You can select from several nationwide, and in some areas, regional dental Preferred Provider Organization (PPO) or Exclusive Provider Organization (EPO) 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.com.  Please see Section 2, Enrollment, 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.

There are no waiting periods associated with our plan options.

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.

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 vision 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 (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 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.

If you or one of your family members is enrolled in or covered by one FEDVIP plan, that person cannot be enrolled in or covered as a family member by another FEDVIP plan offering the same type of coverage; i.e., you (or covered family members) cannot be covered by two FEDVIP dental plans or two FEDVIP vision plans.

Open Season

If you are an eligible employee, annuitant, or TRICARE-eligible individual (TEI), 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; 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.

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
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 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 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.

Your cancellation is effective at the end of the day before the date OPM sets as the Open Season effective date. An eligible family member’s coverage also ends upon the effective date of the 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, 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 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 (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 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. 

We will send you an identification (ID) card when you enroll.  You should carry your ID card with you at all times.  You should present your ID card whenever you receive services from an assigned plan provider.

If you do not receive your ID card within 30 days after the effective date of your enrollment or if you need replacement cards, you may request one through our website at www.FederalDentalPlans.com or call us at 855-836-6337. You may also obtain a digital ID through Dominion National Go, Dominion’s mobile communications service. For more information, please visit www.DominionNational.com/go.

You must visit a participating plan dentist to receive treatment. You can find a current list of dentists online at www.FederalDentalPlans.com. You can also call us at 855-836-6337 to request that a list be mailed to you.  After your effective date, simply call the participating dental office and make an appointment.

A complete list of participating dentists are available on our online provider search at www.FederalDentalPlans.com.  The list is refreshed every night.

You must receive services from a participating dentist or specialist. No referrals are required for specialty care.

This is an in-network only plan. Services received outside the network are limited to out-of-area emergency services. You may have emergency services rendered by any licensed dentist when outside the service area. We will reimburse you for emergency services up to $100 per member per year. Emergency services are defined as "palliative care of injury, toothache, or accident requiring the immediate attention of a dentist or hospital/ambulatory surgical care center." Services are limited to those procedure not excluded under the plan's limitations and general exclusions.

When you visit a provider who participates with both, your FEHB plan and your FEDVIP plan, the FEHB 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 and FEDVIP benefit payments and the FEDVIP plan allowance.  We are responsible for facilitating the process with the primary FEHB first payor. You can assist with this process and also ensure that you are receiving the maximum allowable benefit under each program by presenting both your FEDVIP and FEHB ID cards at the time of your dental appointment. The dentist should include both ID numbers when submitting the claim to the plans.

It is important to bring your FEDVIP and FEHB identification cards to every dental appointment because most FEHB plans offer some level of dental benefits separate from your FEDVIP coverage. Presenting both identification cards can ensure that you receive the maximum allowable benefit under each Program.

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

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

To enroll in this plan, you must live in our service area.  This is where our providers practice.  Our service area is: District of Columbia, Delaware, Maryland, Pennsylvania, parts of Virginia and parts of New Jersey.

Ordinarily, you must get your care from providers within the service area who contract with us.  If you receive care outside our service area, we will pay only for emergency care benefits up to $100 per member per year. Emergency services are defined as "palliative care of injury, toothache, or accident requiring the immediate attention of a dentist or hospital/ambulatory surgical care center.”  Services are limited to those procedures that not excluded under the plan’s limitations and general exclusions. We will not pay for any other services out of our service area unless the services have prior plan approval.

If you move outside of our service area, you may enroll in another plan at that time.  You do not have to wait until Open Season to change plans.  Contact BENEFEDS at

www.benefeds.com or call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680 to change plans.

If you live in a limited access area and you receive covered services from an out-of-network provider, we will pay in accordance with our plan allowance.  You are responsible for any difference between the amount billed and our payment.  You can find a list of our limited access areas at www.FederalDentalPlans.com or by contacting us at 855-836-6337.

There are no alternate benefits associated with this plan.  The copayment for each listed procedure you receive is the total amount you will owe the dentist.

A copayment is a fixed amount of money you pay directly to the dentist when you receive covered services.  Your benefit schedule lists the copayments for each covered procedure. Procedure codes not listed are not covered by this plan. There is also a $10 office visit copay in addition to the listed charge per office visit, not per procedure.

Example: In our Standard Plan, you pay $48 for an amalgam – one surface, primary or permanent (ADA Code D2140).

