You can select from several nationwide, and in some areas, regional dental Preferred Provider Organization (PPO) or Health Maintenance Organization (HMO) plans, and high and standard coverage options.  You can also select from several nationwide vision plans. You may enroll in a dental plan or a vision plan, or both.  Some TRICARE beneficiaries may not be eligible to enroll in both. Visit www.opm.gov/dental or
www.opm.gov/vision for more information.

You enroll online at www.BENEFEDS.gov.  Please see Section 2, Enrollment, for more information.

If you sign up for a dental and/or vision plan during the 2024 Open Season, your coverage will begin on January 1, 2025.  Premium deductions will start with the first full pay period beginning on/after January 1, 2025.  You can use your benefits as soon as your enrollment is confirmed.

Employees automatically pay premiums through payroll deductions using pre-tax dollars.  Annuitants automatically pay premiums through annuity deductions using post-tax dollars.  TRICARE enrollees automatically pay premiums through payroll deduction or automatic bank withdrawal (ABW) using post-tax dollars.

Each year, an open season will be held, during which you may enroll or change your dental and/or vision plan enrollment.  This year, open season runs from November 11, 2024, through midnight EST December 9, 2024; You do not need to re-enroll each open season unless you wish to change plans or plan options; your coverage will continue from the previous year. In addition to the annual open season, there are certain events that allow you to make specific types of enrollment changes throughout the year. Please see Section 2, Enrollment, for more information.

FEDVIP abides by the Current Dental Terminology (CDT) codification system in accordance with standards set by the American Dental Association (ADA).

Current Dental Terminology (CDT), Copyright © American Dental Association. All rights reserved.

If you are a Federal or U.S. Postal Service employee, you are eligible to enroll in FEDVIP, if you are eligible for the Federal Employees Health Benefits (FEHB) Program, Postal Service Health Benefits (PSHB) Program, or the Health Insurance Marketplace (Exchange) and your position is not excluded by law or regulation, you are eligible to enroll in FEDVIP.  Enrollment in the FEHB Program, PSHB Program, or a Health Insurance Marketplace (Exchange) plan is not required.

Certain temporary, intermittent, and seasonal Federal and U.S. Postal Service employees are now eligible to enroll in FEDVIP. To be eligible, these employees must be expected to work 130 hours per calendar month for at least 90 days. In addition, certain firefighters hired under a temporary appointment and intermittent emergency response personnel are eligible to enroll in FEDVIP. The employing agency must determine and notify these employees of their eligibility. 

You are eligible to enroll if you:

• retired on an immediate annuity under the Civil Service Retirement System (CSRS), the Federal Employees Retirement System (FERS) or another retirement system for employees of the Federal Government;
• retired for disability under CSRS, FERS, or another retirement system for employees of the Federal Government.

Your FEDVIP enrollment will continue into retirement if you retire on an immediate annuity or for disability under CSRS, FERS or another retirement system for employees of the Government, regardless of the length of time you had FEDVIP coverage as an employee.  There is no requirement to have coverage for 5 years of service prior to retirement in order to continue coverage into retirement, as there is with the FEHB/PSHB Program.

Your FEDVIP coverage will end if you retire on a Minimum Retirement Age (MRA) + 10 retirement and postpone receipt of your annuity.  You may enroll in FEDVIP again, when you begin to receive your annuity.

An individual who is eligible for FEDVIP dental coverage based on the individual's eligibility to previously be covered under the TRICARE Retiree Dental Program or an individual eligible for FEDVIP vision coverage based on the individual's enrollment in a specified TRICARE health plan.

Retired members of the uniformed services and National Guard/Reserve components, including "gray-area" retirees under age 60 and their families are eligible for FEDVIP dental coverage. These individuals, if enrolled in a TRICARE health plan, are also eligible for FEDVIP vision coverage. In addition, uniformed services active duty family members who are enrolled in a TRICARE health plan are eligible for FEDVIP vision coverage.

Except with respect to TRICARE-eligible individuals, family members include your spouse and unmarried dependent children under age 22.  This includes legally adopted children and recognized natural children who meet certain dependency requirements.  This also includes stepchildren and foster children who live with you in a regular parent-child relationship.  Under certain circumstances, you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support. FEDVIP rules, and FEHB/PSHB rules for family member eligibility are NOT the same. For more information on family member eligibility visit the website at
www.opm.gov/healthcare-insurance/dental-vision/ or contact your employing agency or retirement system.

With respect to TRICARE-eligible individuals, family members include your spouse, unremarried widow, unremarried widower, unmarried child, and certain unmarried persons placed in your legal custody by a court.  Children include legally adopted children, stepchildren, and pre-adoptive children.  Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity. 

The following persons are not eligible to enroll in FEDVIP, regardless of FEHB/PSHB eligibility or receipt of an annuity or portion of an annuity:

• Deferred annuitants
• Former spouses of employees or annuitants.  Note:  Former spouses of TRICARE-eligible individuals may enroll in a FEDVIP vision plan.
• FEHB/PSHB Temporary Continuation of Coverage (TCC) enrollee
• Anyone receiving an insurable interest annuity who is not also an eligible family member
• Active duty uniformed service members.  Note:  If you are an active duty uniformed service member, your dental and vision coverage will be provided by TRICARE.  Your family members will still be eligible to enroll in the TRICARE Dental Plan (TDP).
• Temporary/seasonal employees who do not meet the 130 hours per calendar month for 90 days

You must use BENEFEDS to enroll or change enrollment in a FEDVIP plan. BENEFEDS is a secure enrollment website (www.BENEFEDS.gov) sponsored by OPM.  If you do not have access to a computer, call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680 to enroll or change your enrollment.

If you are currently enrolled in FEDVIP and do not want to change plans, your enrollment will continue automatically.  Please Note:  your plans’ premiums may change for 2025.

Note: You cannot enroll or change enrollment in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency self-service system, such as Employee Express, PostalEase, EBIS, MyPay, or Employee Personal Page.  However, those sites may provide a link to BENEFEDS.

Self Only: A Self Only enrollment covers only you as the enrolled employee or annuitant. You may choose a Self Only enrollment even though you have a family, however, your family members will not be covered under FEDVIP.

Self Plus One: A Self Plus One enrollment covers you as the enrolled employee or annuitant plus one eligible family member whom you specify.  You may choose a Self Plus One enrollment even though you have additional eligible family members, but the additional family members will not be covered under FEDVIP. 

Open Season

If you are an eligible employee, annuitant, or TRICARE-eligible individual, you may enroll in a dental and/or vision plan during the November 11, 2024, through midnight EST December 9, 2024, Open Season.  Coverage is effective January 1, 2025.

