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Preventive Dental Benefits

GEHA Standard, High and HDHP medical plan members have access to the following preventive care dental benefits:

Standard

High

HDHP

In-network & out-of-network providers

Benefits are limited to (per person, per calendar year)

2 exams
2 prophylaxis (cleanings)
2 fluoride (no age limit)

(Exams, prophylaxis and fluoride) are paid at 50% of GEHA's allowable amount. X-ray charges (no frequency/any type of X-ray) are paid at 50%, for a maximum of $75 paid per person per calendar year. In addition:

One surface fillings, the plan pays $21 per tooth
Two or more surface fillings, the plan pays $28 per tooth
Simple extractions, the plan pays $21 per tooth

Benefits are limited to two visits per calendar year. The plan will pay $22 per visit, for a total of $44 paid per person per year. Visits may include any combination of:

Exams
Prophylaxis (cleanings)
Fluoride (no age limit)
X-rays (no frequency limit)

In addition:

One surface fillings, the play pays $21 per tooth
Two or more surface fillings, the plan pays $28 per tooth
Simple extractions, the plan pays $21 per tooth

Benefits are limited to (per person, per calendar year)

2 exams
2 prophylaxis (cleanings)
2 fluoride (no age limit)

(Exams, prophylaxis and fluoride) are paid at 100% of GEHA's allowable amount. X-ray charges (no frequency/any type of X-ray) are paid at 100%, for a maximum of $150 paid per person per calendar year.

In addition:

One surface fillings, the plan pays $21 per tooth
Two or more surface fillings, the plan pays $28 per tooth
Simple extractions, the plan pays $21 per tooth

No calendar year max. No deductible.