2022 GEHA Dental Benefits Guide

Choose from two comprehensive dental plans with a large, nationwide network and worldwide coverage. Download the PDF for a 508-accessible document.

2022 GEHA DENTAL PLANS

Choose from two comprehensive dental plans with a large, nationwide network and worldwide coverage.

geha.com | 877.590.4342

Standard geha.com/StandardDental

High geha.com/HighDental • Provides GEHA’s most comprehensive coverage for intermediate and major dental care services • Offers orthodontic coverage for both children and adults, with no waiting period • Includes an unlimited annual maximum benefit per person Who should consider High dental? • People planning for dental procedures in the near future • Parents with children immediately requiring orthodontic care • People with medical conditions that may affect or can be affected by their dental health • People looking for the peace of mind that comes with comprehensive coverage

Choose from two dental plans GEHA offers two dental plan options – High and Standard. Whatever stage of life you are in and whatever your needs, GEHA has a plan for you. Both dental plans include: • Comprehensive dental services, from preventive care to crowns, bridges and dentures • No in-network deductibles and no waiting periods 1 for most services • Worldwide coverage with a large nationwide network. Search our network at geha.com/Find-Care

• GEHA’s lowest premium dental plan • Offers orthodontic coverage for both children and adults, with a 12-month waiting period • Includes an in-network $2,500 annual maximum benefit per person

Who should consider Standard dental? • People concerned with their overall health and wellness • Parents with children anticipating future orthodontic care • People anticipating dental procedures • People looking for the peace of mind that comes with additional dental coverage beyond what’s included in their medical plan

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 geha.com/PlanBrochureDental

How often you use your plan

Low

Average

High

Low

Average

High

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

02 2022 GEHA DENTAL PLANS

Contents 02

Choose from two dental plans

03 04 05 06 08 09

What’s new for GEHA dental in 2022

Compare GEHA dental plans

In-network preventive care covered 100%

Coverage for major dental needs

Your dentist is probably in-network GEHA has an extensive nationwide network of almost 400,000 provider locations . Check to see if your dentist is in-network. geha.com/Find-Care

Vision discounts are included with both plans

Definitions

10 11 12

Step 1: Use your ZIP code to find your rate code Step 2: Use your rate code to find your 2022 premium

GEHA has a dental plan for your needs

What’s new for GEHA dental in 2022

Need help understanding dental insurance terms?

We know some terms can be confusing. Please refer to the definitions on page 9 as you work your way through this guide to help you understand everything GEHA’s dental plans have to offer.

• Standard premiums are lower for the 2022 plan year • Standard now has a $25 deductible for out-of-network Class B and C services • Standard has updated coverage levels for out-of-network Class A, B and C services • Standard out-of-network orthodontic lifetime maximum is now $2,000 • Standard out-of-network annual maximum is now $2,000 For a complete list of plan changes, download the plan brochure at geha.com/PlanBrochureDental

Learn how to enroll in a plan Visit benefeds.com and follow the prompts to enroll in GEHA Connection Dental Federal. Or call BENEFEDS toll-free at 877.888.3337 TTY: 877.889.5680

03 2022 GEHA DENTAL PLANS

Compare GEHA dental plans No in-network deductibles and no waiting periods 1 for most services . Compare plans at geha.com/CompareDental

High What the plan pays in- or out-of-network 2

Standard What the plan pays in-network 2

Standard What the plan pays out-of-network 2

2022 plan year benefit

Benefit description

Two exams, two cleanings bitewing X-rays per calendar year

3 and two sets of

100%

75%

Class A – Basic

80%

55%

50%

Class B – Intermediate

Fillings, extractions and periodontal maintenance

Root canals, crowns, bridges, dentures, periodontal surgery 4

50%

35%

30%

Class C – Major

• 70% • $3,500

• 70% • $2,500

• 70% • $2,000

Class D – Orthodontic

Adults and children orthodontic

lifetime maximum • No waiting period

lifetime maximum

• 12-month

waiting period

$2,500 per person

$2,000 per person

Calendar year maximum Applies only to Class A, B and C services

Unlimited per person

Out-of-network deductible for Class B and C services is $0 for High, $25 Standard Self Only, $50 Standard Self Plus One and $75 Standard Self and Family.