During future annual open seasons, you may enroll in a plan, or change or cancel your dental and/or vision coverage.  The effective date of these open season enrollments and changes will be set by OPM.  If you want to continue your current enrollment, do nothing.  Your enrollment carries over from year to year, unless you change it.

New hire/Newly eligible

You may enroll within 60 days after you become eligible as:

• a new employee;
• a previously ineligible employee who transferred to a covered position;
• a survivor annuitant if not already covered under FEDVIP; or
• an employee returning to service following a break in service of at least 31 days.
• a TRICARE-eligible individual

Your enrollment will be effective the first day of the pay period following the one in which BENEFEDS receives and confirms your enrollment. 

Qualifying Life Event

A qualifying life event (QLE) is an event that allows you to enroll, or if you are already enrolled, allows you to change your enrollment outside of an open season. 

The following chart lists the QLEs and the enrollment actions you may take.

Qualifying Life Event: Marriage
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes

Qualifying Life Event: Acquiring an eligible family member (non-spouse)
From Not Enrolled to Enrolled: No
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Losing a covered family member
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: Yes
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Losing other dental/vision coverage (eligible or covered person)
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Moving out of regional plan's service area
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes

Qualifying Life Event: Going on active military duty, non- pay status (enrollee or spouse)
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No (enrollee deployment), Yes (spouse deployment)
Cancel: Yes
Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from active military duty (enrollee or spouse)
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from Leave without pay
From Not Enrolled to Enrolled: Yes (if first time enrollment or cancelled during LWOP)
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes (if enrollment cancelled during LWOP)

Qualifying Life Event: Annuity/ compensation restored
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Transferring to an eligible position*
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: Yes
Change from One Plan to Another: No

*Position must be in a Federal agency that provides dental and/or vision coverage with 50 percent or more employer-paid premium and you elect to enroll.

The timeframe for requesting a QLE change is from 31 days before to 60 days after the event. There are two exceptions:

• There is no time limit for a change based on moving from a regional plan’s service area; and
• You cannot request a new enrollment based on a QLE before the QLE occurs, except for enrollment because of a loss of dental or vision insurance. You must make the change no later than 60 days after the event.

Enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives the enrollment or change. BENEFEDS will send you confirmation of your new coverage effective date.

Once you enroll in a plan, your 60-day window for that type of plan ends, even if 60 calendar days have not yet elapsed. That means once you have enrolled in either plan, you cannot change or cancel that particular enrollment until the next open season, unless you experience a QLE that allows such a change or cancellation.

VA Exception for Cancellation

Generally, you may cancel your enrollment only during the annual open season. However, if you are a FEDVIP enrollee paying premiums on a post-tax basis, and you, your family member, or family member becomes eligible for VA dental or vision benefits, then you change your enrollment type or cancel your enrollment within 60 days of receiving notification of VA dental or vision eligibility. This 60-day period may fall outside of open season. VA dental or vision 60 days of notification to support the FEDVIP enrollment change or cancellation.  

Coverage ends for active and retired Federal, U.S. Postal employees, and TRICARE-eligible individuals when you:

• no longer meet the definition of an eligible employee, annuitant, or TRICARE-eligible individual;
• as a Retired Reservist you begin active duty;
• as sponsor or primary enrollee leaves active duty
• begin a period of non-pay status or pay that is insufficient to have your FEDVIP premiums withheld and you do not make direct premium payments to BENEFEDS;
• are making direct premium payments to BENEFEDS and you stop making the payments;
• cancel the enrollment during open season;
• a Retired Reservist begins active duty; or
• the sponsor or primary enrollee leaves active duty.

Coverage for a family member ends when:

• you as the enrollee lose coverage; or
• the family member no longer meets the definition of an eligible family member.

Under FEDVIP, there is no 31-day extension of coverage.  The following are also NOT available under the FEDVIP plans:

• Temporary Continuation of Coverage (TCC);
• spouse equity coverage; or
• right to convert to an individual policy (conversion policy).

If you are planning to enroll in an FSAFEDS Health Care Flexible Spending Account (HCFSA) or Limited Expense Health Care Flexible Spending Account (LEX HCFSA), you should consider how coverage under a FEDVIP plan will affect your annual expenses, and thus the amount that you should allot to an FSAFEDS account. Please note that insurance premiums are not eligible expenses for either type of FSA.   

Please review IRS - Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans (https://www.irs.gov/forms-pubs/about-publication-969) for additional information about carryover and contribution amounts for the upcoming tax year. If you have an HCFSA or LEX HCFSA FSAFEDS account and you have not exhausted your funds by December 31st of the plan year, FSAFEDS can automatically carry over a set maximum amount of unspent funds into another health care or limited expense account for the subsequent year. To be eligible for carryover, you must be employed by an agency that participates in FSAFEDS and actively making allotments from your pay through December 31st. You must also actively re-enroll in a health care or limited expense account during the next open season to be carryover eligible. Your re-enrollment must meet the minimum contribution amount for the plan year. If you do not re-enroll, or if you are not employed by an agency that participates in FSAFEDS and actively making allotments from your pay through December 31st, your funds will not be carried over. 

Because of the tax benefits an FSA provides, the IRS requires that you forfeit any money for which you did not incur an eligible expense and file a claim in the time permitted. This is known as the “Use-it-or-Lose-it” rule. Carefully consider the amount you will elect. 

Current FSAFEDS participants must re-enroll to participate in the program next year. See  
https://www.fsafeds.com or call 1-877-FSAFEDS (372-3337) or TTY: 1-866-353-8058. Note: FSAFEDS is not open to retired employees or to TRICARE eligible individuals. 

If you enroll or are enrolled in a high deductible health plan with a health savings account (HSA) or health reimbursement arrangement (HRA), you may use your HSA or HRA to pay for qualified dental/vision costs not covered by your FEHB/PSHB and/or FEDVIP plans.

ID cards are not provided, and are not required to obtain service.  We will send you an enrollment confirmation letter when you enroll. For members who wish to carry an ID card, you may print a copy online from our Aetna Member website.

It is important to tell your provider about your FEHB/PSHB coverage at every appointment since most FEHB/PSHB plans offer some level of dental benefits separate from your FEDVIP coverage.  This ensures that you receive the maximum allowable benefit under each Program.

You may obtain care from any licensed dentist in the United States or overseas.

