Section 4 Your Costs for Covered Services

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Table of Contents

Changes for 2025

FEDVIP Program Highlights

Section 1 Eligibility

Section 2 Enrollment

Section 3 How You Obtain Care

Section 4 Your costs for Covered Services

Section 5 Dental Services and Supplies Class A Basic

Class B Intermediate

Class D Orthodontic

General Services

Section 6 International Services and Supplies

Section 7 General Exclusions - Things We Do Not Cover

Section 8 Claims Filing and Disputed Claims Process

Section 9 Definitions of Terms We Use in This Brochure

Tools and Resources

Summary of Benefits

Stop Health Care Fraud!

Rate Information

Blue Cross Blue Shield FEP Dental Brochure - 2025

Section 4 Your Costs for Covered Services

Section 4 Your Cost For Covered Services

Annual Benefit Maximum

Lifetime Benefit Maximum

In-Network Services

Out-of-Network Services

Emergency Services

In-Progress Treatment

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