DENTAL BENEFITS gehadental.com - GEHA Connection Dental
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DENTAL BENEFITS gehadental.com
What’s inside
04 COMPARE PLAN BENEFITS
Compare
06 FIND YOUR RATE CODE
Plans
07 FIND YOUR PREMIUM
08 INCLUDED BENEFITS & SAVINGS
11 COVERAGE FOR MAJOR DENTAL NEEDS
12 DEFINITIONS
Help
13 HELPFUL RESOURCES
15 ENDNOTES
16 WHAT’S NEW IN 2020
Learn more at gehadental.com | Questions? Call 877.590.4342 | Enroll online at benefeds.com
2
WHAT’S INSIDE FOR HIGH & STANDARD OPTION
3
Compare plan benefits
GEHA offers two 2020 FEDVIP dental plan options: High Option and Standard Option. Both plans include
comprehensive dental services, along with no deductibles and no waiting periods* for most services.
High Option Standard Option
2020 plan year
PLAN PAYS THE FOLLOWING PERCENTAGE OF THE In-network Out-of-network† In-network Out-of-network†
PLAN ALLOWANCE
Basic – Class A3 100% 100% 100% 100%
Exams, cleanings1 and X-rays
-- Waiting period None None None None
-- Calendar year deductible None None None None
Intermediate – Class B3 80% 80% 55% 55%
Fillings, extractions and periodontal maintenance
-- Waiting period None None None None
-- Calendar year deductible None None None None
Major – Class C3 50% 50% 35% 35%
Root canals, crowns, bridges, dentures, periodontal
surgery and implants2
-- Waiting period None None None None
-- Calendar year deductible None None None None
Orthodontics – Class D4 70% 70% 70% 70%
-- Waiting period None None 12 months 12 months
-- Calendar year deductible None None None None
Calendar year maximum Unlimited per person NEW $2,500 per person
All classes of service are included in both High Option and Standard Option as part of the plan. This is a brief description of services covered under the GEHA
Connection Dental Federal plan. Do NOT rely on this chart alone. All benefits are subject to the definitions, limitations and exclusions set forth in the dental
brochure. Limitations and exclusions: This plan has certain limits on dental coverage to keep plan rates affordable for you and your dependents. A complete
list of plan limitations and exclusions may be found in the GEHA Connection Dental Federal Plan Brochure available online at gehadental.com/PlanBrochure
* 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.
†
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.
1,2,3,4
See full definitions and endnotes on pages 12 and 15.
Learn more at gehadental.com | Questions? Call 877.590.4342 | Enroll online at benefeds.com
4
It pays to stay in-network
COMPARE PLAN BENEFITS
GEHA dental plan members get access to more than 379,000
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 plan’s allowable charges — the agreed-upon fees for covered services. To find a provider, or to
see if your provider is in-network, visit geha.com/Search
Out-of-network For FEHB Prior orthodontic
services medical plans services
If your out-of-network dentist If you have a FEHB medical GEHA does not cover
charges more than GEHA’s plan with dental coverage, orthodontic services
agreed-upon plan allowance your medical plan will be previously started with
for a specific service, you considered the primary another carrier, except for
are responsible for the payer for some preventive, High Option members with
difference between the plan restorative and other services orthodontics started
allowance and the out-of- before any benefits are under TRICARE.
network dentist’s charge plus paid by any FEDVIP dental
regular coinsurance. plan. This includes GEHA’s
FEDVIP plan.
How to enroll
To sign up for a plan online, 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
Find a provider at geha.com/Search
5
Step 1: Locate ZIP code to find rate code
FIND YOUR RATE CODE
Locate your state and the first three digits of your ZIP code in the chart below to get your rate code — a number
between 1 and 5.