When you visit a provider who participates with both, your FEHB/PSHB plan and your FEDVIP plan, the FEHB/PSHB plan will pay benefits first. The FEDVIP plan allowance will be the prevailing charge in these cases.  You are responsible for the difference between the FEHB/PSHB and FEDVIP benefit payments and the FEDVIP plan allowance.  We are responsible for facilitating the process with the primary FEHB/PSHB payor.

SPECIAL NOTE: If you are enrolled in Aetna’s Consumer Driven Health Plan (CDHP) under the FEHB/PSHB, the Dental Fund will not follow the FEHB/PSHB First Payor rule for any service provided by a network dentist. However, preventive services provided by a non-network dentist would be payable from the Dental Fund and follow the FEHB/PSHB First Payor rule.

We will coordinate benefit payments with the payment of benefits under other group health benefits coverage (non-FEHB/non-PSHB) you may have and the payment of dental costs under no-fault insurance that pays benefits without regard to fault. 

SPECIAL NOTE: If you are enrolled in Aetna’s Consumer Driven Health Plan (CDHP) under the FEHB/PSHB the Dental Fund will not follow the FEHB/PSHB First Payor rule for any service provided by a network dentist.  However, preventive services provided by a non-network dentist would be payable from the Dental Fund and follow the FEHB/PSHB First Payor rule.

We may request that you verify/identify your health insurance plan(s) annually or at time of service.  

Here is an example of how we would coordinate benefits if a non-FEHB/non-PSHB plan was primary:

Primary plan payment based on schedule fee, we are secondary.
In-Network Dentist’s Fee: $200.00*
Plan Allowance: $150.00
Primary Plan’s Scheduled Amount: $125.00
Primary Plan’s Payment: $125.00
FEDVIP Payment: $25.00 ($150.00 - $125.00)
Member Payment: $0.00

*You are not responsible for the $50.00 difference between the dentist’s fee and the plan allowance, when you use an in-network dentist.  The dentist cannot bill you for this amount.

If more than one service or procedure can be used to treat the covered person’s dental condition, Aetna may decide to authorize coverage only for the less costly covered service or procedure when that service is deemed by the dental profession to be an appropriate method of treatment and the service selected must meet broadly accepted national standards of dental practice.  If you and your dentist choose the more expensive treatment, you are responsible for the additional charges beyond the allowance for the alternate service, even if services are provided by an in-network provider.

Our review process includes periodontal surgery, crowns, occlusal adjustments and there are other services that are looked at, if they are submitted on the same claim as another service.  Your provider should submit images with crowns and periodontal charting with periodontal surgeries.

A deductible is a fixed amount of expenses you must incur for certain covered services and supplies before we will pay for covered services. For Standard option, the family deductible limit is 2x the self only deductible ($100 for in-network and $200 for out-of-network). Note: Eligible dental services applied to the out-of-network deductible will be applied to satisfy the in-network deductible. Eligible dental services applied to the in-network deductible will be applied to satisfy the out-of-network provider deductible.

Class A
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $0
Out-of-Network Standard Option: $0

Class B
In-Network High Option: $0
In-Network Standard Option: $50
Out-of-Network High Option: $0
Out-of-Network Standard Option: $100

Class C
In-Network High Option: $0
In-Network Standard Option: $50
Out-of-Network High Option: $0
Out-of-Network Standard Option: $100

Orthodontics
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $0
Out-of-Network Standard Option: $0

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance does not begin until you meet your deductible, if applicable.

Class A
In-Network High Option: 0%
In-Network Standard Option: 0%
Out-of-Network High Option: 10%
Out-of-Network Standard Option: 40%

Class B
In-Network High Option: 30%
In-Network Standard Option: 45%
Out-of-Network High Option: 40%
Out-of-Network Standard Option: 70%

Class C
In-Network High Option: 60%
In-Network Standard Option: 65%
Out-of-Network High Option: 60%
Out-of-Network Standard Option: 70%

Orthodontics
In-Network High Option: 50%
In-Network Standard Option: 50%
Out-of-Network High Option: 50%
Out-of-Network Standard Option: 50%

Once you reach this amount, you are responsible for all additional charges. The Annual Benefit Maximums within each option are combined between in and out-of-network services. Note: In-Network and Out-of-Network amounts cross apply. For example on high option, once the $2,000 has been paid for in or out-of-network services, only in-network claims are eligible for reimbursement.

Maximum Annual Benefits

In-Network High Option: Unlimited
In-Network Standard Option: $1,500
Out-of-Network High Option: $2,000
Out-of-Network Standard Option: $1,000

The Lifetime Maximum is applicable to Orthodontia benefits only. There are no other lifetime maximums under this Plan.

Lifetime Orthodontic Maximum
In-Network High Option: up to $2,000
In-Network Standard Option: up to $2,000
Out-of-Network High Option: up to $2,000
Out-of-Network Standard Option: up to $2,000

Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services.  Network provider plans determine their allowance in different ways.  We determine our allowance as follows:

High option:

• Network Providers – we negotiate rates with doctors, dentists and other health care providers to help save you money.  We refer to these providers as “network providers”.  These negotiated rates are our Plan allowance for network providers.  We calculate a member’s coinsurance using these negotiated rates.  The member is not responsible for amounts billed by network providers that are more than our Plan allowance.
• Non-Network providers – Providers that do not participate in our networks are considered non-network providers.  Because they are out of our network, we pay for out-of-network services based on the out-of-network Plan allowance.  To figure out the out-of-network Plan allowance, we get information from FAIR Health. Health plans send FAIR Health claims data for services they receive from providers. FAIR Health combines this information into databases that show how much providers charge for  services by zip code. Providers’ charges for specific procedures are grouped in percentiles from low to high. We use the 80^th percentile as the Plan allowance to calculate how much to pay for out of network services.  The 80^th percentile means 80 percent of charges in the database are the same or less for that service in a particular area.  We use the Plan allowance when calculating a member’s coinsurance amount.  The member is responsible for any amounts billed by the non-network provider that are above the Plan allowance, plus their coinsurance amount.

Standard option: 

• Network Providers – we negotiate rates with doctors, dentists and other health care providers to help save you money. We refer to these providers as “Network providers”. These negotiated rates are our Plan allowance for network providers. We calculate a member’s coinsurance using these negotiated rates. The member is not responsible for amounts billed by network providers that are greater than our Plan allowance.
• Non-Network providers – Providers that do not participate in our networks are considered non-network providers. Our Plan allowance for out-of-network services is based on the in-network negotiated fee for the area. While network providers accept the negotiated fee, members may be billed by out-of-network providers for the difference between the Plan allowance and the provider’s fee.

