2021 GEHA Dental Benefits Guide

DENTAL PLANS 2021 GEHA

Choose from two comprehensive dental plans.

gehadental.com | 877.590.4342

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What’s new in 2021.

Plan overview. GEHA offers two dental plan options – our High Option and Standard Option. Both plans include: X Comprehensive dental services, from preventive care to crowns, bridges and dentures. X No deductibles and no waiting periods¹ for most services. X Benefit levels are the same for in-network and out-of-network providers.

How to enroll To sign up for a GEHA

dental plan, visit benefeds.com

Lower premiums on average Nationally, 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 areas. Update on adult cleanings High 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 necessary. 37 new CDT dental procedure codes We have added 37 new codes. For a full list of new codes, see the plan brochure at gehadental.com/PlanBrochure

Follow the prompts to enroll in GEHA Connection Dental Federal.

You can also call BENEFEDS toll-free at 877.888.3337 TTY: 877.889.5680

High Option

gehadental.com/High

X Includes an unlimited annual maximum benefit per person. X Pays a higher percentage for your covered services. X No waiting period for orthodontic services.

Standard Option

gehadental.com/Standard

X GEHA’s lowest premium dental plan. X Includes a $2,500 annual maximum benefit per person. X 12-month waiting period for orthodontic services.

gehadental.com 877.590.4342

1 No waiting period for Class A, Class B or Class C services. 12-month waiting period for Class D orthodontic services, Standard Option plan only. 2

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Compare plan benefits.

In-network 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 coinsurance. 3 High Option plan members with certain health conditions can be eligible for a third cleaning in a calendar year if considered medically necessary.

No deductibles. No waiting periods. 1

gehadental.com/Choose

2021 plan year

High Option

Standard Option

GEHA dental plan members get access to more than 388,000 in-network locations nationwide and enjoy worldwide coverage. To get the greatest value from your GEHA plan, you are encouraged to use in-network providers. 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 geha.com/Find-Care

What the plan pays

In-network or out-of-network 2

In-network or out-of-network 2

Basic – Class A Two exams, two cleanings 3 and one X-ray per calendar year Intermediate – Class B Fillings, extractions and periodontal maintenance Major – Class C Root canals, crowns, bridges, dentures, periodontal surgery (implants limited to $2,500 per person/year)

100%

100%

80%

55%

50%

35%

70% No waiting period $3,500 lifetime maximum

70% 12-month waiting period $2,500 lifetime maximum

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 coinsurance. If 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 plan. GEHA does not cover cosmetic treatment or orthodontic work in progress (except for High Option members with orthodontics started under TRICARE).

Orthodontics – Class D Adults and children

Out-of- network services

Calendar year maximum for Class A, B and C services

Unlimited per person

$2,500 per person

For FEHB medical plans

This 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 gehadental.com/PlanBrochure

How to enroll To sign up for a plan, visit benefeds.com and follow the prompts to enroll in GEHA Connection Dental Federal. You can also call BENEFEDS toll-free at 877.888.3337 TTY: 877.889.5680

Prior orthodontic services

gehadental.com 877.590.4342

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Step 1: Use your ZIP code to find rate code.

Step 2: Use your rate code to find your 2021 premium.

gehadental.com/Rates

Find your state and the first three digits of your ZIP code in the chart below to determine your rate code. Use that code on the next page to determine your 2021 dental premium. gehadental.com/Rates

