Document list

Document Name Document Number
Cover page D25.00.1.1
Introduction D25.00.1.2
Table of Contents D25.00.1.3
Changes for 2025 D25.00.1.4
A Choice of Plans and Options D25.00.2.1
Enroll Through BENEFEDS D25.00.2.2
Dual Enrollment D25.00.2.3
Coverage Effective Date D25.00.2.4
Pre-Tax Salary Deduction for Employees D25.00.2.5
Annual Enrollment Opportunity D25.00.2.6
Continued Group Coverage After Retirement D25.00.2.7
Compliance with the American Dental Association (ADA) D25.00.2.8
Federal Employees D25.01.1
Temporary/Seasonal Employees D25.01.1.1
Federal Annuitants D25.01.2
Survivor Annuitants D25.01.3
Compensationers D25.01.4
TRICARE-eligible individual D25.01.5
Family Members D25.01.6
Not Eligible D25.01.7
Enroll Through BENEFEDS D25.02.1
Enrollment Types D25.02.2
Dual Enrollment D25.02.3
Opportunities to Enroll or Change Enrollment D25.02.4
When Coverage Stops D25.02.5
Continuation of Coverage D25.02.6
FSAFEDS/High Deductible Health Plans and FEDVIP D25.02.7
Identification Cards/Enrollment Confirmation D25.03.01
Where You Get Covered Care D25.03.02
Plan Dentists D25.03.03
In-Network D25.03.04
Out-of-Network D25.03.05
Emergency Services D25.03.06
Pre-treatment Estimate D25.03.08
Alternate Benefit D25.03.09
Dental Review D25.03.10
FEHB/PSHB First Payor D25.03.11
Example 1: High Option coverage (In-Network provider) D25.03.12
Example 2: High Option coverage (Out-of-Network provider) D25.03.13
Coordination of Benefits D25.03.14
Example 1: High Option coverage (In-Network provider) D25.03.15
Example 2: High Option coverage (Out-of-Network provider) D25.03.16
Rating Areas D25.03.17
Limited Access Area D25.03.18
Section 4 Your Cost For Covered Services D25.04.0
Deductible D25.04.1
Coinsurance D25.04.2
Annual Benefit Maximum D25.04.3
Lifetime Benefit Maximum D25.04.4
In-Network Services D25.04.5
Out-of-Network Services D25.04.6
Plan Allowance D25.04.6.1
Calendar Year D25.04.7
Emergency Services D25.04.8
In-Progress Treatment D25.04.9
Section 5 Dental Services and Supplies Class A Basic D25.05A.0
Diagnostic Services D25.05A.1
Preventive Services D25.05A.2
Additional Procedures Covered as Basic Services D25.05A.3
Services Not Covered D25.05A.4
Class B Intermediate D25.05B.0
Minor Restorative Services D25.05B.1
Endodontic Services D25.05B.2
Periodontal Services D25.05B.3
Prosthodontic Services D25.05B.4
Oral Surgery D25.05B.5
Services Not Covered D25.05B.6
Class C Major D25.05C.0
Major Restorative Services D25.05C.1
Endodontic Services D25.05C.2
Periodontal Services D25.05C.3
Prosthodontic Services D25.05C.4
Implant Services D25.05C.4.1
Oral Surgery D25.05C.5
Services Not Covered D25.05C.6
Class D Orthodontic D25.05D.0
Orthodontic Services D25.05D.1
Services Not Covered D25.05D.2
General Services D25.05G.0
Anesthesia Services D25.05G.1
Medications D25.05G.3
Post-Surgical Services D25.05G.4
Miscellaneous Services D25.05G.5
Services Not Covered D25.05G.6
International Claims Payment D25.06.1
Finding an International Dentist D25.06.2
Filing International Claims D25.06.3
International Rates D25.06.4
Section 7 General Exclusions – Things We Do Not Cover D25.07
How to File a Claim For Covered Services D25.08.1
Deadline for Filing Your Claim D25.08.2
Disputed Claims Process D25.08.3
Section 9 Definitions of Terms We Use in This Brochure D25.09
Discounts D25.10.1
Tools and Resources D25.10.2
Summary of Benefits D25.11.0
High Option Benefits D25.11.1
Standard Option Benefits D25.11.2
Stop Health Care Fraud! D25.12
Rate Information D25.13
Rates D25.14
Terms and Conditions and Privacy Policy SB-FBF-002