First 3 digits of Rate First 3 digits of Rate First 3 digits of Rate
State ZIP code code State ZIP code code State ZIP code code
AK Entire state 5 MA Entire state 4 173-174 4
183 5
AL Entire state 1 205-212, 214, 217 4 PA 189-196 3
MD 219 3 Rest of the state 1
AR Entire state 1 Rest of the state 2
RI Entire state 4
AZ Entire state 2 ME Rest of the state 3
SC Entire state 2
939-941, 943-952, 954 5 480-485 3
CA MI
Rest of the state 4 Rest of the state 2 SD Entire state 1
CO Entire state 4 550-555, 563 3 TN Entire state 2
MN Rest of the state 2
064-069 5 TX Entire state 2
CT Rest of the state 4 MO Entire state 2
UT Entire state 1
DC Entire state 4 MS Entire state 1
201, 205, 220-227 4
VA
DE Entire state 3 MT Entire state 2 Rest of the state 2
330-334 3 NC Entire state 2 VT Entire state 2
FL Rest of the state 2
ND Entire state 1 980-985 5
300-303, 305, 311, 399 3 WA 986 3
GA Rest of the state
Rest of the state 2 NE Entire state 1 4
HI Entire state 3 NH Entire state 4 540 3
WI Rest of the state 2
IA Entire state 1 080-084 3
NJ Rest of the state 5 254 4
ID Entire state 2 WV Rest of the state 2
NM Entire state 3
600-608 3 834 2
IL WY
Rest of the state 1 NV Entire state 3 Rest of the state 1
460-462, 470, 472 2 005, 100-119, 124-126 5 PR Entire territory 1
IN 463, 464 3 NY 063 4
Rest of the state 1 Rest of the state 2 GU Entire territory 1
KS Entire state 2 430-432, 440-443, 450-455, 459 2 VI Entire territory 1
OH Rest of the state 1
410 2 International + all other
KY FO areas not listed
1
Rest of the state 1 OK Entire state 2
LA Entire state 2 OR Entire state 3
6
Step 2: Use your rate code to find your
FIND YOUR PREMIUM
2020 premium
HIGH OPTION
Biweekly cost Rate code 1* Rate code 2* Rate code 3* Rate code 4* Rate code 5*
Self Only $17.27 $19.00 $21.56 $23.28 $25.83
Self Plus One $34.56 $37.97 $43.13 $46.55 $51.70
Self and Family $51.84 $57.00 $64.68 $69.85 $77.59
Retirees monthly
Self Only $37.42 $41.17 $46.71 $50.44 $55.97
Self Plus One $74.88 $82.27 $93.45 $100.86 $112.02
Self and Family $112.32 $123.50 $140.14 $151.34 $168.11
STANDARD OPTION
Biweekly cost Rate code 1* Rate code 2* Rate code 3* Rate code 4* Rate code 5*
Self Only $10.06 $11.04 $12.55 $13.54 $15.02
Self Plus One $20.12 $22.08 $25.05 $27.06 $30.02
Self and Family $30.17 $33.11 $37.58 $40.58 $45.04
Retirees monthly
Self Only $21.80 $23.92 $27.19 $29.34 $32.54
Self Plus One $43.59 $47.84 $54.28 $58.63 $65.04
Self and Family $65.37 $71.74 $81.42 $87.92 $97.59
*
Rates based on member’s primary state of residence.
Learn more at gehadental.com | Questions? Call 877.590.4342 | Enroll online at benefeds.com
7Included benefits & savings
High Option Standard Option
Vision coverage & discounts
$5 copay for routine eye exams at qualified EyeMed™ providers. For out-of-
network exams, EyeMed reimburses you up to $45 per covered member per
year. No limit on the number of discount glasses or contact lenses purchased
each year. EyeMed providers include LensCrafters, Pearle Vision, Target,
JCPenney Optical and independent eye doctors.
gehadental.com/Vision
Hearing aid savings
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.
gehadental.com/Hearing
Electric toothbrush5
GEHA members can save more than 70% off a premium electric toothbrush
by cariPRO™.
gehadental.com/Toothbrush
Teeth whitening
Receive a 20% discount on the lowest published price on all Smile Brilliant
home teeth whitening products. This includes custom-fitted trays, whitening gel
and desensitizing gel.
smilebrilliant.com/GEHA
Medical alert system
GEHA members and extended family are eligible for discounted services from
Life Alert®, the industry leader in responsive emergency care. Members receive
free activation, plus a 10% monthly discount.
gehadental.com/LifeAlert
5
See full definitions and endnotes on pages 12 and 15.
These benefits are neither offered nor guaranteed under contract with the FEDVIP program, but are made available to all enrollees who become members of GEHA and their
eligible family members.
Learn more at gehadental.com | Questions? Call 877.590.4342 | Enroll online at benefeds.com
8INCLUDED BENEFITS & SAVINGS
9Learn more at gehadental.com | Questions? Call 877.590.4342 | Enroll online at benefeds.com 10
Coverage for major dental needs
COVERAGE FOR MAJOR DENTAL NEEDS
With no waiting periods on most services, GEHA’s
plans let you start treatments right away, even You pay $0 deductible
when your needs go beyond annual cleanings.*
Night guards
Coverage Orthodontics Dental implants (occlusal guards)
You pay your regular coinsurance You pay your regular You pay your regular
and/or any amount that exceeds coinsurance and/or any amount coinsurance and/or any amount
In-network
the lifetime benefit maximum. that exceeds the annual that exceeds the annual
benefit maximum. benefit maximum.
You pay any charges that exceed You pay any charges that You pay any charges that
Out-of-network the plan allowance, plus any exceed the plan allowance, plus exceed the plan allowance, plus
regular coinsurance. any regular coinsurance. any regular coinsurance.
$2,500 lifetime max, $2,500 annual,
Standard Option maximum benefit Once per calendar year
per covered member per covered member
$3,500 lifetime max, $2,500 annual,
High Option maximum benefit Once per calendar year
per covered member per covered member
Age limit None None Members age 13 or older
Standard Option waiting period 12 months None None
High Option waiting period None None None
Cosmetic treatment, orthodontic Any service associated with Guards used to treat
work in progress (except for High implants not specifically listed in temporomandibular joint
Not covered Option members with orthodontics the plan brochure. dysfunction (TMJ).
started under TRICARE).
*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.