High Option

Biweekly

Rate code 1*

Rate code 2*

Rate code 3*

Rate code 4*

Rate code 5*

First 3 digits of ZIP code

Rate code

First 3 digits of ZIP code

Rate code

First 3 digits of ZIP code

Rate code

State

State

State

$16.89

$19.00

$20.77

$23.21

$25.16

Self Only

460-462, 470, 472, 473 2

1 2

AL, AR, FM, GU, IA, MH, MP, MS, ND, NE, PR, PW, VI ID, LA, MO, MT, NC, OK, SC, SD, TN, UT, VT AS, DE, HI, NM, OR

IN IN IN KS KS KY KY

NY NY

127, 129-139, 144-149

3 1 2 1 2 1 2 4

463, 464

Rest of state

$33.78

$37.97

$41.54

$46.41

$50.34

Self Plus One

1

Entire state or territory

Rest of state 660-662, 666 Rest of state

430-433, 437, 440-443, 446, 447, 450-455, 459

2

OH

$50.68

$57.00

$62.30

$69.65

$75.56

Self and Family

1 4 5 3 1

OH

Rest of state

2

Entire state

Retirees monthly

Rate code 1*

Rate code 2*

Rate code 3*

Rate code 4*

Rate code 5*

PA PA PA PA

172-174

410

180, 181, 183

Rest of state

3

Entire state or territory

$36.60

$41.17

$45.00

$50.29

$54.51

Self Only

189-196

MA MA MD MD MD ME ME

012

CO, DC, NH, RI

Rest of state

Rest of state

$73.19

$82.27

$90.00

$100.56

$109.07

4

Self Plus One

Entire state

755-759, 763-769, 776-779, 783-785, 788-799, 885

205-212, 214, 216, 217 4

5 3 2

AK AZ AZ

Entire state 850-853, 864 Rest of state

1

TX

$109.81

$123.50

$134.98

$150.91

$163.71

Self and Family

3 2 4 3

219

Rest of state

3 2

TX TX VA VA

733, 786-787 Rest of state

Standard Option

039-042

900-931, 933-935, 939-952, 954, 956-959

5

CA

Biweekly

Rate code 1*

Rate code 2*

Rate code 3*

Rate code 4*

Rate code 5*

Rest of state

201, 203, 205, 220-227 4

4

CA

Rest of state

2 5 3 4 3 2 4 1 2 1 5

Rest of state

3

MI

480-485

$9.84

$11.04

$12.09

$13.50

$14.63

Self Only

5

CT

064-069

WA WA WA

980-985

2

MI

Rest of state

$19.68

$22.08

$24.14

$26.98

$29.24

Self Plus One

986

4

CT

Rest of state

3

MN

550-555, 563

Rest of state

3

FL

329-334, 349

$29.51

$33.11

$36.21

$40.46

$43.87

Self and Family

2

MN

Rest of state

WI WI

540

2

FL

Rest of state

3

NJ

080-084

Retirees monthly

Rate code 1*

Rate code 2*

Rate code 3*

Rate code 4*

Rate code 5*

Rest of state

300-303, 305, 306, 311, 399

3

GA

5

NJ

Rest of state

WV WV WY WY

254

$21.32

$23.92

$26.20

$29.25

$31.70

Self Only

5

NV

897

Rest of state

2 3 2 1

GA

Rest of state 600-609, 613

834

IL IL IL

$42.64

$47.84

$52.30

$58.46

$63.35

Self Plus One

3 5 4

NV NY NY

Rest of state

620, 622

Rest of state

005, 100-119, 124-126

$63.94

$71.74

$78.46

$87.66

$95.05

Self and Family

Rest of state

INTL

All International

063

* Rate based on member’s primary state of residence.

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Vision discounts are included with both dental plans.

An electric toothbrush discount is included with both dental plans.

Teeth whitening discount

Hearing aid discount Get discounts through TruHearing on hearing aids. Most members save 30% to 60% off their hearing aids, averaging more than $2,100 in savings per pair.

GEHA 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.

With GEHA dental plans, you get discounts on eye exams, frames and lenses through EyeMed ™ .

Get a 20% discount off the lowest price listed on all Smile Brilliant home teeth whitening products including custom-fitted trays, whitening geland desensitizing gel.

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 gehadental.com/Vision

Learn more about this discount at gehadental.com/Toothbrush

gehadental.com/Hearing

Enjoy a whiter and brighter smile in just a few weeks.

gehadental.com/Whitening

Examples of common in-network vision services for both plans.

