Blue Cross Blue Shield FEP Dental
Table of Contents

 

Table of Contents

 

Introduction 1
Table of Contents 2
Changes for 2025 4
FEDVIP Program Highlights 5
A Choice of Plans and Options 5
Enroll Through BENEFEDS 5
Dual Enrollment 5
Coverage Effective Date 5
Pre-Tax Salary Deduction for Employees 5
Annual Enrollment Opportunity 5
Continued Group Coverage After Retirement 5
Compliance with the American Dental Association (ADA) 6
Section 1 Eligibility 6
Federal Employees 6
Federal Annuitants 6
Survivor Annuitants 6
Compensationers 6
TRICARE-eligible individual 6
Family Members 7
Not Eligible 7
Section 2 Enrollment 8
Enroll Through BENEFEDS 8
Enrollment Types 8
Dual Enrollment 8
Opportunities to Enroll or Change Enrollment 9
When Coverage Stops 10
Continuation of Coverage 11
FSAFEDS/High Deductible Health Plans and FEDVIP 11
Section 3 How You Obtain Care 12
Identification Cards/Enrollment Confirmation 12
Where You Get Covered Care 12
Plan Dentists 12
In-Network 12
Out-of-Network 12
Emergency Services 12
Pre-treatment Estimate 12
Alternate Benefit 13
Dental Review 13
FEHB/PSHB First Payor 13
Coordination of Benefits (COB) 14
Rating Areas 14
Limited Access Area 14
Section 4 Your Cost For Covered Services 15
Deductible 15
Coinsurance 15
Annual Benefit Maximum 16
Lifetime Benefit Maximum 16
In-Network Services 16
Out-of-Network Services 16
Plan Allowance 16
Calendar Year 16
Emergency Services 16
In-Progress Treatment 16
Section 5 Dental Services and Supplies Class A Basic 17
Class B Intermediate 21
Class C Major 26
Class D Orthodontic 35
General Services 37
Section 6 International Services and Supplies 39
Section 7 General Exclusions – Things We Do Not Cover 40
Section 8 Claims Filing and Disputed Claims Processes 42
Section 9 Definitions of Terms We Use in This Brochure 43
Discounts 45
Tool and Resources 46
Summary of Benefits 47
Stop Health Care Fraud! 49
Rate Information 54
Rates 55