All classes of service are included in both High Option and Standard Option as part of the plan. This is a brief description of services covered under the GEHA Connection Dental Federal plan. Do
NOT rely on this chart alone. All benefits are subject to the definitions, limitations and exclusions set forth in the dental brochure. Limitations and exclusions: This plan has certain limits on dental
coverage to keep plan rates affordable for you and your dependents. A complete list of plan limitations and exclusions may be found in the GEHA Connection Dental Federal Plan Brochure available
online at gehadental.com/PlanBrochure
11Definitions
Term Definition
BENEFEDS 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).
Calendar year maximum The annual benefit maximum that you can receive per person each calendar year.
Class A services Basic services that include oral examinations, cleanings, diagnostic services, sealants and
radiographic images.
Class B services Intermediate services that include restorative procedures such as fillings, prefabricated stainless
steel crowns, periodontal scaling, tooth extractions and denture adjustments.
Class C services 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 D services Orthodontic services.
Coinsurance Coinsurance is the stated percentage of covered expenses you must pay.
Cosmetic procedure A cosmetic procedure is any procedure or portion of a procedure performed primarily to improve
physical appearance or is performed for psychological purposes.
In-network provider Any licensed dentist, dental hygienist or denturist who is a part of GEHA’s provider network.
Plan allowance 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 billed amount.
Premium The total amount paid to an insurance company for coverage, typically paid biweekly or monthly.
Learn more at gehadental.com | Questions? Call 877.590.4342 | Enroll online at benefeds.com
12Helpful resources
DEFINITIONS & RESOURCES
If you have questions after reviewing this benefits guide, the tools, phone numbers and websites below are great places to find helpful answers.
If you’re stuck or overwhelmed, please call 877.590.4342 and talk to one of our Customer Care advisers. They are here to help you.
Helpful tools Description Learn more
Find your dentist Find a provider or see if your provider is in-network. geha.com/Search
Compare GEHA FEDVIP plans Find information about our High Option and Standard Option plans. gehadental.com/Plans
877.590.4342
Procedure Pricing tool Easily verify if a service is covered and estimate how much you’ll pay. gehadental.com/Pricing
Sign up Enroll in the GEHA FEDVIP dental plan of your choice. benefeds.com
877.888.3337
TTY: 877.889.5680
Plan resources Description Learn more
Customer Care Contact GEHA with questions about your plan benefits or coverage. 877.590.4342
Overseas coverage Get information about dental coverage when you‘re outside of the United States. gehadental.com/OutsideUSA
Enrollment help Tips for new enrollees or members who are changing plans. gehadental.com/Enroll
The National Active and Retired Dedicated to helping federal employees and retirees manage their benefits. narfe.org
Federal Employees Association
U.S. Office of Personnel Official information for federal employees eligible for FEDVIP and FEHB plans. opm.gov
Management
1314
Endnotes
ENDNOTES
1 Plans cover two cleanings per calendar year at no cost to you with an
in-network provider.
2 Implants are limited to $2,500 per covered person per year, included in
the regular calendar year maximum.
3 The High Option calendar year maximum for Class A, B and C covered
services is unlimited per person. The Standard Option calendar
year maximum for Class A, B and C covered services is $2,500 per
covered person.
4 Class D orthodontic benefits are limited to a lifetime maximum
of $3,500 for High Option and $2,500 for Standard Option, per
covered person.
The cariPRO™ premium electric toothbrush removes seven times more
plaque than a regular brush, is completely waterproof and comes with
a two-year manufacturer’s warranty. Replacement brush heads with
high-quality DuPont™ bristles are also available at an exclusive,
members-only price.
Learn more at gehadental.com | Questions? Call 877.590.4342
Enroll online at benefeds.com
15WHAT’S NEW
To learn more, visit gehadental.com
XX Unlimited annual maximum benefit. The High Option annual benefit
maximum increased to unlimited per person for combined Class A,
Class B and Class C covered services.2,4
XX Bitewing X-rays. To align with industry standards, these X-rays are
covered once per calendar year for adults 23 and older.
XX 24 new CDT dental procedure codes. We have added new codes,
including D9613 — for the “infiltration of sustained-release therapeutic
drug” — which was added to combat the opioid epidemic. This code
provides dentists an alternative option for pain management. Dentists
can place this medication at the site of a third molar (wisdom tooth)
extraction instead of writing an opioid prescription. This code will be
allowed for third molar extractions only, for children up to 22, and
once per lifetime.
XX Reminder: Children qualify for 100% coverage on tooth sealants and
fluoride treatments when using an in-network dentist.
For a complete list of plan changes, download the plan brochure at
gehadental.com/PlanBrochure
2,4
See full definitions and endnotes on pages 12 and 15.
How to enroll
Enroll in the GEHA FEDVIP dental plan of your choice.
benefeds.com | 877.888.3337 | TTY: 877.889.5680
gehapossible.com
Questions? Call 877.590.4342
/gehahealth /company/gehahealth
This is a brief description of the features of GEHA’s FEDVIP plans. Before making a final decision, please read the
GEHA federal brochure available at gehadental.com/PlanBrochure. All benefits are subject to the definitions,
limitations and exclusions set forth in the federal brochure. © 2019 Government Employees Health Association, Inc.
All rights reserved. Please recycle.
OS-BKT-0819-001
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