The copayment amounts listed in the benefit schedule along with the $10 office visit copay represent your total cost for in-network services (please note that the office visit copay is charged per visit, not per procedure).

This is an in-network only plan.  Services received outside of the network are limited to out-of-area emergency services.  You may have emergency services rendered by any licensed dentist when outside of the service area.  We will reimburse you for emergency services up to $100 per member per year.  Emergency services are defined as “palliative care of injury, toothache, or accident requiring the immediate attention of a dentist or hospital/ambulatory surgical care center.”  Services are limited to those procedures not excluded under  the plan’s limitations and general exclusions. When traveling overseas, we will authorize emergency services only.

The copayments listed in Section 5 and the $10 office visit copay are the only payments you make to the dentist for covered services.  There are no calculations based on plan allowances that will result in any additional costs to you.

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.

D0210 Intraoral – comprehensive series of radiographic images (including bitewings)

D0251 Extraoral - posterior dental radiographic image

$0

$0

D0330 Panoramic film

D0340 Cephalometric film

$0

$0

D0350 Oral/facial images (including intra and extraoral images)

$0

$0

D0372 Intraoral tomosynthesis – comprehensive series of radiographic images

$0

$0

D0373 Intraoral tomosynthesis – bitewing radiographic image

$0

$0

D0374 Intraoral tomosynthesis – periapical radiographic image 

$0

$0

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

$0

$0

D0388 Intraoral tomosynthesis – bitewing radiographic image – image capture only

$0

$0

D0389 Intraoral tomosynthesis – periapical radiographic image – image capture only

$0

$0

D0470 Diagnostic casts

$0

$0

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

$0

$0

D0601 Caries risk assessment & documentation, with a finding of low risk

$0

$0

D0602 Caries risk assessment & documentation, with a finding of low risk

$0

$0

D0603 Caries risk assessment & documentation, with a finding of high risk

$0

$0

D0701 Panoramic radiographic image – image capture only

$0

$0

D0702 2-D cephalometric radiographic image – image capture only

$0

$0

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

$0

$0

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

$0

$0

D0706 Intraoral – occlusal radiographic image – image capture only

$0

$0

D0707 Intraoral – periapical radiographic image – image capture only

$0

$0

D0708 Intraoral – bitewing radiographic image – image capture only

$0

$0

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

$0

$0

D1110 Prophylaxis (cleaning) – adult

$0

$0

D1110* Additional cleaning for all members

D1208 Topical application of fluoride - excluding varnish

D1353 Sealant repair (per tooth)

$0

$0

D1354 Interim caries arresting medicament application - per tooth

$0

$0

D1355 Caries preventive medicament application – per tooth

$0

$0

D1510 Space maintainer – fixed, unilateral – per quadrant

D1516 Space maintainer - fixed - bilateral, maxillary

$0

$0

D1517 Space maintainer - fixed - bilateral, mandibular

$0

$0

D1520 Space maintainer – removable, unilateral – per quadrant

D1526 Space maintainer - removable - bilateral, maxillary

$0

$0

D1527 Space maintainer - removable - bilateral, mandibular

$0

$0

D1551 Re-cement or re-bond bilateral space maintainer, per quadrant

$0

$0

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

$0

$0

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

$0

$0

D1556 Removal of fixed unilateral space maintainer - per quadrant

$0

$0

D1557 Removal of fixed bilateral space maintainer – maxillary

$0

$0

D1558 Removal of fixed bilateral space maintainer - mandibular

$0

$0

D1575 Distal shoe space maintainer – fixed – unilateral

$0

$0

D9110 Palliative treatment of dental pain – per visit

$38

D9995 Teledentistry – synchronous; real-time encounter

$0

$0

D9996 Teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review

$0

$0

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· 
• Any exclusions or limitations listed under Section 7 of this plan document

Prevention Rewards Program

Each family member enrolled with Dominion National who receives two cleanings during the plan year will be reimbursed for their $10 office visit copayments made to the dentist at the time of service (a total reimbursement of $20 per family member).* Checks are sent monthly to enrollees who qualify.

