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.

If you sign up for a dental and/or vision plan during the 2023 Open Season, your coverage will begin on January 1, 2024.  Premium deductions will start with the first full pay period beginning on/after January 1, 2024. You may 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 13, 2023 through midnight EST December 11, 2023. 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.

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 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.

If you are a survivor of a deceased Federal/U.S. Postal Service employee or annuitant and you are receiving an annuity, you may enroll or continue the existing enrollment.

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 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 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 dental plan

• FEHB Temporary Continuation of Coverage (TCC) enrollees
• 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.com) sponsored by OPM.  If you do not have access to a computer, call 1-877-888-FEDS (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 2024.

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.

Self and Family: A Self and Family enrollment covers you as the enrolled employee or annuitant and all of your eligible family members.  You must list all eligible family members when enrolling.

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 13, through midnight EST December 11, 2023, Open Season.  Coverage is effective January 1, 2024.

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; 
• an employee returning to service following a break in service of at least 31 days; or
• a TRICARE-eligible individual.

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 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
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 (LWOP)
From Not Enrolled to Enrolled: Yes (if enrollment 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.

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 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  TEI family member becomes eligible for VA dental or vision benefits, then you may 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 eligibility documentation must be submitted to OPM via the BENEFEDS mailbox (benefedsportal@opm.gov) within 60 days of notification to support the FEDVIP enrollment change or cancellation.  

If you are a FEDVIP enrollee paying premiums on a pre-tax basis, and you, your family member, or TEI family member becomes eligible for VA dental or vision benefits, then you may not change or cancel your FEDVIP enrollment until the next Open Season. 

FEDVIP enrollees can verify if they are paying their premiums on a pre- or post-tax basis by contacting BENEFEDS at 1-877-888-3337, TTY number 1-877-889-5680. 

Coverage ends for active and retired Federal employees, 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;
• the sponsor or primary enrollee leaves active duty
• you 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;
• you are making direct premium payments to BENEFEDS and you stop making the payments;
• you cancel the enrollment during Open Season.

 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.

NOTE: Coverage ends for a covered individual when BCBS FEP Dental does not receive premium payment for that covered individual.

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).

FSAFEDS/High Deductible Health Plans and FEDVIP 

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 and/or FEDVIP plans.

When you enroll for the first time, you will receive a welcome letter along with an identification (ID) card which will serve as confirmation of your enrollment. Each contract holder will receive two BCBS FEP Dental ID cards. The ID cards will only have the contract holder's name on them. Since most FEHB plans offer some level of dental benefits separate from your FEDVIP coverage, presenting both ID cards can ensure that you receive the maximum allowable benefit under each program along with accurate and timely claims processing.

Existing members who were previously issued ID cards will not receive new ID cards unless otherwise requested. You may order a replacement ID card via                         www.bcbsfepdental.com or by calling customer service at 1-855-504-BLUE (2583). 

An ID card is neither a guarantee of benefits nor does your dentist need it to render dental services. Your dentist may call 1-855-504-BLUE (2583) to confirm your enrollment and the benefits available to you.

Network dentist are listed on our website at  www.bcbsfepdental.com/findadentist  and on the BCBS FEP Dental mobile app. Our directory is updated weekly. You may also contact us at 1-855-504-BLUE (2583) for further assistance.

BCBS FEP Dental negotiates rates with dentists to help reduce your costs. We refer to these dentists as in-network. If you use one of these dentists, benefits are paid at the in-network level. To find a dentist in your area go to www.bcbsfepdental.com/findadentist or contact customer service at 1-855-504-BLUE (2583).

Note:  The BCBS FEP Dental dentist network may be different from the BCBS Federal Employee Program (FEP) medical network. 

Before each appointment, verify the dentist is in-network at the service location.

You may obtain care from any licensed dentist. If the dentist you use is not part of our network, we will pay for their services based on an out-of-network benefit level and plan allowance, resulting in a lower annual maximum benefit. You are responsible for the difference between our payment and the amount billed. If you choose to go out of network, we will pay our portion to the contract holder directly.

Emergency services are defined as those dental services needed to relieve pain or prevent the worsening of a condition that would be caused by a delay.

Pre-treatment estimates are not mandatory. However, we do recommend that your dentist submits a pre-treatment estimate if you are considering major or extensive dental care. Pre-treatment estimates should include a comprehensive treatment plan and necessary supporting documentation such as, chart notes, radiographic images, and photos.

Benefits may be alternated to a least costly procedure that meets broadly accepted national standards of dental practice.

We will provide a non-binding, explanation of benefits to both you and your dentist that will indicate if procedures are covered and an estimate of what we will pay for those specific services. The estimated plan allowance is based on your current eligibility and benefits in effect at the time of the pre-treatment estimate. Submission of other claims or changes in eligibility or benefits may alter final payment. A pretreatment estimate is not a guarantee of benefits.

Pre-treatment estimates are valid through the calendar year in which they are processed, or 12 months, subject to eligibility and plan limitations.

Submit pre-treatment estimates to BCBS FEP Dental at the address below. Do not send pre-treatment estimates to your medical plan.

BCBS FEP Dental
P.O. Box 75
Minneapolis, MN 55440-0075

If more than one service or procedure can be used to treat the dental condition, we reserve the right to authorize an alternate, less costly covered service as deemed by a dental professional to be appropriate and to meet broadly accepted national standards of dental practice. 

If you and your dentist choose the more expensive treatment instead of the alternate benefit, you are responsible for the additional charges beyond the plan allowance for the alternate service. 

Example: If a dental professional determines an implant is not dentally necessary or a less expensive appropriate treatment is available, no benefits will be allowed for the individual implant or implant related procedures, and the allowance for the less expensive treatment may be approved. 

Some dental services submitted on a claim may be reviewed for benefit determination and dental necessity. This review is conducted by licensed dental professionals who will review the clinical documentation and diagnostic images submitted by your treating dentist.

There may be situations resulting from the dental review where an alternate benefit is applied that meets broadly accepted national standards of dental practice. This review applies to procedures including but not limited to, onlays, crowns, buildups, bridges, implants, periodontal treatment, extractions and anesthesia.

It is important to know that, per FEDVIP requirements, the FEHB plan will always be the first payor when you are also covered under BCBS FEP Dental. Therefore, always provide your dental office with both your FEHB and BCBS FEP Dental ID cards at each appointment. Your dental office should submit your claim(s) to the FEHB carrier first.

When you visit a provider who participates with both your FEHB plan and your FEDVIP plan, the FEHB plan will pay benefits first.

In these cases, the BCBS FEP Dental plan allowance will be the negotiated allowable charge between the plan and the dentist. You are responsible for the difference between the total FEHB and BCBS FEP Dental payment and the plan allowance.

We are responsible for facilitating the process if the primary FEHB payor is FEP medical. 