High Option

Standard Option

Routine eye exams at qualified EyeMed providers (what you pay)

$5

$5

Medical alert discount Get free activation on LifeAlert ® services, plus a 10% monthly discount.

$45 per covered member, per year

$45 per covered member, per year

Out-of-network exams are reimbursed by EyeMed

Discount glasses purchased per year

gehadental.com/LifeAlert

No limit

No limit

X Replacement brush heads with high-quality DuPont ™ bristles are also available at this exclusive, member-only price. X The cariPRO premium electric toothbrush removes 7x more plaque than a regular toothbrush, is completely waterproof, and comes with a 2-year manufacturer’s warranty.

Discount conventional contact lenses purchased per year

No limit

No limit

gehadental.com 877.590.4342

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Definitions.

Coverage for major dental needs.

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 plan only.

You pay $0 deductible. No waiting period ¹ on most services. GEHA’s plans let you start treatments right away, even when your needs go beyond annual cleanings.

BENEFEDS is the government-authorized and U.S. Office of Personnel Management (OPM)-sponsored enrollment portal that eligible participants use to enroll in the Federal Employees Dental and Vision Insurance Program (FEDVIP). benefeds.com

BENEFEDS

Night guards (occlusal guards)

Calendar year maximum

The annual benefit maximum that you can receive per person each calendar year.

Coverage

Orthodontics

Dental implants

Basic services that include oral examinations, cleanings, diagnostic services, sealants and radiographic images. Intermediate services that include restorative procedures such as fillings, prefabricated stainless steel crowns, periodontal scaling, tooth extractions and denture adjustments. Major services that include endodontic services such as root canals, periodontal services such as gingivectomy, major restorative services such as crowns, oral surgery, bridges, implants and prosthodontic services such as complete dentures.

Class A services

You pay your regular coinsurance and/or any amount that exceeds the lifetime benefit maximum.

You pay your regular coinsurance and/or any amount that exceeds the annual benefit maximum.

You pay your regular coinsurance and/or any amount that exceeds the annual benefit maximum.

In-network

Class B services

You pay any charges that exceed the plan allowance, plus any regular coinsurance.

Out-of-network

Class C services

Members age 13 or older

Age limit

None

None

Class D services

Orthodontic services.

High Option maximum benefit

$3,500 lifetime max, per covered member

$2,500 annual max, per covered member

Coinsurance

Once per calendar year

Coinsurance is the stated percentage of covered expenses you must pay.

A cosmetic procedure is any procedure or portion of a procedure performed primarily to improve physical appearance or is performed for psychological purposes.

Standard Option maximum benefit

$2,500 lifetime max, per covered member

$2,500 annual max, per covered member

Cosmetic procedure

Once per calendar year

In-network provider

Any licensed dentist, dental hygienist or denturist who is a part of GEHA’s provider network.

High Option waiting period

None

None

None

The 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 amount.

Standard Option waiting period

12 months

None

None

Plan allowance

Cosmetic treatment or orthodontic work in progress ( except for High Option members with orthodontics started under TRICARE ).

Any service associated with implants not specifically listed in the plan brochure.

Guards used to treat temporomandibular joint dysfunction (TMJ).

Not covered

Premium

The total amount paid to an insurance company for coverage, typically paid biweekly or monthly.

gehadental.com 877.590.4342

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Helpful resources.

Talk with a helpful GEHA Benefits Adviser.

877.590.4342

gehadental.com 877.590.4342

Compare GEHA’s Standard Option and High Option dental plans.

gehadental.com/Choose

/gehahealth

Find a dentist or see if yours is in-network.

geha.com/Find-Care

/company/gehahealth

See if a dental service is covered and estimate how much you’ll pay.

gehadental.com/Pricing

gehadental.com/Rates

Check rates for 2021.

benefeds.com

Enroll online for a dental plan.

877.888.3337 TTY 877.889.5680

Call BENEFEDS to enroll by phone for a dental plan.

Download the plan brochure For information and changes, see the official, detail-filled plan brochure. gehadental.com/PlanBrochure

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