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