D2160 Amalgam – three surfaces, primary or permanent

$75

$88

$67

D2335 Resin-based composite – four or more surfaces, anterior

D2390 Resin based composite crown - anterior

$125

$37

D2610 Inlay – porcelain/ceramic, one surface

$315

$202

D2620 Inlay – porcelain/ceramic, two surfaces

$288

$183

D2630 Inlay – porcelain/ceramic, three or more surfaces

$423

$252

D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage rest

D2915 Re-cement cast or prefab post and core

$38

$12

D2920 Re-cement or re-bond crown

D2921 Reattachment of tooth fragment - incisal edge or cusp

$71

$23

$28

$74

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

$81

D3355 Pulpal regeneration - initial visit

$170

$109

D3356 Pulpal regeneration - interim medication replacement

$156

$156

D3357 Pulpal regeneration - completion of treatment

$200

$150

D4342 Periodontal scaling and root planning – one to three teeth, per quadrant

$64

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

$48

$32

D4381 Localized delivery of antimicrobial agents

$25

$7

D5511 Repair broken complete denture base, mandibular

D5512 Repair broken complete denture base, maxillary

$56

$20

D5611 Repair resin partial denture base, mandibular

D5612 Repair resin partial denture base, maxillary

$56

$20

D5621 Repair cast partial framework, mandibular

D5622 Repair cast partial framework, maxillary

$56

$20

D5630 Repair or replace broken retentive/clasping material - per tooth

D5660 Add clasp to existing partial denture - per tooth

$320

D5725 Rebase hybrid prosthesis

$184

$55

D5730 Reline complete maxillary denture (direct)

D5731 Reline complete mandibular denture (direct)

D5740 Reline maxillary partial denture (direct)

D5741 Reline mandibular partial denture (direct)

D5750 Reline complete maxillary denture (indirect)

D5751 Reline complete mandibular denture (indirect)

D5760 Reline maxillary partial denture (indirect)

D5761 Reline mandibular partial denture (indirect)

D5765 Soft liner for complete or partial removable denture (indirect)

$50

$15

D6930 Recement or rebond fixed partial denture

D6980 Fixed partial denture repair necessitated by restorative material failure

D7210 Erupted tooth req. bone cut

D7250 Removal of residual tooth roots

D7251 Coronectomy – intentional partial tooth removal, impacted teeth only

D7280 Exposure of an unerupted tooth

$68

$83

D7509 Marsupialization of odontogenic cyst

$400

$360

D7979 Non-surgical sialolithotomy

$38

$35

D2740 Crown – porcelain/ceramic 

$583

$548

D2794 Crown – titanium and titanium alloys

$120

$146

D2980 Crown repair necessitated by restorative material failure

D2981 Inlay repair necessitated by restorative material failure

D2982 Onlay repair necessitated by restorative material failure

D2983 Veneer repair necessitated by restorative material failure

$332

D3320 Premolar root canal (excluding final restoration)

$408

$535

$416

$436

D3347 Retreatment of previous root canal therapy-premolar

$513

$617

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

$139

$139

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

$231

$231

D3410 Apicoectomy, anterior

$396

D3421 Apicoectomy, premolar (first root)

$432

D3425 Apicoectomy, molar (first root)

$489

D3426 Apicoectomy (each additional root)

$163

$208

$208

$105

$105

$120

$174

$174

$588

$244

D3471 Surgical repair of root resorption – anterior

$396

$238

D3472 Surgical repair of root resorption – premolar

$432

$268

D3473 Surgical repair of root resorption – molar

$489

$283

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

$396

$238

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

$432

$268

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

$489

$283

$189

D3921 Decoronation or submergence of an erupted tooth

$100

$64

$290

$77

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

$341

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

$365

D4260 Osseous surgery (including flap entry and closure), four or more contiguous teeth or bounded teeth spaces per quadrant

$551

$404

$407

D4273 Autogenous connective tissue graft procedures (including donor site surgery)

$526

D4275 Non-autogenous connective tissue graft procedures (including recipient site and donor material)

$480

$581

$490

D4278 Free soft tissue graft procedure, each additional contiguous tooth or edentulous tooth position in a graft site

$80

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

$475

$305

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

$427

$274

D4286 Removal of non-resorbable barrier

$100

$90

D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit

$78

D4999 Periodontal procedure, unspecified by report

$45

$30

$598

$598

$653

$653

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 base (including retentive/clasping materials, rests and teeth)

$661

$549

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

$661

D5221 Immediate maxillary partial denture - resin base

$467

$315

D5222 Immediate mandibular partial denture - resin base

$467

$315

D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases

$661

$525

D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases

$661

$525

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

$693

$661

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

$693

$661

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

$693

$661

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

$693

$661

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

$393

$281

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

$393

$281

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

$393

$281

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

$393

$281

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

$58

$17

$1073

D6011 Surgical access to an implant body (second stage implant surgery)