1 There is no waiting period for Class A, B or C services. There is a 12-month waiting period for Class D orthodontic services on the Standard 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 plan members with certain health conditions can be eligible for a third cleaning in a calendar year if considered medically necessary. 4 Implants are limited to $2,500 per person per year in- or out-of-network on High. For Standard, implants are limited to $2,500 per person per year in-network, or $2,000 per person per year out-of-network. 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 geha.com/PlanBrochureDental

04 2022 GEHA DENTAL PLANS

In-network preventive care covered 100% GEHA’s dental plans offer close to 400,000 in-network locations nationwide as well as worldwide coverage. Use in-network providers to get the greatest value from your GEHA dental plan. In-network preventive care is covered at 100% . For all other dental services, in-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

All GEHA dental plan members have access to a nationwide provider network and enjoy worldwide coverage. 400,000 IN-NETWORK LOCATIONS

Term

Definition

If your out-of-network dentist charges more than GEHA’s agreed-upon fee (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 and the deductible if it applies. If you have a FEHB medical plan with dental coverage, your medical plan will be considered the primary payer for some services before any benefits are paid by your FEDVIP dental plan. GEHA does not cover cosmetic treatment or orthodontic work in progress (except for High plan members with orthodontics started under TRICARE).

Out-of-network services

FEHB medical plans

Prior orthodontic services

Ready to enroll in a plan? Visit benefeds.com and follow the prompts to enroll in GEHA Connection Dental Federal. Or call BENEFEDS toll-free at 877.888.3337 TTY: 877.889.5680

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 geha.com/PlanBrochureDental

05 2022 GEHA DENTAL PLANS

Coverage for major dental needs

You pay $0 deductible in-network No waiting period 1 on most services (except Standard orthodontic care).

GEHA’s dental plans let you start treatments right away, 1 even when your needs go beyond annual cleanings.

Examples of three common major dental services

Night guards (occlusal guards) coverage

Coverage type

Orthodontic coverage

Dental implant coverage

In-network for both dental plans

You pay your regular coinsurance and/or any amount that exceeds the lifetime benefit maximum. You pay any charges that exceed the plan allowance, plus any regular coinsurance. You pay any charges that exceed the plan allowance, plus any regular coinsurance.

You pay your regular coinsurance and/or any amount that exceeds the annual benefit maximum. You pay any charges that exceed the plan allowance, plus any regular coinsurance.

High out-of-network

Standard out-of-network

You pay the $25 deductible plus any charges that exceed the plan allowance, plus any regular coinsurance.

High maximum benefit

GEHA pays a $3,500 lifetime maximum, per covered member.

GEHA pays a $2,500 calendar year maximum, per covered member.

GEHA pays once per calendar year.

Standard maximum benefit

GEHA pays a $2,500 in-network , $2,000 out-of-network , lifetime maximum, per covered member.

GEHA pays a $2,500 in-network , $2,000 out-of-network , calendar year maximum, per covered member.

GEHA pays once per calendar year.

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. 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 geha.com/PlanBrochureDental

06 2022 GEHA DENTAL PLANS

geha.com | 877.590.4342

Coverage details for three common major dental services

Other coverage detail

Orthodontic coverage

Dental implant coverage

Night guards (occlusal guards) coverage

Age limit for both dental plans

None

Members age 13 or older

High waiting period

None

Standard waiting period

12 months

None

Services not covered

Cosmetic treatment or orthodontic work in progress is not covered (except for High plan members with orthodontics that started under TRICARE) .

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

Guards used to treat temporomandibular joint dysfunction (TMJ) are not covered.