If you are covered under the Blue Cross Blue Shield Service Benefit Plan Basic Option and BCBS FEP Dental, you are not responsible for the $30 co-pay (up to 2 evaluations per year).  If your dentist collects the co-pay upfront, they are required to reimburse the co-pay in full once the claim has processed under BCBS FEP Dental.

Please see the following examples that assume all deductibles have been met and annual maximums have not been reached. 

Example 1: High Option coverage (In-Network dentist)
Class B dentist fee: $108.00
FEHB payment: $16.00
BCBS FEP Dental plan allowance: $60.00
BCBS FEP Dental payment: $42.00 ($60.00 at 70%)
Member’s responsibility*: $2.00 ($60-$16-$42)

Example 2: High Option coverage (Out-of-Network dentist).
Class B dentist fee: $108.00
FEHB payment: $16.00
BCBS FEP Dental payment: $64.80 ($108.00 at 60%)
Member’s responsibility*: $27.20 ($108-$16-$64.80)

 *Assumes dentist charge is within the plan allowance

If you are covered under a non-FEHB plan, your BCBS FEP Dental benefits will be coordinated using traditional COB provisions for determining payment. We will coordinate benefit payments with the payment of benefits under other group health benefits coverage (non-FEHB) you may have and the payment of dental costs under no-fault insurance that pays benefits without regard to fault. Please see the following examples that assume all deductibles have been met and annual maximums have not been reached. 

Example 1: High Option coverage (In-Network dentist)
Class B dentist fee: $121.00
FEHB payment: $60.50
BCBS FEP Dental plan allowance: $73.00
BCBS FEP Dental payment: $51.10 ($73.00 at 70%)
Payment by BCBS FEP Dental: $12.50 
Member’s responsibility*: $0.00 ($73-$60.50-$12.50)

Example 2: High Option coverage (Out-of-Network dentist)
Class B dentist fee: $121.00
FEHB payment: $96.80
BCBS FEP Dental payment: $72.60 ($121.00 at 60%) 
Payment by BCBS FEP Dental: $24.20 ($121-$96.80)
Member’s responsibility*: $27.20 ($121-$96.80-$24.20)

 *Assumes dentist charge is within the plan allowance

Your rates are determined based on where you live. This is called a rating area. If you move, you must update your address through BENEFEDS at www.BENEFEDS.com or by phone at 877-888-FEDS (3337).  Your rates might change because of the move. Your rates will not be impacted if you temporarily reside at another location.

If you live in an area with limited access to a network dentist and you receive covered services from an out-of-network dentist, we will pay the same benefit level as if you utilized the services of an in-network dentist. A limited access area is a driving distance greater than 15 miles in urban areas, or greater than 35 miles in rural areas. You are responsible for any difference between the amount billed and our payment. 

If you need assistance locating an in-network dentist in your area, please call us at 1-855-504-BLUE (2583).

A deductible is a fixed amount of expenses you must incur for certain covered services and supplies before we will pay for covered services.  There is no family deductible limit.  Covered charges credited to the deductible are also counted towards the Plan maximum and limitations.

Class A
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $50
Out-of-Network Standard Option: $75

Class B
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $50
Out-of-Network Standard Option: $75

Class C
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $50
Out-of-Network Standard Option: $75

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: 60%

Class C
In-Network High Option: 50%
In-Network Standard Option: 65%
Out-of-Network High Option: 60%
Out-of-Network Standard Option: 80%

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 plan option are combined between in- and out-of-network services.  The total Annual Benefit Maximum will never be greater than the in-network Annual Benefit Maximum.

Annual Benefit Maximum:

In-Network High Option: Unlimited
In-Network Standard Option: $1,500
Out-of-Network High Option: $3,000
Out-of-Network Standard Option: $750

The Lifetime Benefit Maximum is applicable to orthodontia benefits only.  There are no other Lifetime Benefit Maximums under this Plan.

Lifetime Benefit Maximum

In-Network High Option: up to $3,500
In-Network Standard Option: up to $2,500
Out-of-Network High Option: up to $3,500
Out-of-Network Standard Option: up to $1,250

You pay the coinsurance percentage of our plan allowance for covered services. Before each appointment, verify the dentist is in-network at the service location.

Only dentists listed with their corresponding locations are in network. Not all dentists at a location may be in network and the same dentist at a different location may not be in network. It is your responsibility to ensure that the listed dentist is active and in network at the time and location at which you receive services.

If the dentist you use is not part of our network, benefits will be considered at the out-of- network level. All services provided by an out-of-network dentist will be paid at out-of-network levels, except for limited access benefits. We pay for services rendered by an out-of-network dentist based on an out-of-network plan allowance.  You will be responsible for your co-insurance percentage plus the billed amount over plan allowance.  

Our plan allowance is the amount we use to determine our payment and your coinsurance for covered services. We determine our allowance as follows:

• For in-network dentists, based on our contracted dental rates. The member is not responsible for billed amounts that are more than the plan allowance.
• For out-of-network dentists, based on the out-of-network plan allowance. FAIR Health (a non-profit, non-insurance operation) data is utilized to determine the out-of-network plan allowance. The member is responsible for any amounts billed by out-of-network dentists that are above the plan allowance, plus their coinsurance amount.

The calendar year refers to the plan year, which is defined as January 1, 2024 to December 31, 2024.

Emergency or accident related services are covered the same as any other benefit.

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 2024 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 2024 plan year, such as crowns and implants.

D0120 Periodic oral evaluation - established patient - Limit 2 per calendar year - see additional benefit limitations at the end of this section

D0140 Limited oral evaluation - problem focused - Limit 1 per calendar year - see additional limitations at the end of this section 

D0145 Oral evaluation for a patient under 3 years of age and counseling with a primary caregiver. Limit 2 per calendar year – see additional benefit limitations at the end of this section

D0150 Comprehensive oral evaluation - new or established patient - Limit 1 per calendar year - see additional benefit limitations at the end of this section

D0160 Detailed and extensive oral evaluation - problem focused, by report - Limit 1 per calendar year - see additional limitations at the end of this section

D0180 Comprehensive periodontal evaluation - new or established patient - Limit 1 per calendar year - see additional benefit limitations at the end of this section. If billed with a D4910, the D0180 will alternate to a D0120.     

D0210 Intraoral - comprehensive series of radiographic images including bitewings - Limit 1 every 60 months for any combination of comprehensive series of radiographic images

D0220 Intraoral - periapical radiographic image

D0230 Intraoral - periapical each additional radiographic image 

D0240 Intraoral - occlusal radiographic image 

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

D0251 Extra-oral - posterior dental radiographic image 

D0270 Bitewing - single - radiographic image - Limit 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination of bitewings for all others

D0272 Bitewings - two radiographic images - Limit 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination of bitewings for all others.

D0273 Bitewings - three radiographic images Limit - 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination of bitewings for all others.

D0274 Bitewings - four radiographic images - Limit 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination of bitewings for all others.

D0277 Bitewings - Seven to eight radiographic images - Limit 2 per calendar year for any combination of bitewings for patients up to age 22, 1 per calendar year for any combination of bitewings for all others.