D6040 Subperiosteal implant

$953

$612

D6050 Transosseous mandibular implant

$1830

$1176

$720

$720

$312

$438

$692

$629

$584

$625

$645

$642

$715

$708

D6066 Implant supported crown – porcelain fused to high noble alloys

$713

D6067 Implant supported crown – high noble alloys

$738

$664

$652

$653

$700

$632

$594

$699

$778

D6076 Implant supported retainer for FPD – porcelain fused to high noble alloys

$702

D6077 Implant supported retainer for metal FPD – high noble alloys

$810

$44

D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant including cleaning of the implant surfaces, without flap entry and closure

$64

$23

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

$34

$22

D6092 Re-cement implant/abutment supported crown

$44

$39

D6093 Re-cement implant/abutment supported fixed partial denture

$68

$49

D6094 Abutment supported crown – titanium and titanium alloys

$175

$175

D6100 Surgical removal of implant body

$182

D6102 Debridement of periimplant defect

$477

$307

D6104 Bone graft at the time of implant placement

$281

$180

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

$91

$78

D6110 Implant/abutment supported removable denture for completely endentulous arch -maxillary 

$1346

$865

D6111 Implant/abutment supported removable denture for completely endentulous arch -mandibular

$1260

$809

D6112 Implant/abutment supported removable denture for partially endentulous arch - maxillary

$1238

$795

D6113 Implant/abutment supported removable denture for partially endentulous arch - mandibular

$1162

$746

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

$1346

$865

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

$1260

$809

D6116 Implant/abutment supported fixed denture for partially edentulous arch – maxillary

$958

$615

D6117 Implant/abutment supported fixed denture for partially edentulous arch - mandibular

$958

$615

D6191 Semi-precision abutment – placement

$274

$176

D6192 Semi-precision attachment – placement

$274

$176

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

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

$55

$16

$538

D6214 Pontic – titanium and titanium alloys

$530

$459

$517

$585

$224

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

$600

D6750 Retainer crown – porcelain fused to high noble metal

D6751 Retainer crown – porcelain fused to predominately base metal

$542

D6752 Retainer crown – porcelain fused to noble metal

D6780 Retainer crown – 3/4 cast high noble metal

D6781 Retainer crown – 3/4 cast predominately base metal

D6782 Retainer crown – 3/4 cast noble metal

D6783 Retainer crown – 3/4 porcelain/ceramic

D6790 Retainer crown – full cast high noble metal

$366

D6791 Retainer crown – full cast predominately base metal

D6792 Retainer crown – full cast noble metal

D6794 Retainer crown – titanium -- an alternate benefit will be provided on posterior teeth

D9932 Cleaning and inspection of removable complete denture, maxillary

$24

$24

D9933 Cleaning and inspection of removable complete denture, mandibular

$24

$24

D9934 Cleaning and inspection of removable partial denture, maxillary

$24

$24

D9935 Cleaning and inspection of removable partial denture, mandibular

$24

$24

Not covered:

• Any exclusions or limitations listed under Section 7 of this plan document

D8040 Limited orthodontic treatment of adult dentition

$1664

$1664

D8681 Removable orthodontic retainer adjustment

$31

$31

Not covered:

• Any exclusions or limitations listed under Section 7 of this plan document

Enrollees will have access to a discounted rate of $1,850 on clear aligners through Dominion National's partnership with SmileDirectClub, Inc.* This discount is separate from the orthodontia benefits covered on the FEDVIP plans. Learn more at www.DominionNational.com/sdc.

D9219 Evaluation for deep sedation or general anesthesia

$0

$0

D9222 Deep sedation/general anesthesia - first 15 minutes

$76

$76

$76

$76

D9230 Inhalation of nitrous oxide/analgesia, anxiolysis

$31

$24

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

$90

$81

D9243 Intravenous conscious sedation/analgesia – each 15 minute increment

$90

$81

D9311 Consultation with a medical health care professional

$0

$0

Office visit

$48

D9613 Infiltration of sustained release therapeutic drug, per quadrant

$190

$190

$42

D9943 Occlusal guard adjustment

$43

$42

D9944 Occlusal guard - hard appliance, full arch

$285

$191

D9945 Occlusal guard - soft appliance, full arch

$285

$191

D9946 Occlusal guard - hard appliance, partial arch

$285

$191

D9953 Reline custom sleep apnea appliance (indirect)

$175

$158

D9974 Internal bleaching – per tooth

$84

D9975 External bleaching for home application - per arch (includes materials and fabrication of custom trays)

This plan provides a benefit for emergency services when overseas.  Emergency services are defined as "palliative care of injury, toothache, or accident requiring the immediate attention of a dentist or hospital/ambulatory surgical care center." Services are limited to those procedures not excluded under Plan Limitations and Exclusions. We will reimburse you for emergency services up to $100 per member per year.

