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

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

If you or one of your family members are 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.

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.

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.

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.

Your enrollment or your eligibility to enroll may continue after retirement. You do not need to be enrolled in FEDVIP for any length of time to continue enrollment into retirement. Your family members may also be able to continue enrollment after your death. Please see Section 1, Eligibility, 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.

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

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

You are eligible to enroll if you:

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

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

A compensationer is someone receiving monthly compensation from the Department of Labor’s Office of Workers’ Compensation Programs (OWCP) due to an on-the-job injury/illness who is determined by the Secretary of Labor to be unable to return to duty. You are eligible to enroll in FEDVIP or continue FEDVIP enrollment into compensation status.

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 does 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 877-888-FEDS (877-888-3337), TTY number 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 (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:

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
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 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;
• 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 within 15 days of your effective date. It is important to bring your FEDVIP and FEHB ID card to every dental appointment because 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.

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 http://your.humana.com/feds or call us at 877-692-2468.

High PPO option:

You can obtain care from any licensed dentist you choose. You may be able to reduce your out-of-pocket expenses for covered services by selecting an in-network provider. You can find in-network plan providers by visiting our website at: http://your.humana.com/feds.

Standard Advantage EPO option:

Members should receive services from in-network providers.  There is no coverage for services rendered by an out-of-network provider, with the exception of emergency services.

You can find in-network providers by visiting our website: http://your.humana.com/feds.

Plan providers, also referred to as “in-network providers”, are licensed dentist and dental providers who have contracted with us to provide negotiated discounts on covered services. We list plan providers in the provider directory, which we update periodically. The list is on our website at: http://your.humana.com/feds.

You may see any in-network general dentist or specialist (e.g. Endodontist, Periodontist, etc.). You do not need a referral to see a specialist. You can find in-network providers by visiting our website at  http://your.humana.com/feds.

High PPO option:

You may obtain care from any licensed dentist you choose. If the dentist you use is not part of our network, or not in our service area, benefits will be determined based on the out-of-network benefit level of the out-of-network plan allowance.

You are responsible for the difference between our payment and the amount billed.  

Standard Advantage EPO option:

There are no out-of-network benefits available except for emergency care.

High PPO option:

All expenses for emergency services are payable as any other expense and are subject to plan limitations such as frequencies, deductibles, and maximums. If you utilize the services of an out-of-network dentist for emergency services, benefits will be paid under the out-of-network Plan provisions. You are responsible for the difference between our payment and billed charges.

 Standard Advantage EPO option:

If you have an emergency outside of the service area, visit any general dentist or specialist for care. We will reimburse you for emergency services up to $100 per member per year.

High PPO option:

The plan allowance is the amount we allow for a specific procedure. When you use an in-network provider, your out-of-pocket cost is limited to the difference between the plan allowance and our payment. When you use an out-of-network provider, you are responsible for the difference between the plan allowance and our payment plus the difference between the amount the provider bills and the plan allowance.

Note: The plan allowance only applies to the High PPO option.

High PPO option:

In the event a procedure is anticipated to cost at least $300, you or your dentist may submit a dental treatment plan for us to review before your treatment. An estimate for services is not a guarantee of what we will pay. It tells you and your dentist in advance about the benefits payable for the covered expenses in the treatment plan. An estimate for services is not necessary for emergency care.

High PPO option:

If two or more services are acceptable to correct a dental condition, we will base benefits payable on the plan allowance for the least expensive covered service that produces a professionally satisfactory result, as determined by us. If you or your dentist decide on a more costly treatment than we determine to be satisfactory for treatment of the condition, you will be responsible for the remaining expense incurred.

Standard Advantage EPO option:

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.

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 either plan, you must live in our service area. This is where our providers are located. Our service area is: Alabama, Arkansas, majority of Arizona, California, Colorado, District of Columbia, Florida, Georgia, majority of Illinois, Indiana, Kansas, Kentucky, Louisiana, parts of Maryland, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, parts of Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, and West Virginia.

Ordinarily, on the Standard Advantage EPO, 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. An emergency is treatment due to injury, accident or severe pain requiring the services of a dentist which occurs under circumstances where it is neither medically or physically possible for you to be treated by a plan provider. 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 877-888-FEDS (877-888-3337), TTY number 877-889-5680 to change plans.

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. Your rates might change because of the move.

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 by contacting us at 877-692-2468.

High PPO option:

Claims submitted may be subject to dental review prior to payment. In these cases, the determination of benefits is based upon the review of clinical documentation by a licensed dentist.

Standard Advantage EPO option:

Claims submitted by dentists that may be for cosmetic purposes only are subject to dental review prior to payment.

A deductible is a fixed amount of expenses you must incur each calendar year for certain covered services and supplies before we will pay for covered services. Note, deductibles only apply to the PPO High option. There are no deductibles for the Standard Advantage EPO option.

Calendar Year Deductible:

In-Network High PPO Option: $50/individual
In-Network High PPO Option: $100/family
Out-of-Network High PPO Option: $50/individual
Out-of-Network High PPO Option: $150/family

Coinsurance is the percentage of the plan allowance that you must pay for your care. Coinsurance does not begin until after you meet your deductible, if applicable. Note, Coinsurance only applies to the High PPO option. There is no Coinsurance for the Standard Advantage EPO option.