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 geha.com/PlanBrochureDental

07 2022 GEHA DENTAL PLANS

Vision discounts are included with both plans With all GEHA dent al plans, you get low copays on eye exams, and discounts on frames and lenses through EyeMed. ™ There is no limit on the number of discounted glasses or conventional contacts you may purchase each year. The EyeMed network includes LensCrafters, Target Optical, independent eye doctors and top optical retailers. Members also save on LASIK at participating U.S. Laser Network locations. Learn more at geha.com/Vision

Included with both plans

Electric toothbrush discount Save more than 70% off a premium electric toothbrush by cariPRO. ™ 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. Replacement brush heads with high-quality DuPont ™ bristles are also available to you at this exclusive, member-only price. geha.com/Toothbrush Teeth whitening discounts Get a 20% discount off the lowest price listed on all Smile Brilliant home teeth whitening products including custom-fitted trays, whitening gel and desensitizing gel. geha.com/Whitening Hearing aid discount Get discounts through TruHearing on hearing aids. Most members save 30% to 60% off their hearing aids, averaging more than $2,500 in savings per pair. geha.com/Hearing Medical alert discount Get free activation on LifeAlert ® services, plus a 10% monthly discount. geha.com/LifeAlert

What you pay in-network

What you pay out-of-network

Vision service

The plan will reimburse $45 per covered member, per year

Routine annual eye exams

60% of retail price

Frames

Eyeglass lenses (pair): • Standard plastic single vision • Standard plastic bifocal • Standard progressive lens Eyeglass lens options: • UV treatment • Tint (solid and gradient) • Standard plastic scratch coating • Standard polycarbonate • Standard anti-reflective coating • Photochromatic/transitions plastic • Conventional contact lenses • Disposable contact lenses

• $50 • $70 • $135

• $15 • $15 • $15 • $40 • $45 • 80% of retail price • 85% of retail price • Not covered

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.

08 2022 GEHA DENTAL PLANS

Definitions

Visit geha.com/#GetInTouch for ways to connect with a GEHA Benefits Adviser.

Term

Definition

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

Calendar year deductible

What you pay each year before the plan begins to pay out benefits.

Calendar year maximum

The maximum benefits that the plan will pay per person each calendar year.

Basic services that include preventive care such as oral exams, cleanings, diagnostic services, sealants and radiographic images.

Class A services

Intermediate services that include restorative procedures such as fillings, prefabricated stainless steel crowns, periodontal scaling, tooth extractions and denture adjustments.

Class B 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 C services

Class D services

Orthodontic services (braces).

Coinsurance

The percentage of covered expenses you must pay.

Any procedure or portion of a procedure performed primarily to improve physical appearance or performed for psychological purposes.

Cosmetic procedure

In-network provider

Any licensed dentist who is a part of GEHA’s provider network. To search for a provider, visit geha.com/Find-Care

The maximum benefits that the plan will pay per person. Orthodontic care on our Standard and High plans is subject to a lifetime maximum.

Lifetime maximum

The maximum amount the plan will pay for a specific procedure. 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 the plan’s payment amount and the provider’s billed amount.

Plan allowance

Premium

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

09 2022 GEHA DENTAL PLANS

Step 1: Use your ZIP code to find your rate code Find your state and the first three digits of your ZIP in the chart below to determine your rate code. Use that code on the next page to determine your 2022 dental premium. geha.com/DentalRates