D0330 Panoramic radiographic image - Limit 1 every 60 months

D0372 Intraoral tomosynthesis – comprehensive series of radiographic images - Limit 1 every 60 months for any combination of comprehensive series of radiographic images

D0373 Intraoral tomosynthesis – bitewing radiographic image - Limit 2 per calendar year of any combination of bitewings for patients up to age 22, 1 per calendar year of any combination of bitewings for all others

D0374 Intraoral tomosynthesis – periapical radiographic image

D0425 Caries susceptibility tests

D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report

Class A Diagnostic Services Notes and Limitations:

Non-problem focused exams – Limit 2 per year

• Periodic oral evaluation (D0120), oral evaluation for a child under age 3 (D0145), comprehensive oral evaluation (D0150) and comprehensive periodontal evaluation (D0180) are combined and limited to a total of 2 per year  
  • Comprehensive oral evaluation (D0150) and comprehensive periodontal evaluation(D0180) are combined and limited to 1 per year
  • Comprehensive oral evaluations in excess of the 1 per year limit will be processed as a periodic evaluation

Problem-focused exams – Limit 1 per year

• Limited oral evaluation (D0140) and detailed and extensive oral evaluation (D0160) are combined and limited to 1 per year

Diagnostic Imaging

• 14 or more radiographic images on the same date of service will be processed as a D0210 (complete set of radiographic images)
• Bitewing radiographic images with the same date of service as a panoramic radiographic image will be processed as a D0210

D1110 Prophylaxis – Adult:  Limit 3 during the calendar year.  Age 13 and under will be processed as D1120 - additional information on the following page.

D1120 Prophylaxis – Child:  Limit 3 during the calendar year.  Age 14 and over will be processed as D1110 - additional information on the following page.

D1206 Topical application of fluoride varnish - Limit 2 during the calendar year for patients up to age 22 in combination with D1208

D1208 Topical application of fluoride - excluding varnish - Limit 2 during the calendar year for patients up to age 22 in combination with D1206

D1351 Sealant - per tooth - unrestored 1st and 2nd permanent molars for patient up to age 22 - any combination of a sealant or a preventive resin restoration - Limit 1 every 36 months

D1352 Preventive resin restoration in a moderate to high caries risk patient - unrestored 1st and 2nd permanent tooth for patient up to age 22 - any combination of a sealant or a preventive resin restoration - Limit 1 every 36 months

D1353 Sealant repair - per unrestored 1st and 2nd permanent molar for patient up to age 22 - any combination of a sealant or preventive resin restoration - Limit 1 every 36 months

D1354  Application of caries arresting medicament - per tooth

D1510 Space maintainer - fixed - unilateral - per quadrant - Limited to patients up to age 22

D1516 Space maintainer – fixed – bilateral, maxillary- Limited to patients up to age 22

D1517 Space maintainer – fixed – bilateral, mandibular - Limited to patients up to age 22

D1520 Space maintainer - removable - unilateral - per quadrant  - Limited to patients up to age 22

D1526 Space maintainer – removable – bilateral, maxillary - Limited to patients up to age 22

D1527 Space maintainer – removable – bilateral, mandibular - Limited to patients up to age 22

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. Allowed if removed by dentist or dental practice that did not originally place the appliance

D1557 Removal of fixed bilateral space maintainer – maxillary. Allowed if removed by dentist or dental practice that did not originally place the appliance

D1558 Removal of fixed bilateral space maintainer – mandibular. Allowed if removed by dentist or dental practice that did not originally place the appliance

D1575 Distal shoe space maintainer - Fixed – Unilateral - per quadrant - Limited to patients up to age 22

Class A Preventive Services Notes:

• Prophylaxis and scaling in presence of generalized moderate or severe gingival inflammation: Limit 3 per calendar year for any combination of D1110, D1120, and D4346, age 13 and under will be processed as D1120 and age 14 and over will be processed as D1110
• Treatments such as fluorides are combined under one limitation by the plan. For example, topical application of fluoride – varnish (D1206) and topical application of fluoride - excluding varnish (D1208) are combined and limited to 2 per calendar year for patients up to age 22

D9110 Palliative treatment of dental pain – per visit - Not covered the same day as final treatment

D9440 Office visit after regularly scheduled hours

D2140 Amalgam – one surface, primary or permanent - Limit 1 every 24 months per surface per tooth

D2150 Amalgam – two surfaces, primary or permanent - Limit 1 every 24 month per surface per tooth

D2160 Amalgam – three surfaces, primary or permanent - Limit 1 every 24 months per surface per tooth

D2161 Amalgam – four or more surfaces, primary or permanent - Limit 1 every 24 months per surface per tooth

D2330 Resin-based composite – one surface, anterior - Limit 1 every 24 months per surface per tooth

D2331 Resin-based composite – two surfaces, anterior - Limit 1 every 24 months per surface per tooth

D2332 Resin-based composite – three surfaces, anterior - Limit 1 every 24 months per surface per tooth

D2335 Resin-based composite – four or more surfaces (anterior) - Limit 1 every 24 months per surface per tooth

D2390 Resin-based composite - resin crown anterior - Limit every 24 months per tooth

D2610 Inlay-porcelain/ceramic - one surface - Limit 1 every 60 months - An alternate benefit will be provided

D2620 Inlay-porcelain/ceramic - two surfaces - Limit 1 every 60 months - An alternate benefit will be provided 

D2630 Inlay-porcelain/ceramic - three or more surfaces - Limit 1 every 60 months - An alternate benefit will be provided 

D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration - Limit 1 every 6 months after initial installation, if less than 6 months from installation, no patient liability

D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core - Limit 1 every 6 months after initial installation, if less than 6 months from installation, no patient liability

D2920 Re-cement or re-bond crown - Limit 1 every 6 months after initial installation, if less than 6 months from installation, no patient liability

D2921 Re-attachment of tooth fragment, incisal edge or cusp - Limit to 1 every 24 months per surface per tooth, included with fillings

D2928 Prefabricated porcelain/ceramic crown – permanent tooth – Limit 1 every tooth every 60 months for patients up to age 15 – an alternate benefit will be provided

D2929 Prefabricated porcelain/ceramic crown – primary tooth – Limit 1 per tooth every 60 months for patients up to age 15 - an alternate benefit will be provided

D2951 Pin retention – per tooth, in addition to restoration

D2989 Excavation of a tooth resulting in the determination of non-restorability -Limit 1 per tooth per lifetime

Class B Minor Restorative Services Notes:

• Restorations are covered benefits only when necessary to replace tooth structure due to fracture or decay

D3222 Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development - 1 per lifetime

D3355 Pulpal regeneration - initial visit 

D3356 Pulpal regeneration - interim medication replacement

D3357 Pulpal regeneration completion of treatment 

D4341 Periodontal scaling and root planing - four or more teeth per quadrant - Limit 1 every 24 months, 2 quadrants per date of service

