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2021 GEHADENTAL PLANSChoose from twocomprehensive dental plans.gehadental.com 877.590.4342.51

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.High Optiongehadental.com/HighX 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 Optiongehadental.com/StandardX GEHA’s lowest premium dental plan.X Includes a 2,500 annual maximum benefit per person.X 12-month waiting period for orthodontic services.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

What’s new in 2021.How to enrollLower premiums on averageNationally, on average, GEHA dental premiums have been reduced slightlyfor the 2021 plan year. Members in some areas will see a premium increase tomore accurately reflect the cost of services for those areas.Update 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 calendaryear if considered medically necessary.To sign up for a GEHAdental plan, visitbenefeds.comFollow the prompts toenroll in GEHA ConnectionDental Federal.You can also callBENEFEDS toll-free at877.888.3337TTY: 877.889.568037 new CDT dental procedure codesWe have added 37 new codes. For a full list of new codes, see the planbrochure at 3423

Compare plan benefits.No deductibles. No waiting periods.1gehadental.com/Choose2021 plan yearHigh OptionStandard OptionWhat the plan paysIn-network or out-of-network2In-network or out-of-network2Basic – 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 personThis 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 DentalFederal Plan Brochure available online at gehadental.com/PlanBrochureHow to enrollTo sign up for a plan, visit benefeds.com and follow the prompts to enroll in GEHA Connection Dental Federal. You canalso call BENEFEDS toll-free at 877.888.3337 TTY: 877.889.56804

In-network preventive carecovered 100%.GEHA dental plan members get access to more than388,000 in-network locations nationwide and enjoyworldwide coverage.To get the greatest value from your GEHA plan, you are encouraged to usein-network providers. All in-network preventive care is covered at 100% withany GEHA dental plan.1There is no waiting period for Class A, ClassB or Class C services. There is a 12-monthwaiting period for Class D orthodonticservices on the Standard Option plan only.2If your out-of-network dentist charges morethan GEHA’s agreed-upon plan allowancefor a specific service, you are responsible forthe difference between the plan allowanceand the out-of-network dentist’s charge plusregular coinsurance.3High Option plan members with certainhealth conditions can be eligible for a thirdcleaning in a calendar year if consideredmedically necessary.For other services, network providers will not bill you more than theagreed-upon fees for covered services. To find a provider, or to see if yourprovider is in-network, visit geha.com/Find-CareOut-ofnetworkservicesIf your out-of-network dentist charges more thanGEHA’s agreed-upon plan allowance for a specificservice, you are responsible for the differencebetween the plan allowance and the out-of-networkdentist’s charge plus regular coinsurance.For FEHBmedicalplansIf you have a FEHB medical plan with dental coverage,your medical plan will be considered the primarypayer for some preventive, restorative and otherservices before any benefits are paid by any FEDVIPdental plan. This includes GEHA’s FEDVIP plan.PriororthodonticservicesGEHA does not cover cosmetic treatment ororthodontic work in progress (except for High Optionmembers with orthodontics startedunder TRICARE).gehadental.com877.590.43425

Step 1: Use your ZIP code to find rate code.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 nextpage to determine your 2021 dental premium. gehadental.com/RatesStateFirst 3 digits ofZIP codeAL, AR, FM,GU, IA, MH,MP, MS, ND,NE, PR, PW, VIEntire state or territoryID, LA, MO, MT,NC, OK, SC,SD, TN, UT, VTEntire stateAS, DE, HI, NM,OREntire state or territoryRatecode123CO, DC,NH, RIEntire state4AKEntire state5AZ850-853, 8643AZRest of state2CA900-931, 933-935,939-952, 954, 956-9595CARest of stateCTStateFirst 3 digits ofZIP codeRatecodeStateFirst 3 digits ofZIP codeRatecodeIN460-462, 470, 472, 4732NY127, 129-139, 144-1491IN463, 4643NYRest of state2INRest of state1KS660-662, 6662OH430-433, 437, 440-443,446, 447, 450-455, 4592KSRest of state1OHRest of state1KY4102PA172-1744KYRest of state1PA180, 181, 1835MA0122PA189-1963PARest of state1TX755-759, 763-769,776-779, 783-785,788-799, 8851MARest of state4MD205-212, 214, 216, 2174MD2193MDRest of state2TX733, 786-7873ME039-0424TXRest of state2MERest of state3VA201, 203, 205, 220-22744MI480-4853VARest of state2064-0695MIRest of state2WA980-9855CTRest of state4MN550-555, 5633WA9863FL329-334, 3493MNRest of state2WARest of state4FLRest of state2NJ080-0843WI5403300-303, 305, 306,311, 399WIRest of state2GA3NJRest of state5WV2544GARest of state2NV8975WVRest of state1IL600-609, 6133NVRest of state3WY8342IL620, 6222NY005, 100-119, 124-1265WYRest of state1ILRest of state1NY0634INTLAll International56

