303, 305, 306, 311, 3993 GARest of state2IL600-609, 6133IL620, 6222 ILRest of state1 StateFirst 3 digits of ZIP codeRate codeIN460-462, 470, 472, 4732IN463, 4643 INRest of state1KS660-662, 6662 KSRest of state1KY4102 KYRest of state1MA0122 MARest of state4MD205-212, 214, 216, 2174MD2193 MDRest of state2ME039-0424 MERest of state3MI480-4853 MIRest of state2MN550-555, 5633 MNRest of state2NJ080-0843 NJRest of state5NV8975 NVRest of state3NY005, 100-119, 124-1265NY0634 StateFirst 3 digits of ZIP codeRate codeNY127, 129-139, 144-1491 NYRest of state2OH430-433, 437, 440-443, 446, 447, 450-455, 4592 OHRest of state1PA172-1744PA180, 181, 1835PA189-1963 PARest of state1TX755-759, 763-769, 776-779, 783-785, 788-799, 8851TX733, 786-7873 TXRest of state2VA201, 203, 205, 220-2274 VARest of state2WA980-9855WA9863 WARest of state4WI5403 WIRest of state2WV2544 WVRest of state1WY8342 WYRest of state1 INTLAll International5 Step 1: Use your ZIP code to find rate your state and the first three digits of your ZIP code in the chart below to determine your rate code.

6 Use that code on the next page to determine your 2021 Dental premium. OptionBiweekly Rate code 1*Rate code 2*Rate code 3*Rate code 4*Rate code 5*Self Only$ $ $ $ $ Plus One$ $ $ $ $ and Family$ $ $ $ $ monthlyRate code 1*Rate code 2*Rate code 3*Rate code 4*Rate code 5*Self Only$ $ $ $ $ Plus One$ $ $ $ $ and Family$ $ $ $ $ OptionBiweekly Rate code 1*Rate code 2*Rate code 3*Rate code 4*Rate code 5*Self Only$ $ $ $ $ Plus One$ $ $ $ $ and Family$ $ $ $ $ monthlyRate code 1*Rate code 2*Rate code 3*Rate code 4*Rate code 5*Self Only$ $ $ $ $ Plus One$ $ $ $ $ and Family$ $ $ $ $ 2: Use your rate code to find your 2021 premium.* Rate based on member s primary state of OptionStandard OptionRoutine eye exams at qualified EyeMed providers (what you pay)$5$5 Out-of-network exams are reimbursed by EyeMed$45 per covered member, per year$45 per covered member, per yearDiscount glasses purchased per yearNo limitNo limitDiscount conventional contact lenses purchased per yearNo limitNo limitVision discounts are included with both Dental GEHA Dental plans, you get discounts on eye exams, frames and lenses through EyeMed.

7 The EyeMed network includes LensCrafters, Target Optical, independent eye doctors and top optical retailers. Members also save on LASIK at participating US Laser Network locations. This is a sampling of the supplemental vision discounts available with GEHA Dental plans. To learn more, visit of common in-network vision services for both alert discountGet free activation on LifeAlert services, plus a 10% monthly aid discountGet discounts through TruHearing on hearing aids. Most members save 30% to 60% off their hearing aids, averaging more than $2,100 in savings per electric toothbrush discount is included with both Dental members can save more than 70% off a premium electric toothbrush by cariPRO . The cariPRO premium electric toothbrush helps reduce plaque buildup and improve gum health.

8 XReplacement brush heads with high-quality DuPont bristles are also available at this exclusive, member-only price. XThe cariPRO premium electric toothbrush removes 7x more plaque than a regular toothbrush, is completely waterproof, and comes with a 2-year manufacturer s more about this discount at whitening discountGet a 20% discount off the lowest price listed on all Smile Brilliant home teeth whitening products including custom-fitted trays, whitening geland desensitizing a whiter and brighter smile in just a few is the government-authorized and Office of Personnel Management (OPM)-sponsored enrollment portal that eligible participants use to enroll in the Federal Employees Dental and Vision Insurance Program (FEDVIP). year maximumThe annual benefit maximum that you can receive per person each calendar A servicesBasic services that include oral examinations, cleanings, diagnostic services, sealants and radiographic B servicesIntermediate services that include restorative procedures such as fillings, prefabricated stainless steel crowns, periodontal scaling, tooth extractions and denture C servicesMajor services that include endodontic services such as root canals, periodontal services such as gingivectomy, major restorative services such as crowns, oral surgery, bridges.

9 Implants and prosthodontic services such as complete D servicesOrthodontic is the stated percentage of covered expenses you must procedureA cosmetic procedure is any procedure or portion of a procedure performed primarily to improve physical appearance or is performed for psychological providerAny licensed dentist, Dental hygienist or denturist who is a part of GEHA s provider allowanceThe amount we allow for a specific procedure. When you use an in-network provider, your out-of-pocket cost is limited to the difference between the plan allowance and our payment. The plan allowance may vary by geographic location and/or an in-network provider s contracted fee schedule. When you use an out-of-network provider, you are responsible for the difference between our payment and the provider s billed total amount paid to an insurance company for coverage, typically paid biweekly or implantsNight guards (occlusal guards)

10 In-networkYou pay your regular coinsurance and/or any amount that exceeds the lifetime benefit pay your regular coinsurance and/or any amount that exceeds the annual benefit pay your regular coinsurance and/or any amount that exceeds the annual benefit pay any charges that exceed the plan allowance, plus any regular limitNoneNoneMembers age 13 or olderHigh Option maximum benefit$3,500 lifetime max, per covered member$2,500 annual max, per covered memberOnce per calendar yearStandard Option maximum benefit$2,500 lifetime max, per covered member$2,500 annual max, per covered memberOnce per calendar yearHigh Option waiting periodNoneNoneNoneStandard Option waiting period12 monthsNoneNoneNot coveredCosmetic treatment or orthodontic work in progress (except for High Option members with orthodontics started under TRICARE).