D4342 Periodontal scaling and root planing - one to three teeth per quadrant - Limit 1 every 24 months, 2 quadrants per date of service

D4346 Scaling in presence of generalized moderate or severe gingival inflammation - Full mouth, after oral exam - Limited 3 in combination with D1110 and/or D1120 during calendar year 

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

D4910 Periodontal maintenance - Limit 4 every12 months combined with adult prophylaxis, and scaling in presence of generalized moderate or severe gingival inflammation, after the completion of active periodontal therapy

Class B Periodontal Services Notes: 

Supporting documentation and criteria;

• Full mouth diagnostic quality radiographic images and/or a panoramic radiographic image including bitewings radiographs; labeled and dated (within 12 months of submitted procedure).
• Periodontal Charting: 6-point periodontal pocket depth charting as described by the ADA and American Academy of Periodontology (AAP) labeled and dated (within 12 months of submitted procedure).
• Teeth to be treated must demonstrate at least 4 millimeter (mm) pocket depths, bleeding on probing, with demonstrable radiographic evidence of bone loss (either vertical or horizontal) of the alveolar crest.
• Bone loss is considered to be a bone level that is greater 1.5 mm apical to the cementoenamel junction (CEJ).

Non-surgical periodontal and periodontal maintenance procedures will be disallowed with no patient responsibility when submitted on the same date of service as preventive prophylaxis procedures.

D5410 Adjust complete denture – maxillary - Limit 1 per year beginning 6 months after the initial installation

D5411 Adjust complete denture – mandibular - Limit 1 per year beginning 6 months after the initial installation

D5421 Adjust partial denture – maxillary - Limit 1 per year beginning 6 months after the initial installation

D5422 Adjust partial denture – mandibular - Limit 1 per year beginning 6 months after the initial installation

D5511 Repair broken complete denture base mandibular - Limit 1 per year beginning 6 months after the initial installation

D5512 Repair broken complete denture base, maxillary - Limit 1 per year beginning 6 months after the initial installation

D5520 Replace missing or broken teeth – complete denture (each tooth) - Limit 1 per year beginning 6 months after the initial installation

D5611 Repair resin denture base mandibular - Limit 1 per year beginning 6 months after the initial installation

D5612 Repair resin partial denture base, maxillary - Limit 1 per year beginning 6 months after the initial installation

D5621 Repair cast framework, mandibular - Limit 1 per year beginning 6 months after the initial installation

D5622 Repair cast partial framework, maxillary - Limit 1 per year beginning 6 months after the initial installation

D5630 Repair or replace broken retentive/clasping materials per tooth - Limit 1 per year beginning 6 months after the initial installation

D5640 Replace broken teeth – per tooth - Limit 1 per year beginning 6 months after the initial installation

D5650 Add tooth to existing partial denture - Limit 1 per year beginning 6 months after the initial installation

D5660 Add clasp to existing partial denture - Limit 1 per year beginning 6 months after the initial installation

D5670 Replace all teeth and acrylic on cast metal framework, maxillary – Limit 2 every 24 months beginning 6 months after the initial installation

D5671 Replace all teeth and acrylic on cast metal framework, mandibular – Limit 2 every 24 months beginning 6 months after the initial installation

D5710 Rebase complete maxillary denture – Limit 1 every 36 months beginning 6 months after the initial installation

D5711 Rebase complete mandibular denture – Limit 1 every 36 months beginning 6 months after the initial installation

D5720 Rebase maxillary partial denture – Limit 1 every 36 months beginning 6 months after the initial installation

D5721 Rebase mandibular partial denture - Limit 1 every 36 months beginning 6 months after the initial installation

D5725 Rebase hybrid prosthesis – Limit 1 every 36 months beginning 6 months after the initial installation

D5730 Reline complete maxillary denture (direct) – Limit 1 every 36 months beginning 6 months after the initial installation

D5731 Reline complete mandibular denture (direct) - Limit 1 every 36 months beginning 6 months after the initial installation

D5740 Reline maxillary partial denture (direct) – Limit 1 every 36 months beginning 6 months after the initial installation

D5741 Reline mandibular partial denture (direct) – Limit 1 every 36 months beginning 6 months after the initial installation

D5750 Reline complete maxillary denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation

D5751 Reline complete mandibular denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation

D5760 Reline maxillary partial denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation                                                                                                                       

D5761 Reline mandibular partial denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation

D5765 Soft liner for complete or partial removable denture – indirect – Limit 1 every 36 months beginning 6 months after the initial installation.

D5850 Tissue conditioning (maxillary) 

D5851 Tissue conditioning (mandibular) 

D6930 Re-cement or re-bond fixed partial denture - Limit 1 per bridge beginning 6 months after the initial installation

D6980 Fixed partial denture repair, by report

Class B Prosthodontic Services Notes:

• For reporting and benefit purposes, the completion date for crowns and fixed partial dentures is the cementation date. The completion date is the insertion date for removable prosthodontic appliances. For immediate dentures, the dentist who fabricated the denture may be reimbursed for the service after insertion by another dentist (e.g., oral surgeon).
• Tissue conditioning is considered inclusive when performed on the same day as the delivery of a denture or a reline/rebase.

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 Surgical removal of residual tooth roots (cutting procedure)

D7251 Coronectomy - intentional partial tooth removal, impacted teeth only

D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth

D7280 Exposure of an unerupted tooth

D7310 Alveoloplasty in conjunction with extractions – per quadrant

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

D7320 Alveoloplasty not in conjunction with extractions – 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

D7921 Collection and application of autologous blood concentrate product - Limit 1 in 36 months

D7953 Bone replacement graft for ridge preservation - per site - No review on anterior teeth. Posterior teeth reviewed to determine if covered or not. 3rd Molar extraction sites denied unless D7251 performed. Anterior teeth and approved posterior teeth, Limit 1 every 60 months

D7971 Excision of pericoronal gingiva

D7972 Surgical reduction of fibrous tuberosity – Limit 1 every 6 months

D7999 Unspecified oral surgery procedure, by report

Class B Oral Surgery Notes:

• Bone replacement grafts for ridge preservation are limited to extraction sites when implants are approved for placement or when implant removal may be necessary.