Step 2: Use your rate code to find your 2021 premium.gehadental.com/RatesHigh OptionBiweeklyRate code 1*Rate code 2*Rate code 3*Rate code 4*Rate code 5*Self Only 16.89 19.00 20.77 23.21 25.16Self Plus One 33.78 37.97 41.54 46.41 50.34Self and Family 50.68 57.00 62.30 69.65 75.56Retirees monthlyRate code 1*Rate code 2*Rate code 3*Rate code 4*Rate code 5*Self Only 36.60 41.17 45.00 50.29 54.51Self Plus One 73.19 82.27 90.00 100.56 109.07Self and Family 109.81 123.50 134.98 150.91 163.71BiweeklyRate code 1*Rate code 2*Rate code 3*Rate code 4*Rate code 5*Self Only 9.84 11.04 12.09 13.50 14.63Self Plus One 19.68 22.08 24.14 26.98 29.24Self and Family 29.51 33.11 36.21 40.46 43.87Retirees monthlyRate code 1*Rate code 2*Rate code 3*Rate code 4*Rate code 5*Self Only 21.32 23.92 26.20 29.25 31.70Self Plus One 42.64 47.84 52.30 58.46 63.35Self and Family 63.94 71.74 78.46 87.66 95.05Standard Option* Rate based on member’s primary state of residence.7

Vision discounts areincluded with bothdental plans.Hearing aid discountGet discounts through TruHearing on hearingaids. Most members save 30% to 60% offtheir hearing aids, averaging more than 2,100 in savings per pair.gehadental.com/HearingWith GEHA dental plans, you get discounts on eye exams,frames and lenses through EyeMed .The EyeMed network includes LensCrafters, Target Optical,independent eye doctors and top optical retailers. Members also saveon LASIK at participating US Laser Network locations.This is a sampling of the supplemental vision discounts available withGEHA dental plans. To learn more, visit gehadental.com/VisionExamples of common in-network vision services for both plans.Medical alert discountGet free activation on LifeAlert services,plus a 10% monthly discount.gehadental.com/LifeAlert8High OptionStandard OptionRoutine eye exams at qualifiedEyeMed providers (what you pay) 5 5Out-of-network exams arereimbursed by EyeMed 45 per coveredmember, per year 45 per coveredmember, per yearDiscount glasses purchasedper yearNo limitNo limitDiscount conventional contactlenses purchased per yearNo limitNo limit

An electric toothbrushdiscount is includedwith both dental plans.GEHA members can save more than 70% off a premiumelectric toothbrush by cariPRO . The cariPRO premiumelectric toothbrush helps reduce plaque buildup andimprove gum health.Learn more about this discount at gehadental.com/ToothbrushTeeth whiteningdiscountGet a 20% discount off the lowest price listedon all Smile Brilliant home teeth whiteningproducts including custom-fitted trays,whitening geland desensitizing gel.Enjoy a whiter and brighter smile in justa few weeks.gehadental.com/WhiteningX Replacement brush heads with high-quality DuPont bristles are alsoavailable at this exclusive, member-only price.X The cariPRO premium electric toothbrush removes 7x more plaquethan a regular toothbrush, is completely waterproof, and comes witha 2-year manufacturer’s warranty.gehadental.com877.590.43429

Definitions.BENEFEDSBENEFEDS is the government-authorized and U.S. Office of Personnel Management(OPM)-sponsored enrollment portal that eligible participants use to enroll in the FederalEmployees Dental and Vision Insurance Program (FEDVIP). benefeds.comCalendar year maximumThe annual benefit maximum that you can receive per person each calendar year.Class A servicesBasic services that include oral examinations, cleanings, diagnostic services, sealants andradiographic images.Class B servicesIntermediate services that include restorative procedures such as fillings, prefabricated stainlesssteel crowns, periodontal scaling, tooth extractions and denture adjustments.Class C servicesMajor services that include endodontic services such as root canals, periodontal services suchas gingivectomy, major restorative services such as crowns, oral surgery, bridges, implants andprosthodontic services such as complete dentures.Class D servicesOrthodontic services.CoinsuranceCoinsurance is the stated percentage of covered expenses you must pay.Cosmetic procedureA cosmetic procedure is any procedure or portion of a procedure performed primarily to improvephysical appearance or is performed for psychological purposes.In-network providerAny licensed dentist, dental hygienist or denturist who is a part of GEHA’s provider network.Plan allowanceThe amount we allow for a specific procedure. When you use an in-network provider, yourout-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 contractedfee schedule. When you use an out-of-network provider, you are responsible for the differencebetween our payment and the provider’s billed amount.PremiumThe total amount paid to an insurance company for coverage, typically paid biweekly or monthly.10