This plan provides a benefit for international emergency services when services are received from a licensed dentist.  The Dominion National network does not extend outside of the United States.  You have the right to choose any licensed dental practitioner; you do not need to contact Dominion first.

Note: Because international claims do not have the consideration of stateside cost containment, members must be cautious to guard against inappropriate/excessive services.

The following should be provided when submitting a claim for International emergency services:

• Name of country where services were received
• American Dental Association procedure codes
• Translation of language to English
• Translation into US currency or accurate day rate
• Tooth number(s) and/or quadrants
• Date(s) of service
• Dentist name

Our plan website is www.FederalDentalPlans.com.  You may also contact us by phone at 855-836-6337.

For in-network services, there are no claims for you to file.

This plan does not offer an out-of-network benefit.  If you see an out-of-network provider for emergency services, the claim (a standard ADA claim form) should be submitted to:

Dominion National
P.O. Box 211424
Eagan, MN  55121

International Claims

If you see an international dentist for emergency services, a dental claim form should be completed for each patient in full and accompanied by fully itemized bills. The claim form should be submitted in English, but it is not necessary for you to convert currency.  If a claim is submitted with non-U.S. currency, the currency submitted will be converted as of the date of service, using the website http://www.xe.com.

You can print a claim form from our website at www.DominionNational.com.

Since the claim will not be returned, please be sure to keep photocopies of all bills and supporting documentation for your personal records. If you need assistance in completing the claim form, please call Dominion Customer Service at 855-836-6337.

Dominion National – Special Handling
P.O. Box 211424
Eagan, MN  55121

The plan must receive written proof of loss within 180 days of treatment. Failure to provide proof of loss within the time required does not invalidate or reduce a claim if it was not reasonably possible to submit the proof within the required time, if the proof is furnished as soon as reasonably possible and, except in the absence of legal capacity of the claimant, not later than one year from the time proof is otherwise required. Instructions for submitting proof of loss to the plan can be found on the Membership Identification Card.

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.

Disputed Claim Steps

1 Ask us in writing to reconsider our initial decision. Please submit with your appeal any pertinent information related to the claim including written comments from the treating dentist, supporting documents and dental records. Your appeal must be filed within 180 days of receipt of the initial denial of the claim(s).

2 Send your appeal to Grievances and Appeals c/o Dominion National, 251 18^th Street South, Suite 900, Arlington, VA 22202 or fax to 703.518.4450. We will conduct a thorough review of your appeal and provide a written response within 60 days from the date of receipt. If additional time is needed to complete our review, we will notify you in writing.

3 If the dispute is not resolved through the reconsideration process, you may request a second review within 30 days of the first review of the decision. Any dentist advisor involved in reviewing the appeal will be different from and not in a subordinate position to the dentist advisor involved in the initial benefit determination.

4 If you do not agree with our final decision, after the internal appeal process is exhausted, you may request an independent third party, mutually agreed upon by Dominion National and OPM, to review the decision. You must file the appeal in writing to Dominion National at the address above. The appeal should include the appropriate written comments from the treating dentist, supporting documents and dental records relating to the claim(s). The independent third party reviewer will thoroughly review the appeal and provide the decision to Dominion National who will respond to you in writing within 60 days from the date we receive the request. The decision of the independent third party is binding and is the final review of your claim.

Palliative care of injury, toothache, or accident requiring the immediate attention of a dentist or hospital/ambulatory surgical care center.

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

The standards set by the American Dental Association or which are customarily used for dental care. Dominion National reserves the right to determine the level of necessary treatment.

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

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.

Dominion National

Copayment (Approximately 0%)

Copayment (Approximately 0%)

Copayment (Approximately 28%)

Copayment (Approximately 11%)

Copayment (Approximately 37%)

Copayment (Approximately 27%)

Class D Services – orthodontic

No Lifetime Maximum
No Waiting Period

Copayment (Approximately 56%)

Copayment (Approximately 56%)