D2410 Gold Foil – one surface – Limit 1 every 24 months  - An alternate benefit will be provided

D2510 Inlay - metallic - one surface - Limit 1 per tooth every 60 months  - An alternate benefit will be provided

D2520 Inlay - metallic - two surfaces  -Limit 1 per tooth every 60 months  - An alternate benefit will be provided

D2530 Inlay - metallic - three surfaces - Limit 1 per tooth every 60 months  - An alternate benefit will be provided

D2642 Onlay-porcelain/ceramic - two surfaces - Limit 1 per tooth every 60 months

D2643 Onlay-porcelain/ceramic - three surfaces - Limit 1 per tooth every 60 months

D2644 Onlay porcelain/ceramic - four or more surfaces - Limit 1 per tooth every 60 months

D2650 Inlay - resin-based composite - one surface, lab proc - Limit 1 every 60 months - An alternate benefit will be provided

D2651 Inlay - resin-based composite -  two surfaces, lab proc - Limit 1 every 60 months - An alternate benefit will be provided

D2652 Inlay - resin-based composite - three surfaces, lab proc - Limit 1 every 60 months - An alternate benefit will be provided

D2662 Onlay - resin-based composite - two surfaces, lab proc - Limit 1 every 60 months

D2663 Onlay - resin-based composite - three surfaces, lab proc - Limit 1 per tooth every 60 months

D2664 Onlay - resin-based composite - four or more surfaces, lab proc - Limit 1 per tooth every 60 months

D2710 Crown - resin-based composite, lab proc - Limit 1 every 60 months

D2712 Crown - 3/4 resin-based composite, lab proc - Limit 1 per tooth every 60 months

D2720 Crown - resin with high noble metal - Limit 1 per tooth every 60 months

D2721 Crown - resin with predominantly base metal - Limit 1 per tooth every 60 months

D2722 Crown - resin with noble metal - Limit 1 per tooth every 60 months

D2753 Crown - porcelain fused to titanium and titanium alloys- Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2794 Crown - titanium and titanium alloys - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics

D2950 Core buildup, including any pins - Limit 1 buildup procedure, per tooth every 60 months

D2952 Post and core in addition to crown, indirectly fabricated - Limit 1 buildup procedure, per tooth, every 60 months

D2954 Prefabricated post and core, in addition to crown - Limit 1 buildup procedure, per tooth every 60 months

D2955 Post removal

D2980 Crown repair necessitated by restorative material failure – Limit 1 every 12 months

D2981 Inlay Repair necessitated by restorative material failure - Limit 1 every 12 months

D2982 Onlay Repair necessitated by restorative material failure – Limit 1 every 12 months

D2983 Veneer Repair necessitated by restorative material failure – Limit 1 every 12 months

D2990 Resin infiltration of incipient smooth surface lesions

Class C Major Restorative Services Notes:

• For reporting and benefit purposes, the completion date for crowns is the cementation date. 
• An implant is a covered procedure of the plan only if determined to be dentally necessary and the least expensive appropriate treatment. 
• All major restorative and prosthodontic services (i.e., crown, bridges, implants and dentures) are combined under one replacement limitation under the plan.  Benefits for major restorative and prosthodontic services are combined and limited to one every 60 months per tooth or arch depending on the service.  For example, if benefits for a removable partial denture are paid, this includes benefits to replace all missing teeth in the arch.  No additional benefits for the arch would be considered until the 60 month replacement limit was met. 
• When dental services that are subject to a frequency limitation were performed prior to your effective date of coverage, the date of the prior service may be counted toward the time, frequency limitations and/or replacement limitations under this dental insurance.  (For example, even if a crown, partial bridge, etc. was not placed while covered under BCBS FEP Dental, or paid by BCBS FEP Dental, the frequency limitations may apply.)

D3310 Endodontic therapy, anterior tooth (excluding final restoration)

D3320 Endodontic therapy, premolar tooth (excluding final restoration)

D3330 Endodontic therapy, molar tooth (excluding final restoration)

D3346 Retreatment of previous root canal therapy – anterior

D3347 Retreatment of previous root canal therapy – premolar

D3348 Retreatment of previous root canal therapy – molar

D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, etc.)

D3352 Apexification/recalcification – interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.)

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

D3410 Apicoectomy/periradicular surgery – anterior

D3421 Apicoectomy/periradicular surgery – premolar (first root)

D3425 Apicoectomy/periradicular surgery – molar (first root)

D3426 Apicoectomy/periradicular surgery (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 

D3501 Surgical exposure of root surface without apicoectomy or repair of root resorption – anterior 

D3502 Surgical exposure of root surface without apicoectomy or repair of root resorption – premolar 

D3503 Surgical exposure of root surface without apicoectomy or repair of root resorption – molar 

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

D3921 Decoronation or submergence of an erupted tooth

D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant - Limit 1 every 36 months

D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months

D4212 Gingivectomy or gingivoplasty - to allow access for restorative procedure, per tooth – Limit 1 every 36 months

D4240 Gingival flap procedure, including root planing- four or more contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months

D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months

D4245 Apically positioned flap – Limit 1 every 36 months, permanent teeth only 

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 – Limit 1 every 36 months 

D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36 months

D4263 Bone replacement graft – retained natural tooth - first site in quadrant - Limit 1 every 36 months, permanent teeth only

D4264 Bone replacement graft – retained natural tooth - each additional site in quadrant - Limit 1 every 36 months, permanent teeth only 

D4273 Autogenous connective tissue graft procedures first tooth (including donor and recipient surgical site) first tooth, implant, or edentulous tooth position in graft – Limit 1 every 36 months

D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) – Limit 1 every 36 months, permanent teeth only 

D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft - Limit 1 every 36 months

D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant, or edentulous tooth position in graft – Limit 1 every 36 months

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 – Limit 1 every 36 months

D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) - each additional contiguous tooth,  implant or edentulous tooth position in same graft site – Limit 1 every 36 months

D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material), each additional contiguous tooth, implant, or edentulous tooth position in same graft site – Limit 1 every 36 months

D4355 Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis on a subsequent visit - Limit 1 per lifetime

D4999 Unspecified periodontal procedure, by report 

Class C Periodontal Services Notes:

Supporting documentation and criteria:

• Full mouth diagnostic quality radiographic images and/or a panoramic radiographic image including bitewings radiographs, labeled and dated (within 12 months of submitted procedure)
• Periodontal charting: 6-point periodontal pocket depth charting as described by the ADA and AAP labeled and dated (within 12 months of submitted procedure)
• Teeth to be treated must demonstrate at least 5 mm pocket depths
• Gingival flap procedure must be a surface adjacent to an edentulous/terminal tooth area

Gingivectomy or gingivoplasty performed in conjunction with restorative services are considered to be inclusive of the restoration and will not be reimbursed.

Clinical crown lengthening: Prior to final restoration of a tooth, a minimum of six weeks must be allowed for healing of bone and soft tissue following clinical crown lengthening.

D5110 Complete denture – maxillary – Limit 1 every 60 months – Denied if using as an interim denture

D5120 Complete denture - mandibular  – Limit 1 every 60 months – Denied if using as an Interim denture

D5130 Immediate denture – maxillary – Limit 1 every 60 months – Denied if using as an interim denture

D5140 Immediate denture - mandibular – Limit 1 every 60 months – Denied if using as an interim denture

D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth) – Limit 1 every 60 months. Denied if using as an interim denture

D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth) – Limit 1 every 60 months. Denied if using as an interim denture.

