Blue Cross Blue Shield FEP Dental
Summary of Benefits

Class A (Basic) Services – preventive and diagnostic
Class A, B, and C Services are subject to a $1,500 annual maximum benefit for the in-network benefits and $750 for the out-of-network benefits
You Pay
In-Network: 0%
Out-of-Network: 40%

Class B (Intermediate) Services – includes minor restorative services
Class A, B, and C Services are subject to a $1,500 annual maximum benefit for the in-network benefits and $750 for the out-of-network benefits
You Pay
In-Network: 45%
Out-of-Network: 60%

Class C (Major) Services – includes major restorative, endodontic, and prosthodontic services
Class A, B, and C Services are subject to a $1,500 annual maximum benefit for the in-network benefits and $750 for the out-of-network benefits
You Pay
In-Network: 65%
Out-of-Network: 80%

Class D (Orthodontic) Services – Class D Orthodontic Services are subject to a Lifetime Maximum Benefit up to
$2,500 for In-network per treatment or
$1,250 for Out-of-network per treatment
You Pay
In-Network: 50%
Out-of-Network: 50%