In-progress treatment for dependents of retiring active duty service members who were enrolled in the TRICARE Dental Program (TDP) will be covered for the 2025 plan year; regardless of any current plan exclusion for care initiated prior to the enrollee's effective date.

This requirement includes assumption of payments for covered orthodontia services up to the FEDVIP policy limits, and full payment where applicable up to the terms of FEDVIP policy for covered services completed (but not initiated) in the 2025 plan year such as crowns and implants.

D0120 Periodic oral evaluation - established patient – Limited to two per calendar year – see benefit limitations at the end of this section

D0140 Limited oral evaluation – problem focused – Limited to two per calendar year – see benefit limitations

D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver – Limited to two per calendar year

D0150 Comprehensive oral evaluation - new or established patient – Limited to two per calendar year – see benefit limitations

D0160 Detailed and extensive oral evaluation - problem focused, by report – Limited to two per calendar year – see benefit limitations

D0180 Comprehensive periodontal evaluation - new or established patient – Limited to two per calendar year

D0210 Intraoral – comprehensive series of radiographic images – Limited to one set every 36 months. (Full Mouth series or panoramic images)

D0220 Intraoral - periapical first radiographic image

D0230 Intraoral - periapical each additional radiographic image

D0240 Intraoral - occlusal radiographic image

D0250 Extra-oral – 2D projection radiographic image created using a stationary radiation source, and detector

D0251 Extra-oral posterior dental radiographic image

D0270 Bitewing - single radiographic image – Limited to one set per calendar year

D0272 Bitewings - two radiographic images – Limited to one set per calendar year

D0273 Bitewings - three radiographic images – Limited to one set per calendar year

D0274 Bitewings - four radiographic images – Limited to one set per calendar year

D0277 Vertical bitewings - 7 to 8 radiographic images – Limited to one set every 36 months.

D0330 Panoramic radiographic image – Limited to one set every 36 months. (Full Mouth series or panoramic images)

D0372 Intraoral tomosynthesis - comprehensive series of radiographic images

D0373 Intraoral tomosynthesis – bitewing radiographic image

D0374 Intraoral tomosynthesis - periapical radiographic image

D0387 Intraoral tomosynthesis – comprehensive series of radiographic images – image capture only

D0388 Intraoral tomosynthesis – bitewing radiographic image – image capture only

D0389 Intraoral tomosynthesis – periapical radiographic image – image capture only

D0425 Caries susceptibility tests

D0600 Non-ionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin, and cementum

D0701 Panoramic radiographic image – image capture only - Limited to one set every 36 months. (Full Mouth series or panoramic images)

D0705 Extra-oral posterior dental radiographic image – image capture only

D0706 Intraoral – occlusal radiographic image – image capture only

D0707 Intraoral – periapical radiographic image – image capture only

D0708 Intraoral – bitewing radiographic image – image capture only - Limited to one set per calendar year

D0709 Intraoral - comprehensive series of radiographic images - image capture only

D1206 Topical application of fluoride varnish - Limited to twice per calendar year

D1208 Topical application of fluoride – excluding varnish - Limited to twice per calendar year

D1351 Sealant – per tooth – Limited to children under age 19. One sealant per tooth in a 3-year period

D1352 Preventive resin restoration in a moderate to high caries risk patient – permanent tooth - Limited to children under age 19

D1353 Sealant repair - per tooth - Limited to children under age 19

D1354 Application of caries arresting medicament – per tooth - Limited to children under age 19

D1355 Caries preventive medicament application – per tooth - Limited to children under age 19

D1510 Space maintainer - fixed, unilateral – per quadrant - Limited to children under age 19

D1516 Space maintainer – fixed – bilateral, maxillary

D1517 Space maintainer – fixed – bilateral, mandibular

D1520 Space maintainer - removable, unilateral - per quadrant - Limited to children under age 19

D1526 Space maintainer – removable – bilateral, maxillary

D1527 Space maintainer – removable – bilateral, mandibular

D1551 Re-cement or re-bond bilateral space maintainer – maxillary

D1552 Re-cement or re-bond bilateral space maintainer – mandibular

D1553 Re-cement or re-bond unilateral space maintainer – per quadrant

D1556 Removal of fixed unilateral space maintainer – per quadrant

D1557 Removal of fixed bilateral space maintainer – maxillary

D1558 Removal of fixed bilateral space maintainer – mandibular

D1575 Distal shoe space maintainer - fixed, unilateral - per quadrant - Limited to children under age 19

D2990 Resin infiltration of incipient smooth surface lesions

D2991 Application of hydroxyapatite regeneration medicament – per tooth

D4346 Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation

D9110 Palliative treatment of dental pain – per visit

D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician

D9440 Office visit - after regularly scheduled hours

Benefit limitations:

• D0120 Periodic oral evaluation - established patient, D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver, and D0150 Comprehensive oral evaluation - new or established patient are limited to 2 exams in total, per calendar year.
• D0140 Limited oral evaluation - problem focused, D0160 Detailed and extensive oral evaluation - problem focused, by report, and D0180 Comprehensive periodontal evaluation - new or established patient are limited to 2 exams in total, per calendar year.

Not covered:

• Plaque control programs
• Oral hygiene instruction
• Dietary instructions
• Sealants for teeth other than permanent molars
• Over-the-counter dental products, such as teeth whiteners, toothpaste, dental floss

D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report

D2140 Amalgam - one surface, primary or permanent

D2150 Amalgam - two surfaces, primary or permanent

D2160 Amalgam - three surfaces, primary or permanent

D2161 Amalgam - four or more surfaces, primary or permanent

D2330 Resin–based composite - one surface, anterior

D2331 Resin-based composite - two surfaces, anterior

D2332 Resin-based composite - three surfaces, anterior

D2335 Resin-based composite - four or more surfaces (anterior)

D2390 Resin-based composite crown, anterior

D2391 Resin-based composite - one surface, posterior - An alternate benefit of an amalgam will be provided on posterior teeth

D2392 Resin-based composite - two surfaces, posterior - An alternate benefit of an amalgam will be provided on posterior teeth

D2393 Resin-based composite - three surfaces, posterior - An alternate benefit of an amalgam will be provided on posterior teeth

D2394 Resin-based composite - four or more surfaces, posterior - An alternate benefit of an amalgam will be provided on posterior teeth

D2610 Inlay - porcelain/ceramic - one surface

D2620 Inlay - porcelain/ceramic - two surfaces 

D2630 Inlay - porcelain/ceramic - three or more surfaces

D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration - Limited to once per 6 month period per tooth

D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core

D2920 Re-cement or re-bond crown - Limited to once per 6 month period per tooth

D2921 Reattachment of tooth fragment, incisal edge or cusp

D2930 Prefabricated stainless steel crown - primary tooth - Limited to one per patient, per tooth, per lifetime

D2931 Prefabricated stainless steel crown - permanent tooth - Limited to one per patient, per tooth, per lifetime

D2951 Pin retention - per tooth, in addition to restoration

D2989 Excavation of a tooth resulting in the determination of non-restorability

Not Covered:

• Restorations, including veneers, which are placed for cosmetic purposes only 
• Gold foil restorations
• Dentures, crowns, inlays, onlays, bridges, or other appliances or services used for the purpose of splinting, to alter vertical dimension, to restore occlusion, or correction attrition, abrasion, or erosion.