D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) – Limit 1 every 60 months

D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) – Limit 1 every 60 months

D5221 Immediate maxillary partial denture, resin base – (including retentive/clasping materials, rests and teeth) - Limit 1 every 60 months – Denied if using as an interim denture

D5222 Immediate mandibular partial denture, resin base – (including retentive/clasping materials, rests and teeth) - Limit 1 every 60 months – Denied if using as an interim denture

D5223 Immediate maxillary partial denture, cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) - Limit 1 every 60 months

D5224 Immediate mandibular partial denture, cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)- Limit 1 every 60 months

D5225 Maxillary partial denture – flexible base (including retentive/clasping materials, rests and teeth)– Limit 1 every 60 months - Denied if using as an interim denture

D5226 Mandibular partial denture – flexible base (including retentive/clasping materials, rests and teeth) – Limit 1 every 60 months - Denied if using as an inteirm denture

D5227 Immediate maxillary partial denture – flexible base (including any clasps, rest and teeth) – Limit 1 every 60 months – Denied if using as an interim denture

D5228 Immediate mandibular partial denture – flexible base (including any clasps, rest and teeth) – Limit 1 every 60 months – Denied if using as an interim denture

D5282 Removable unilateral partial denture - one piece cast metal (including retentive/clasping materials, rests and teeth), maxillary - Limit 1 every 60 months

D5283 Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests and teeth), mandibular - Limit 1 every 60 months

D5876 Add metal substructure to acrylic full denture (per arch) – Limit 1 every 60 months 

D6010 Surgical placement of implant body: endosteal implant – Limit 1 per site every 60 months

D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant – Limit 1 per site every 60 months

D6013 Surgical placement of mini implant – Limit 1 per site every 60 months

D6040 Surgical placement: eposteal implant – Limit 1 per site every 60 months

D6050 Surgical placement: transosteal implant – Limit 1 per site every 60 months

D6055 Connecting bar – implant supported or abutment supported – Limit 1 every 60 months

D6056 Prefabricated abutment - includes modification and placement – Limit 1 every 60 months

D6057 Custom fabricated abutment - includes placement – Limit 1 every 60 months

D6058 Abutment supported porcelain/ceramic crown – Limit 1 every 60 months

D6059 Abutment supported porcelain fused to metal crown (high noble metal) - Limit 1 every 60 months

D6060 Abutment supported porcelain fused to metal crown (predominately base metal) - Limit 1 every 60 months

D6061 Abutment supported porcelain fused to metal crown (noble metal) - Limit 1 every 60 months

D6062 Abutment supported cast metal crown (high noble metal) - Limit 1 every 60 months

D6063 Abutment supported cast metal crown (predominately base metal) – Limit 1 every 60 months

D6064 Abutment supported cast metal crown (noble metal) – Limit 1 every 60 months

D6066 Implant supported crown - porcelain fused to high noble alloys – Limit 1 every 60 months

D6067 Implant supported crown - high noble alloys – Limit 1 every 60 months

D6071 Abutment supported retainer for porcelain fused to metal FPD - noble metal – Limit 1 every 60 months

D6073 Abutment supported retainer for cast metal FPD - predominately base metal - Limit 1 every 60 months

D6074 Abutment supported retainer for cast metal FPD - noble metal - Limit 1 every 60 months

D6075 Implant supported retainer for ceramic FPD – Limit 1 every 60 months

D6076 Implant supported retainer for FPD porcelain fused to high noble alloys - Limit 1 every 60 months

D6077 Implant supported retainer for metal FPD - high noble alloys – Limit 1 every 60 months

D6082 Implant supported crown – porcelain fused to predominantly base alloys - Limit 1 every 60 months

D6083 Implant supported crown – porcelain fused to noble alloys - Limit 1 every 60 months

D6084 Implant supported crown – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months

D6086 Implant supported crown – predominantly base alloys - Limit 1 every 60 months

D6087 Implant supported crown – noble alloys - Limit 1 every 60 months

D6088 Implant supported crown – titanium and titanium alloys - Limit 1 every 60 months

D6089 Accessing and retorquing loose implant screw - per screw - Limit 1 per 12 months

D6091 Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment – Limit 1 every 60 months

D6092 Recement or re-bond implant/abutment supported crown - Limit 1 every 60 months

D6093 Recement or re-bond implant/abutment supported fixed partial denture – Limit 1 every 60 months

D6094 Abutment supported crown - titanium and titanium alloys - Limit 1 every 60 months

D6095 Repair implant abutment, by report – Limit 1 every 60 months

D6097 Abutment supported crown – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months

D6098 Implant supported retainer – porcelain fused to predominantly base alloys - Limit 1 every 60 months

D6099 Implant supported retainer for FPD – porcelain fused to noble alloys - Limit 1 every 60 months

D6100 Surgical removal of implant body – Limit once per implant location

D6101 Debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of exposed implant surfaces, including flap entry and closure – Limit 1 per lifetime

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 – Limit 1 per lifetime

D6103 Bone graft for repair of peri-implant defect – does not include flap entry and closure - Limit 1 every 36 months

D6105 Removal of implant body not requiring bone removal or flap elevation - Limit once per implant location

D6106 Guided tissue regeneration – resorbable barrier, per implant - Limit 1 every 36 months

D6107 Guided tissue regeneration – non-resorbable barrier, per implant - Limit 1 every 36 months

D6110 Implant/abutment supported removable denture for edentulous arch - maxillary - Limit 1 every 60 months

D6111 Implant/abutment supported removable denture for edentulous arch - mandibular - Limit 1 every 60 months

D6112 Implant/abutment supported removable denture for partially edentulous arch - maxillary - Limit 1 every 60 months

D6113 Implant/abutment supported removable denture for partially edentulous arch - mandibular - Limit 1 every 60 months

D6114 Implant/abutment supported fixed denture for edentulous arch - maxillary - Limit 1 every 60 months

D6115 Implant/abutment supported fixed denture for edentulous arch - mandibular - Limit 1 every 60 months

D6116 Implant/abutment supported fixed denture for partially edentulous arch - maxillary - Limit 1 every 60 months

D6117 Implant/abutment supported fixed denture for partially edentulous arch - mandibular - Limit 1 every 60 months

D6120 Implant supported retainer – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months

D6121 Implant supported retainer for metal FPD – predominantly base alloys - Limit 1 every 60 months

D6122 Implant supported retainer for metal FPD – noble alloys - Limit 1 every 60 months

D6123 Implant supported retainer for metal FPD – titanium and titanium alloys - Limit 1 every 60 months

D6190 Radiographic/surgical implant index, by report – Limit 1 every 60 months

D6191 Semi-precision abutment – placement – Limit 1 every 60 months                                                                                           

D6192 Semi-precision attachment – placement – Limit 1 every 60 months 

D6194 Abutment supported retainer crown for FPD - titanium and titanium alloys - Limit 1 every 60 months

D6195 Abutment supported retainer – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months

D6214 Pontic - titanium and titanium alloys - Limit 1 every 60 months, including all other crowns, bridges, prosthetics

D6240 Pontic - porcelain fused to high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics

D6241 Pontic - porcelain fused to predominately base metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics

D6242 Pontic - porcelain fused to noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics

D6243 Pontic – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months, including all other crowns, bridges, prosthetics

D6245 Pontic - porcelain/ceramic - Limit 1 every 60 months, including all other crowns, bridges, prosthetics

D6549 Resin retainer - for resin bonded fixed prosthesis - Limit 1 every 60 months

D6600 Retainer inlay - porcelain/ceramic, two surfaces - Limit 1 every 60 months - An alternate benefit will be provided

D6601 Retainer inlay - porcelain/ceramic, three or more surfaces - Limit 1 every 60 months - An alternate benefit will be provided

D6602 Retainer inlay - cast high noble metal, two surfaces – Limit 1 every 60 months

D6603 Retainer inlay - cast high noble metal, three or more surfaces – Limit 1 every 60 months

D6604 Retainer inlay - cast predominantly base metal, two surfaces - Limit 1 every 60 months

D6605 Retainer inlay - cast predominantly base metal, three or more surfaces - Limit 1 every 60 months

D6606 Retainer inlay - cast noble metal, two surfaces – Limit 1 every 60 months

D6607 Retainer inlay - cast noble metal, three or more surfaces – Limit 1 every 60 months

D6608 Retainer onlay - porcelain/ceramic, two or more surfaces - Limit 1 every 60 months - An alternate benefit will be provided

D6609 Retainer onlay - porcelain/ceramic, three or more surfaces - Limit 1 every 60 months - An alternate benefit will be provided

D6610 Retainer onlay - cast high noble metal, two surfaces – Limit 1 every 60 months

D6611 Retainer onlay - cast high noble metal, three or more surfaces – Limit 1 every 60 months

D6612 Retainer onlay - cast predominantly base metal, two surfaces – Limit 1 every 60 months

D6613 Retainer onlay - cast predominantly base metal, three or more surfaces – Limit 1 every 60 months

D6614 Retainer onlay - cast noble metal, two surfaces – Limit 1 every 60 months

D6615 Retainer onlay - cast noble metal, three or more surfaces – Limit 1 every 60 months

D6624 Retainer inlay – titanium – Limit 1 every 60 months

D6634 Retainer onlay - titanium – Limit 1 every 60 months

D6710 Retainer crown - indirect resin based composite - Limit 1 every 60 months

D6720 Retainer crown - resin with high noble metal - Limit 1 every 60 months

D6721 Retainer crown - resin with predominantly base metal - Limit 1 every 60 months

D6722 Retainer crown - resin with noble metal – Limit 1 every 60 months

D6740 Retainer crown - porcelain/ceramic – Limit 1 every 60 months

D6750 Retainer crown - porcelain fused to high noble metal - Limit 1 every 60 months

D6751 Retainer crown - porcelain fused to predominately base metal – Limit 1 every 60 months

D6752 Retainer crown - porcelain fused to noble metal - Limit 1 every 60 months

D6753 Retainer crown – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months

D6780 Retainer crown - 3/4 cast high noble metal - Limit 1 every 60 months

D6781 Retainer crown - 3/4 cast predominately base metal - Limit 1 every 60 months

D6782 Retainer crown - 3/4 cast noble metal – Limit 1 every 60 months

D6783 Retainer crown - 3/4 porcelain/ceramic – Limit 1 every 60 months

D6784 Retainer crown ¾ – titanium and titanium alloys - Limit 1 every 60 months

D6790 Retainer crown - full cast high noble metal - Limit 1 every 60 months

D6791 Retainer crown - full cast predominately base metal - Limit 1 every 60 months

D6792 Retainer crown - full cast noble metal - Limit 1 every 60 months

D6794 Retainer crown - titanium and titanium alloys - Limit 1 every 60 months

D7994 Surgical placement zygomatic implant – Limit 1 per tooth every 60 months 

D9932 Cleaning and inspection of removable complete denture, maxillary – Limit 3 times per calendar year 

D9933 Cleaning and inspection of removable complete denture, mandibular – Limit 3 times per calendar year 

D9934 Cleaning and inspection of removable partial denture, maxillary – Limit 3 times per calendar year 

D9935 Cleaning and inspection of removable partial denture, mandibular – Limit 3 times per calendar year 

Class C Major Services Notes: 

• For reporting and benefit purposes, the completion date for fixed partial dentures is the cementation date. The completion date is the insertion date for removable prosthodontic appliances. For immediate dentures, the dentist who fabricated the denture may be reimbursed for the service after insertion by another dentist (e.g., oral surgeon).
• All major restorative and prosthodontic services (i.e., crown, bridges, implants and dentures) are combined under one replacement limitation under the plan.  Benefits for major restorative and prosthodontic services are combined and limited to one every 60 months per tooth or arch depending on the service.  For example, if benefits for a removable partial denture are paid, this includes benefits to replace all missing teeth in the arch.  No additional benefits for the arch would be considered until the 60 month replacement limit was met.
• When dental services that are subject to a frequency limitation were performed prior to your effective date of coverage, the date of the prior service may be counted toward the time, frequency limitations and/or replacement limitations under this dental insurance.  (For example, even if a crown, partial bridge, etc. was not placed while covered under BCBS FEP Dental, or paid by BCBS FEP Dental, the frequency limitations may apply.)

D7340 Vestibuloplasty - Ridge extension (secondary epithelialization)

D7350 Vestibuloplasty - Ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue)

D0340 2D cephalometric radiographic image – acquisition, measurement and analysis - may be allowed if completed more than 3 months prior to the start of orthodontic treatment

D0350 2D oral/facial photographic image obtained intra-orally or extra-orally – may be allowed if completed more than 3 months prior to the start of orthodontic treatment

D0470 Diagnostic casts – may be allowed if completed more than 3 months prior to the start of orthodontic treatment 

D0801 3D dental surface scan – direct - may be allowed if completed more than 3 months prior to the start of orthodontic treatment

D0802 3D dental surface scan – indirect - may be allowed if completed more than 3 months prior to the start of orthodontic treatment

D8010 Limited orthodontic treatment of the primary dentition

D8020 Limited orthodontic treatment of the transitional dentition

D8030 Limited orthodontic treatment of the adolescent 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

D8210 Removable appliance therapy

D8220 Fixed appliance therapy

D8660 Pre-orthodontic treatment examination to monitor growth and development

D8670 Periodic orthodontic treatment visit (as part of contract) – monthly payments automatically made if orthodontic treatment plan is in place 

D8681 Removable orthodontic retainer adjustment

Refer to Section 7 for a list of general exclusions:

• Repair of damaged orthodontic appliances
• Replacement of lost or missing appliances
• 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.
• Over-the-counter or mail order orthodontic treatments

D9219 Evaluation for moderate sedation, deep sedation or general anesthesia 

D9222 Deep sedation/general anesthesia – first 15 minutes. Up to 8 total units of anesthesia (D9222 & D9223)

D9223 Deep sedation/general anesthesia - each subsequent 15 minute increment. Up to 8 total units of anesthesia (D9222 & D9223)

D9230 Inhalation of nitrous oxide/analgesia, anxiolysis - for children 5 and under and other individuals with a medical condition that may require it

D9239 Intravenous moderate (conscious) sedation/analgesia – first 15 minutes. Up to 8 total units of anesthesia (D9239 & D9243)

D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment. Up to 8 total units of anesthesia (D9239 & D9243)

D9610 Therapeutic parenteral drug, single administration, by report.