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

Rest of state 660-662, 666 Rest of state

1 2 1 2 1 2 4

Rest of state

AL, AR, GU, IA, MS, ND, NE, PR, VI ID, LA, MO, MT, NC, OK, SC, SD, TN, UT, VT

Entire state or territory

KS KS KY KY

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

410

Entire state

OH PA PA PA PA

Rest of state

1 4 5 3 1

Rest of state

172-174

DE, HI, NM, OR Entire state or territory

MA MA

012

180-181, 183

Rest of state 205-212, 214, 216, 217

CO, DC, NH, RI

Entire state Entire state

4 5 3 2

189-196

AK AZ AZ

Rest of state

850-853, 864 Rest of state

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

MD MD ME ME

219

3 2 4 3 3 2 3 2 3 5 5

Rest of state

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

TX TX

733, 786-787 Rest of state 201, 203, 205, 220-227 Rest of state

3 2

039-042

Rest of state

CA CT CT

Rest of state

4 5 4 3 2

MI MI

480-485

064-069

Rest of state 550-555, 563 Rest of state

2 5 3 4 3 2 4 1 2 1 5

Rest of state 329-334, 349 Rest of state

MN MN

WA WA WA

980-985

FL FL

986

NJ NJ

080-084

Rest of state

300-303, 305, 306, 311, 399

Rest of state

WI WI

540

Rest of state 600-609, 613

2 3 2 1

897

Rest of state

IL IL IL

WV WV WY WY INTL

254

Rest of state

620, 622

Rest of state

005, 100-119, 124-126

Rest of state

834

460-462, 470, 472, 473

Rest of state

063

All international

127, 129-139, 144-149

463,464

10 2022 GEHA DENTAL PLANS

Step 2: Use your rate code to find your 2022 premium

High premium biweekly - employed

Rate code 1 *

Rate code 2 *

Rate code 3 *

Rate code 4 *

Rate code 5 *

$17.28

$19.43

$21.24

$23.73

$25.72

Self Only

$34.56

$38.85

$42.48

$47.46

$51.45

Self Plus One

$51.85

$58.28

$63.72

$71.19

$77.17

Self and Family

High premium monthly - retired

Rate code 1 *

Rate code 2 *

Rate code 3 *

Rate code 4 *

Rate code 5 *

$37.44

$42.10

$46.02

$51.42

$55.73

Self Only

$74.88

$84.18

$92.04

$102.83

$111.48

Self Plus One

$112.34

$126.27

$138.06

$154.25

$167.20

Self and Family

Standard premium biweekly - employed

Rate code 1 *

Rate code 2 *

Rate code 3 *

Rate code 4 *

Rate code 5 *

$9.56

$10.72

$11.74

$13.10

$14.18

Self Only

$19.13

$21.43

$23.43

$26.16

$28.36

Self Plus One

$28.68

$32.15

$35.15

$39.25

$42.53

Self and Family

Standard premium monthly - retired

Rate code 1 *

Rate code 2 *

Rate code 3 *

Rate code 4 *

Rate code 5 *

$20.71

$23.23

$25.44

$28.38

$30.72

Self Only

$41.45

$46.43

$50.77

$56.68

$61.45

Self Plus One

$62.14

$69.66

$76.16

$85.04

$92.15

Self and Family

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

2022 GEHA DENTAL PLANS

GEHA has a dental plan for your needs Choose from two comprehensive dental plans with a large, nationwide network and worldwide coverage.

Call us Talk with a helpful GEHA Benefits Adviser. 877.590.4342

Ready to enroll? Visit benefeds.com and follow the prompts to enroll in GEHA Connection Dental Federal. Call BENEFEDS toll-free at 877.888.3337 TTY: 877.889.5680

Compare plans Easily compare GEHA’s High and Standard dental plans. geha.com/CompareDental

Find a provider Find a dentist or see if yours is in-network. geha.com/Find-Care

Estimate costs See if a dental service is covered and estimate how much you will pay for those services. geha.com/DentalPricing

Check rates for 2022 geha.com/DentalRates

Download the plan brochure. For information and changes, see the official, detail- filled plan brochure at geha.com/PlanBrochureDental ©2021-2022 Government Employees Health Association, Inc. All rights reserved. Please recycle.

Get in touch Let us help you choose a GEHA plan that can work for you.

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geha.com

877.590.4342

/gehahealth

/company/gehahealth

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