D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament

D3221 Pulpal debridement, primary and permanent teeth

D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development

D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)

D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)

D4341 Periodontal scaling and root planing - four or more teeth per quadrant – Limited to once per quadrant every 24 months

D4342 Periodontal scaling and root planing - one to three teeth per quadrant – Limited to once per site every 24 months

D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth

D4910 Periodontal maintenance – Limited to twice per calendar year

D5410 Adjust complete denture - maxillary

D5411 Adjust complete denture - mandibular

D5421 Adjust partial denture - maxillary

D5422 Adjust partial denture - mandibular

D5511 Repair broken complete denture base, mandibular

D5512 Repair broken complete denture base, maxillary

D5520 Replace missing or broken teeth – complete denture – per tooth

D5611 Repair resin partial denture base, mandibular

D5612 Repair resin partial denture base, maxillary

D5621 Repair cast partial framework, mandibular

D5622 Repair cast partial framework, maxillary

D5630 Repair or replace broken retentive clasping materials – per tooth

D5640 Replace missing or broken teeth – partial denture – per tooth

D5650 Add tooth to existing partial denture – per tooth

D5660 Add clasp to existing partial denture - per tooth

D5670 Replace all teeth and acrylic on cast metal framework (maxillary)

D5671 Replace all teeth and acrylic on cast metal framework (mandibular)

D5710 Rebase complete maxillary denture – Not covered within first six months of placement, limited to once in a 36-month period

D5711 Rebase complete mandibular denture - Not covered within first six months of placement, limited to once in a 36-month period

D5720 Rebase maxillary partial denture – Not covered within first six months of placement, limited to once in a 36-month period

D5721 Rebase mandibular partial denture – Not covered within first six months of placement, limited to once in a 36-month period

D5725 Rebase hybrid prosthesis

D5730 Reline complete maxillary denture (direct) – Not covered within first six months of placement, limited to once in a 36-month period

D5731 Reline complete mandibular denture (direct) – Not covered within first six months of placement, limited to once in a 36-month period

D5740 Reline maxillary partial denture (direct) – Not covered within first six months of placement, limited to once in a 36-month period

D5741 Reline mandibular partial denture (direct) – Not covered within first six months of placement, limited to once in a 36-month period

D5750 Reline complete maxillary denture (indirect) – Not covered within first six months of placement, limited to once in a 36-month period

D5751 Reline complete mandibular denture (indirect) – Not covered within first six months of placement, limited to once in a 36-month period

D5760 Reline maxillary partial denture (indirect) – Not covered within first six months of placement, limited to once in a 36-month period

D5761 Reline mandibular partial denture (indirect) – Not covered within first six months of placement, limited to once in a 36-month period

D5765 Soft liner for complete or partial removable denture – indirect

D5850 Tissue conditioning, maxillary

D5851 Tissue conditioning, mandibular

D5876 Add metal substructure to acrylic full denture (per arch)

D6092 Re-cement or re-bond implant/abutment supported crown

D6093 Re-cement or re-bond implant/abutment supported fixed partial denture

D6197 Replacement of restorative material used to close an access opening of a screw-retained implant supported prosthesis, per implant

D6930 Re-cement or re-bond fixed partial denture

D6980 Fixed partial denture repair necessitated by restorative material failure

D7921 Collection and application of autologous blood concentrate product

D7111 Extraction, coronal remnants – primary tooth

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated

D7220 Removal of impacted tooth - soft tissue

D7230 Removal of impacted tooth - partially bony

D7240 Removal of impacted tooth - completely bony

D7241 Removal of impacted tooth - completely bony, with unusual surgical complications

D7250 Removal of residual tooth roots (cutting procedure)

D7251 Coronectomy – intentional partial tooth removal, impacted teeth only

D7270 Tooth re-implantation and/or stabilization of accidentally evulsed or displaced tooth

D7280 Exposure of an unerupted tooth

D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant

D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant

D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant

D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant

D7471 Removal of lateral exostosis (maxilla or mandible)

D7510 Incision and drainage of abscess - intraoral soft tissue

D7910 Suture of recent small wounds up to 5 cm

D7971 Excision of pericoronal gingiva

D2510 Inlay - metallic - one surface - An alternate benefit will be provided

D2520 Inlay - metallic - two surfaces - An alternate benefit will be provided

D2530 Inlay - metallic - three or more surfaces - An alternate benefit will be provided

D2542 Onlay - metallic - two surfaces

D2543 Onlay - metallic - three surfaces

D2544 Onlay - metallic - four or more surfaces

D2740 Crown - porcelain/ceramic - An alternate benefit will be provided on posterior teeth

D2750 Crown - porcelain fused to high noble metal - An alternate benefit will be provided

D2751 Crown - porcelain fused to predominantly base metal - An alternate benefit will be provided on posterior teeth

D2752 Crown - porcelain fused to noble metal - An alternate benefit will be provided on posterior teeth

D2753 Crown - porcelain fused to titanium and titanium alloys

D2780 Crown - 3/4 cast high noble metal - An alternate benefit will be provided on posterior teeth

D2781 Crown - 3/4 cast predominantly base metal 

D2782 Crown - 3/4 cast noble metal 

D2783 Crown - 3/4 porcelain/ceramic - An alternate benefit will be provided on posterior teeth

D2790 Crown - full cast high noble metal - An alternate benefit will be provided on posterior teeth

D2791 Crown - full cast predominantly base metal

D2792 Crown - full cast noble metal

D2794 Crown - titanium and titanium alloys - An alternate benefit will be provided on posterior teeth

D2950 Core buildup, including any pins when required

D2954 Prefabricated post and core in addition to crown

D2980 Crown repair necessitated by restorative material failure

Not covered:

• Gold foil restorations
• Sedative restorations
• Restorations for cosmetic purposes only
• Porcelain/Ceramic inlays, Composite resin inlays  
• Porcelain/Ceramic onlays, Composite resin onlays
• Cast or processed restorations and crowns for purposes other than treatment for decay or acute traumatic injury, when teeth can be restored with a filling material
• Replacement of existing dentures, casts and processed restorations, crowns, removable dentures, fixed bridgework, or other covered prosthetic services that had been installed less than five years prior to the current replacement

D3310 Endodontic therapy, anterior tooth (excluding final restoration)

D3320 Endodontic therapy, premolar tooth (excluding final restoration)

D3330 Endodontic therapy, molar tooth (excluding final restoration)

D3347 Retreatment of previous root canal therapy - premolar

D3352 Apexification/recalcification – interim medication replacement 

D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.)