D9613 Infiltration of sustained release therapeutic drug, per quadrant

D9941 Fabrication of athletic mouthguard –Limit 1 every 12 months

D9943 Occlusal guard adjustment - Limit 1 every 6 months for patients 13 and older

D9944 Occlusal guard – hard appliance, full arch – Limit 1 every 12 months for patients 13 and older 

D9945 Occlusal guard – soft appliance, full arch – Limit 1 every 12 months for patients 13 and older 

D9946 Occlusal guard – hard appliance, partial arch – Limit 1 every 12 months for patients 13 and older

D9999 Unspecified Adjunctive procedure, by report

General Services Notes:

• Deep sedation/general anesthesia and intravenous sedation are covered when provided in conjunction with covered surgical procedures. The services must be rendered by a dentist licensed and approved to provide anesthesia in the state where rendered.
• Deep sedation/general anesthesia and intravenous sedation are covered when determined to be medically or dentally necessary for documented handicapped or uncontrollable patients or justifiable conditions.
• In order for deep sedation/general anesthesia and intravenous conscious sedation to be covered, submission must include the procedure for which it was necessary.

Refer to Section 7 for a list of general exclusions.

We will pay benefits, subject to plan provisions, in an amount equal to the covered percentage for the charges incurred by you. You are responsible for paying the dentist and for submitting your claims to BCBS FEP Dental.  We will reimburse you in US dollars based on the OANDA currency conversion rate.

You may visit any dentist and you will receive in-network benefits for any covered benefits received internationally. Our international dental program includes English-speaking dentists in approximately 100 countries worldwide. Customer service is available 24/7 to assist in making an appointment.

For help locating an English-speaking dentist, you may call 24 hours a day (outbound calling code for the country you are calling from) plus 353-94-9372257.  If calling from Ireland, press 0-94-9372257.

Customer service (in the U.S.)  1-855-504-BLUE (2583)

Customer service (international) call collect 651-994-2583

You are responsible for paying the dentist and submitting the claims to BCBS FEP Dental for reimbursement. The claim form can be accessed online at 
www.bcbsfepdental.com/claimform. Mail the completed claim form and receipt to:

BCBS FEP Dental Claims
P.O. Box 75
Minneapolis, MN  55440-0075

There is one rating area for all international locations. Use rating area 1 in the rate table to find international premium amounts.  

To avoid delay in the payment of your dental claims, please have your dentist submit your claims directly to your FEHB plan (should you be enrolled), then to BCBS FEP Dental. Pre-treatment estimates and diagnostic quality preoperative periapical radiographs and/or panoramic images can be submitted directly to BCBS FEP Dental (Exception: If accidental injury occurs, pre-treatment estimates should be submitted to your FEHB plan).

If you need to send in a claim you may download a claim form from BCBS FEP Dental’s website, www.bcbsfepdental.com

Mail completed claim form to: 

BCBS FEP Dental Claims
P.O. Box 75
Minneapolis, MN 55440-0075

You must submit your claim and any requested documentation within 24 months from the date the service was rendered.

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

Members may appeal any claims decision by submitting a written notice via U.S. Mail or email.

If we determine a service less costly than the one performed by your dentist could have been performed by your dentist, we will pay benefits based upon the less costly services. See Section 3, How You Get Care.

The maximum annual benefit that a member can receive.

Federal retirees (who retired on an immediate annuity) and survivors (of those who retired on an immediate annuity or died in service) receiving an annuity.  This also includes those receiving compensation from the Department of Labor’s Office of Workers’ Compensation Programs, who are called compensationers.  Annuitants are sometimes called retirees.

From January 1, 2024 through December 31, 2024. Also referred to as the plan year.

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

Intermediate services, which include restorative procedures such as fillings, prefabricated stainless steel crowns, periodontal scaling and root planing, extractions, and denture adjustments.

Major services, which include endodontic services such as root canals, periodontal services, such as gingivectomy, major restorative services such as crowns, oral surgery, bridges, and prosthodontic services such as complete dentures.

Coinsurance is the stated percentage of covered expenses you must pay.

A copayment is a fixed amount of money you pay the dentist when you receive the service.

A cosmetic procedure is any procedure or portion of a procedure performed primarily to improve physical appearance or is performed for psychological purposes.

Covered services shall include only those services specifically listed in Section 5 Dental Services and Supplies. A covered service must be incurred and completed while the person receiving the service is a covered person. Covered services are subject to plan provisions for exclusions and limitations and must meet broadly accepted national standards of practice.

The calendar date on which you visit the dentist's office and services are rendered. 

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

Generally accepted dental protocol means that a dental service or treatment is performed in accordance with broadly accepted national standards of practice, as determined from multiple sources, including but not limited to, relevant clinical dental research from various research organizations, including dental schools, current recognized dental school standard of care curriculums and organized dental groups, including the American Dental Association, which is necessary to treat decay, disease or injury of teeth, or essential for the care of teeth and supporting tissues of the teeth.

Dental services that initiated in 2023 that will be completed in 2024.

A covered service is deemed incurred on the date care, treatment or service is received.

The amount we use to determine our payment for services.  If services are provided by an in-network dentist, the allowance is based on the negotiated fee they accept as payment in full.  If services are provided by an out-of-network dentist, the plan allowance is based on the out-of-network plan allowance.

Network allowance means the allowance per procedure that BCBS FEP Dental has negotiated with the dentist, and they have agreed to accept as payment in full.

BCBS FEP Dental

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 amount of time that you must be enrolled in this plan before you can receive services.  Note: There are no waiting periods for BCBS FEP Dental.

BCBS FEP Dental

Class A (Basic) Services – preventive and diagnostic

Class A, B, and C Services are subject to an unlimited annual maximum benefit amount for in-network services and $3,000 for out-of-network services.

0%

10%

Class B (Intermediate) Services – includes minor restorative services

Class A, B, and C Services are subject to an unlimited annual maximum benefit amount for in-network services and $3,000 for out-of-network services.

30%

40%

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

Class A, B, and C Services are subject to an unlimited annual maximum benefit amount for in-network services and $3,000 for out-of-network services.

50%

60%

Class D Services – orthodontic 

up to $3,500 Lifetime Maximum

50%

50%

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

0%

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

45%

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

65%

80%

Class D Services – orthodontic 

$2,500 Lifetime Maximum for in-network, or

$1,250 Lifetime Maximum for out-of-network

50%

50%