D3410 Apicoectomy - anterior

D3421 Apicoectomy - premolar (first root)

D3425 Apicoectomy - molar (first root)

D3426 Apicoectomy (each additional root)

D3450 Root amputation - per root

D3471 Surgical repair of root resorption - anterior

D3472 Surgical repair of root resorption – premolar

D3473 Surgical repair of root resorption – molar

D3920 Hemisection (including any root removal), not including root canal therapy

D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant - Limited to once in a 36 month period

D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant - Limited to once in a 36 month period

D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth

D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant

D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant

D4249 Clinical crown lengthening – hard tissue

D4260 Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant - Limited to once in a 36 month period

D4261 Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant - Limited to once in a 36 month period

D4270 Pedicle soft tissue graft procedure

D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft

D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft

D4276 Combined connective tissue and pedicle graft, per tooth

D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft

D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant or edentulous tooth position in same graft site

D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit - Limited to once per lifetime

D4999 Unspecified periodontal procedure, by report

D5110 Complete denture - maxillary

D5120 Complete denture - mandibular

D5130 Immediate denture - maxillary

D5140 Immediate denture - mandibular

D5211 Maxillary partial denture – resin base (including, retentive/clasping materials, rests, and teeth)

D5212 Mandibular partial denture – resin base (including, retentive/clasping materials, rests, and teeth)

D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5221 Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth)

D5222 Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth)

D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5225 Maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth)

D5226 Mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth)

D5227 Immediate maxillary partial denture - flexible base (including any clasps, rests and teeth)

D5228 Immediate mandibular partial denture - flexible base (including any clasps, rests and teeth)

D5282 Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), maxillary

D5283 Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), mandibular

D5284 Removable unilateral partial denture – one piece flexible base (including retentive/clasping materials, rests, and teeth) – per quadrant

D5286 Removable unilateral partial denture – one piece resin (including retentive/clasping materials, rests, and teeth) – per quadrant

D6010 Surgical placement of implant body: endosteal implant

D6040 Surgical placement: eposteal implant

D6050 Surgical placement: transosteal implant

D6055 Connecting bar – implant supported or abutment supported

D6056 Prefabricated abutment – includes modification and placement

D6057 Custom fabricated abutment – includes placement

D6058 Abutment supported porcelain/ceramic crown

D6059 Abutment supported porcelain fused to metal crown (high noble metal) - An alternate benefit will be provided

D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) - An alternate benefit will be provided on posterior teeth

D6061 Abutment supported porcelain fused to metal crown (noble metal) - An alternate benefit will be provided on posterior teeth

D6062 Abutment supported cast metal crown (high noble metal) - An alternate benefit will be provided

D6063 Abutment supported cast metal crown (predominantly base metal)

D6064 Abutment supported cast metal crown (noble metal)

D6065 Implant supported porcelain/ceramic crown - An alternate benefit will be provided on posterior teeth

D6066 Implant supported crown – porcelain fused to high noble alloys - An alternate benefit will be provided

D6067 Implant supported crown – high noble alloys - An alternate benefit will be provided

D6068 Abutment supported retainer for porcelain/ceramic FPD - An alternate benefit will be provided

D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) - An alternate benefit will be provided

D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) - An alternate benefit will be provided on posterior teeth

D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) - An alternate benefit will be provided on posterior teeth

D6072 Abutment supported retainer for cast metal FPD (high noble metal) - An alternate benefit will be provided

D6073 Abutment supported retainer for cast metal FPD (predominantly base metal)

D6074 Abutment supported retainer for cast metal FPD (noble metal)

D6075 Implant supported retainer for ceramic FPD - An alternate benefit will be provided

D6076 Implant supported retainer for FPD – porcelain fused to high noble alloys - An alternate benefit will be provided

D6077 Implant supported retainer for metal FPD – high noble alloys - An alternate benefit will be provided

D6080 Implant maintenance procedures when a full arch fixed hybrid prosthesis is removed and reinserted, including cleansing of prosthesis and abutments

D6081 Scaling and debridement of a single implant in the presence of mucositis, including inflammation, bleeding upon probing and increased pocket depths; includes cleaning of the implant surfaces, without flap entry and closure

D6082 Implant supported crown – porcelain fused to predominantly base alloys

D6083 Implant supported crown – porcelain fused to noble alloys

D6084 Implant supported crown - porcelain fused to titanium and titanium alloys

D6086 Implant supported crown – predominantly base alloys

D6087 Implant supported crown – noble alloys

D6088 Implant supported crown – titanium and titanium alloys

D6089 Accessing and retorquing loose implant screw - per screw

D6090 Repair of implant/abutment supported prosthesis

D6091 Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment

D6094 Abutment supported crown - titanium and titanium alloys

D6096 Remove broken implant retaining screw

D6097 Abutment supported crown – porcelain fused to titanium and titanium alloys

D6098 Implant supported retainer – porcelain fused to predominantly base alloys

D6099 Implant supported retainer for FPD – porcelain fused to noble alloys

D6100 Surgical removal of implant body

D6101 Debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure

D6102 Debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant and includes surface cleaning of the exposed implant surfaces, including flap entry and closure

D6104 Bone graft at time of implant placement

D6105 Removal of implant body not requiring bone removal or flap elevation

D6110 Implant /abutment supported removable denture for edentulous arch – maxillary

D6111 Implant /abutment supported removable denture for edentulous arch – mandibular

D6112 Implant /abutment supported removable denture for partially edentulous arch – maxillary

D6113 Implant /abutment supported removable denture for partially edentulous arch – mandibular

D6114 Implant /abutment supported fixed denture for edentulous arch – maxillary

D6115 Implant /abutment supported fixed denture for edentulous arch – mandibular

D6120 Implant supported retainer – porcelain fused to titanium and titanium alloys

D6121 Implant supported retainer for metal FPD – predominantly base alloys

D6122 Implant supported retainer for metal FPD – noble alloys

D6123 Implant supported retainer for metal FPD – titanium and titanium alloys

D6180 Implant maintenance procedures when a full arch fixed hybrid prosthesis is not removed, including cleansing of prosthesis and abutments  

D6191 Semi-precision abutment – placement

D6193 Replacement of an implant screw

D6194 Abutment supported retainer crown for FPD – titanium and titanium alloys

D6195 Abutment supported retainer – porcelain fused to titanium and titanium alloys

D6205 Pontic - indirect resin based composite - An alternate benefit will be provided on posterior teeth

D6210 Pontic - cast high noble metal - An alternate benefit will be provided on posterior teeth

D6211 Pontic - cast predominantly base metal

D6212 Pontic - cast noble metal

D6214 Pontic - titanium and titanium alloys - An alternate benefit will be provided on posterior teeth

D6240 Pontic - porcelain fused to high noble metal - An alternate benefit will be provided on posterior teeth

D6241 Pontic - porcelain fused to predominantly base metal - An alternate benefit will be provided on posterior teeth

D6242 Pontic - porcelain fused to noble metal - An alternate benefit will be provided on posterior teeth

D6243 Pontic – porcelain fused to titanium and titanium alloys

D6245 Pontic - porcelain/ceramic - An alternate benefit will be provided on posterior teeth

D6545 Retainer - cast metal for resin bonded fixed prosthesis

D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis - An alternate benefit will be provided on posterior teeth

D6601 Retainer inlay - porcelain/ceramic, three or more surfaces

D6604 Retainer inlay - cast predominantly base metal, two surfaces

D6605 Retainer inlay - cast predominantly base metal, three or more surfaces

D6613 Retainer onlay - cast predominantly base metal, three or more surfaces

D6740 Retainer crown - porcelain/ceramic - An alternate benefit will be provided on posterior teeth

D6750 Retainer crown - porcelain fused to high noble metal - An alternate benefit will be provided on posterior teeth

D6751 Retainer crown - porcelain fused to predominantly base metal - An alternate benefit will be provided on posterior teeth

D6752 Retainer crown - porcelain fused to noble metal - An alternate benefit will be provided on posterior teeth

D6753 Retainer crown – porcelain fused to titanium and titanium alloys

D6780 Retainer crown - 3/4 cast high noble metal - An alternate benefit will be provided on posterior teeth

D6781 Retainer crown - 3/4 cast predominantly base metal

D6782 Retainer crown - 3/4 cast noble metal

D6783 Retainer crown - 3/4 porcelain/ceramic - An alternate benefit will be provided on posterior teeth

D6784 Retainer crown ¾ – titanium and titanium alloys

D6790 Retainer crown - full cast high noble metal - An alternate benefit will be provided on posterior teeth

D6791 Retainer crown - full cast predominantly base metal

D6792 Retainer crown - full cast noble metal

D6794 Retainer crown - titanium and titanium alloys – An alternate benefit will be provided on posterior teeth

D7252 Partial extraction for immediate implant placement

D9999 Unspecified adjunctive procedure, by report

Not covered:

• Partial or full removable denture, fixed bridgework or other covered prosthetic services (including implant abutments/crowns) if it includes replacement of one or more natural teeth missing prior to you being covered under a participating FEDVIP plan or the prior TRDP plan.  This does not apply if it also includes replacement of a natural tooth that is removed while you are covered and was not an abutment to a prosthetic appliance installed during the prior five years
• Precision attachments, personalization, precious metal bases, and other specialized technique
• Replacement of existing dentures, casts and processed restorations, crowns, removable dentures, fixed bridgework, or other covered prosthetic services that had been installed less than five years prior to the current replacement
• Replacement of dentures that have been lost, stolen or misplaced
• Removable or fixed prostheses inserted/cemented after the coverage ending date.  This does not apply to prostheses that were initiated during the coverage period and inserted/cemented within 30 days of the coverage ending date.
• Dentures, crowns, inlays, onlays, bridges, or other appliances or services used for the purpose of splinting, to alter vertical dimension, to restore occlusion, or correction attrition, abrasion, or erosion.

D0340 2D cephalometric radiographic image – acquisition, measurement and analysis

D0350 2D oral/facial photographic image obtained intra-orally or extra-orally

D0396 3D printing of a 3D dental surface scan

D0702 2-D cephalometric radiographic image – image capture only

D0703 2-D oral/facial photographic image obtained intra-orally or extra-orally – image capture only

D0801 3D intraoral surface scan – direct

D0802 3D dental surface scan – indirect

D0803 3D facial surface scan – direct

D0804 3D facial surface scan – indirect

D8010 Limited orthodontic treatment of the primary dentition

D8020 Limited orthodontic treatment of the transitional dentition

D8030 Limited orthodontic treatment of the adolescent dentition

D8040 Limited orthodontic treatment of the adult dentition

D8070 Comprehensive orthodontic treatment of the transitional dentition

D8080 Comprehensive orthodontic treatment of the adolescent dentition

D8090 Comprehensive orthodontic treatment of the adult dentition

D8091 Comprehensive orthodontic treatment with orthognathic surgery

D8210 Removable appliance therapy

D8220 Fixed appliance therapy

D8660 Pre-orthodontic treatment examination to monitor growth and development

D8670 Periodic orthodontic treatment visit

D8671 Periodic orthodontic treatment visit associated with orthognathic surgery

D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s))

Not covered:

• Repair of damaged orthodontic appliances
• Replacement of lost or missing appliance
• Dentures, crowns, inlays, onlays, bridges, or other appliances or services used for the purpose of splinting, to alter vertical dimension, to restore occlusion, or correction attrition, abrasion, or erosion.
• Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth

D9219 Evaluation for moderate sedation, deep sedation or general anesthesia

D9222 Deep sedation/general anesthesia – first 15 minutes  

D9223 Deep sedation/general anesthesia – each subsequent 15 minute increment

D9239 Intravenous moderate (conscious) sedation/analgesia- first 15 minutes

D9243 Intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minute increment

D9610 Therapeutic parenteral drug, single administration

D9612 Therapeutic parenteral drugs, two or more administrations, different medications

D9613 Infiltration of sustained release therapeutic drug, per quadrant

D9930 Treatment of complications (post-surgical) - unusual circumstances, by report

D9941 Fabrication of athletic mouthguard - Limited to one per 12 month period

D9944 Occlusal guard – hard appliance, full arch - Limited to once in a 36 month period

D9945 Occlusal guard – soft appliance, full arch - Limited to once in a 36 month period

D9946 Occlusal guard – hard appliance, partial arch - Limited to once in a 36 month period

D9974 Internal bleaching - per tooth - Limited to once per tooth per three year period

Not covered:

• Nitrous oxide
• Oral sedation
• General anesthesia and IV sedation unless determined to be medically necessary and unless done in conjunction with another necessary covered service

Please send us all of your documents for your claim to:

Aetna
P.O. Box 14094
Lexington, KY 40512-4094

You may look up information on our plan or ask a question at www.aetnafeds.com.  (Our toll-free number will not work overseas).

There is one international region.  Please see the rate table for the actual premium amount.

Send us all of the documents for your claim, as soon as possible, to: Aetna, PO Box 14094, Lexington, KY 40512-4094.

You must submit claims by December 31 of the year after the year you received the service unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as possible.  Once we pay the benefits, there is a two-year limitation on the reissuance of uncashed checks.

Follow this disputed claims process if you disagree with our decision on your claim or request for services.  The FEDVIP law does not provide a role for OPM to review disputed claims.

1. Ask us in writing to reconsider our initial decision.  You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at: Aetna, Attention: National Accounts, P.O. Box 14597, Lexington, KY 40512-4597; and

Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.  This is your first level appeal.

2. We have 30 days from the date we receive your request to:

a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or

b) Write to you and maintain our denial – go to step 3; or

c) Ask you or your provider for more information.  If we ask your provider, we will send you a copy of our request.

You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.

We will write to you with our decision.

3. If the dispute is not resolved through the reconsideration process, and the reason for the denial was based on medical necessity or for experimental or investigational reasons, you have the right to file a second level appeal.  That appeal must be submitted within 60 days following the receipt of our first level denial.

4. If you do not agree with our final decision, and the amount of your claim is more than $300 and the plan denied your claim because it did not consider the treatment medical necessity, you may request an independent third party, mutually agreed upon by us and OPM, review the decision.  You have 30 days from the date you received our final decision to request a third party review.

The decision of the independent third party is binding and is the final review of your claim.  This decision is not subject to judicial review.

If more than one service or procedure can be used to treat the covered person’s dental condition, Aetna may decide to authorize coverage only for the less costly covered service or procedure when that service is deemed by the dental profession to be an appropriate method of treatment and the service selected must meet broadly accepted national standards of dental practice.  If you and your dentist choose the more expensive treatment, you are responsible for the additional charges beyond the allowance for the alternate service, even if services are provided by an in-network provider.

Basic services, which include oral examinations, prophylaxis, diagnostic evaluations, sealants and images.

The Federal employee, annuitant, or TRICARE-eligible individual enrolled in this plan.

Dental services that initiated in 2024 that will be completed in 2025.

Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Network provider plans determine their allowance in different ways. We determine our allowance as follows:

High option:

• Network Providers – we negotiate rates with doctors, dentists and other health care providers to help save you money.  We refer to these providers as “network providers”.  These negotiated rates are our Plan allowance for network providers.  We calculate a member’s coinsurance using these negotiated rates.  The member is not responsible for amounts billed by network providers that are more than our Plan allowance.
• Non-Network providers – Providers that do not participate in our networks are considered non-network providers.  Because they are out of our network, we pay for out-of-network services based on the out-of-network Plan allowance.  To figure out the out-of-network Plan allowance, we get information from FAIR Health. Health plans send FAIR Health claims data for services they receive from providers. FAIR Health combines this information into databases that show how much providers charge for services by zip code. Providers’ charges for specific procedures are grouped in percentiles from low to high. We use the 80^th percentile as the Plan allowance to calculate how much to pay for out of network services. The 80^th percentile means 80 percent of charges in the database are the same or less for that service in a particular area.  We use the Plan allowance when calculating a member’s coinsurance amount.  The member is responsible for any amounts billed by the non-network provider that are above the Plan allowance, plus their coinsurance amount.

Standard option: 

• Network Providers – we negotiate rates with doctors, dentists and other health care providers to help save you money. We refer to these providers as “Network providers”. These negotiated rates are our Plan allowance for network providers. We calculate a member’s coinsurance using these negotiated rates. The member is not responsible for amounts billed by network providers that are greater than our Plan allowance.
• Non-Network providers – Providers that do not participate in our networks are considered non-network providers. Our Plan allowance for out-of-network services is based on the in-network negotiated fee for the area. While network providers accept the negotiated fee, members may be billed by out-of-network providers for the difference between the Plan allowance and the provider’s fee.

Generally, a sponsor means the individual who is eligible for medical or dental benefits under 10 U.S.C. chapter 55 based on their direct affiliation with the uniformed services (including military members of the National Guard and Reserves).

Under circumstances where a sponsor is not an enrollee, a TEI family member may accept responsibility to self-certify as an enrollee and enroll TEI family members.

TEI family members include a sponsor's spouse, unremarried widow, unremarried widower, unmarried child, and certain unmarried persons placed in a sponsor's legal custody by a court. Children include legally adopted children, stepchildren, and pre- adoptive children. Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity.

The first installation of complete dentures, removable partial dentures, fixed partial dentures (bridges), and other prosthetic services will be covered if:

• The dentures, bridges or other prosthetic services are needed to replace one or more natural teeth that were removed while covered under a participating FEDVIP plan or the prior TRDP plan; and
• The tooth that was removed was not an abutment to a removable or fixed partial denture installed during the prior 5 years. The extraction of third molars does not qualify. Any such appliance or fixed bridge must include the replacement of an extracted tooth or teeth.

High Option: There is no waiting period for any benefits on this plan option.
Standard Option: There is no waiting period for any benefits on this plan option.

10%

30%

40%

60%

Annual maximum benefit - applies to Class A, B, and C Services 

Unlimited

$2,000

Class D Services – orthodontic

$2,000 Lifetime Maximum

50%

Deductible

$50 self only; $100 self plus or self and family (applies only to Class B and C services)

$100 self only; $200 self plus or self and family (applies only to Class B and C services)

Class A (Basic) Services – preventive and diagnostic

Nothing

40%

Class B (Intermediate) Services – includes minor restorative services

45%

70%

Class C (Major) Services – includes major restorative, endodontic, and prosthodontic services

65%

70%

Annual maximum benefit - applies to Class A, B, and C Services 

$1,500

$1,000

Class D Services – orthodontic
$2,000 Lifetime Maximum

Plan payment percentages are applied to the plan allowance. When you use an out-of-network provider, in addition to your coinsurance percentage, you are responsible for the difference between the plan allowance and the billed charges.

50%

50%