Class A
In-Network High PPO Option You Pay: 0%, no deductible
Out-of-Network High PPO Option You Pay: 10%, no deductible

Class B
In-Network High PPO Option You Pay: 20%, after deductible
Out-of-Network High PPO Option You Pay: 40%, after deductible

Class C
In-Network High PPO Option You Pay: 50%, after deductible
Out-of-Network High PPO Option You Pay: 60%, after deductible

Orthodontics
In-Network High PPO Option You Pay: 50% (no deductible) up to $2,500 lifetime orthodontic maximum 
Out-of-Network High PPO Option You Pay: 50% (no deductible) up to $2,500 lifetime orthodontic maximum 

A co-payment is a fixed amount of money you pay directly to the dentist when you receive covered services. Co-payments only apply to the Standard Advantage EPO option. There are no co-payments for the High PPO option. The benefit schedule for the Standard Advantage EPO option lists the co-payments for each covered procedure. There are no additional charges.

Example: In the Standard Advantage EPO option, you pay $23 for an amalgam – one surface primary or permanent.

High PPO option:

The Annual Benefit Maximum is the total amount of benefits that will be paid for each covered person during a calendar year. The Annual Benefit Maximum is unlimited.

Standard Advantage EPO option:

The annual benefit maximum under this plan is unlimited.  

There is no lifetime benefit maximum under this plan (except for orthodontic services under the High PPO option).

High PPO option:

You pay the coinsurance percentage of the plan allowance for covered services after your in-network calendar year deductible has been satisfied. You are not responsible for charges above that allowance.

Standard Advantage EPO option:

The co-payment amounts listed in the benefit schedule for the Standard Advantage EPO option represent your total cost for in-network services.

High PPO option:

You pay the coinsurance percentage of the plan allowance for covered services after your out-of-network calendar year deductible has been satisfied. You are also responsible for the difference between the plan allowance and billed charges.

Standard Advantage EPO option:

Benefits under your plan must be received through in-network dentists. There is no coverage for services rendered by an out-of-network provider.

An emergency is treatment due to injury, accident or severe pain requiring the services of a dentist which occurs under circumstances where it is neither medically or physically possible for you to be treated by a plan provider. We will not pay for any other services out of our service area unless the services have prior plan approval. We will reimburse you up to $100 per member per year. When traveling overseas, we will authorize emergency services only.

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

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 – Limited to three per calendar year

D0140 Limited oral evaluation – problem focused – Limited to one per calendar year

D0145 Oral evaluation for a child under three years of age and counseling with the primary caregiver – Limited to three per calendar year (cross reduces limit under D0120)

D0150 Comprehensive oral evaluation – Limited to two per calendar year

D0160 Detailed and extensive oral evaluation – problem focused, by report (limited to 1 per patient per lifetime)

D0180 Comprehensive periodontal evaluation – Limited to two per calendar year

D0210 Intraoral – comprehensive series (including bitewings) – Limited to one set (Full Mouth series or panoramic images)

D0270 Bitewing – single images

D0272 Bitewings – two images – (codes D0272, D0273, D0274, D0277 share frequency limitation of one set per calendar year)

D0273 Bitewings – three images – (codes D0272, D0273, D0274, D0277 share frequency limitation of one set per calendar year)

D0274 Bitewings – four images – (codes D0272, D0273, D0274, D0277 share frequency limitation of one set per calendar year)

D0277 Vertical bitewings – 7 to 8 images – (codes D0272, D0273, D0274, D0277 share frequency limitation of one set per calendar year)

D0330 Panoramic film – Limited to one set (Full Mouth series or panoramic images)

D0431 Oral cancer screening – Limited to one per calendar year for members age 40 and older

D1110 Prophylaxis – adult – Limited to three per calendar year

D1120 Prophylaxis – child – Limited to three per calendar year

D1206 Topical application of fluoride varnish - Limited to twice per calendar year for members age 16 and younger

D1208 Topical application of fluoride - Limited to twice per calendar year for members age 16 and younger

D1351 Sealant – per tooth – Limited to children under age 19. One sealant per tooth in a lifetime

D1353 Sealant Repair (Per tooth)

D1354 Interim caries arresting medicament application

D1510 Space maintainer – fixed – unilateral – Limited to children age 15 and younger

D1516 Space maintainer – fixed – bilateral, maxillary - Limited to children age 15 and younger

D1517 Space maintainer – fixed – bilateral, mandibular - Limited to children age 15 and younger

D1520 Space maintainer – Removable – unilateral – Limited to children age 15 and younger

D1526 Space maintainer – Removable – bilateral, maxillary - Limited to children age 15 and younger

D1527 Space maintainer – Removable – bilateral, mandibular - Limited to children age 15 and younger

D1551 Re-cement or re-bond bilateral space maintainer - maxillary - Limited to children age 15 and younger

D1552 Re-cement or re-bond bilateral space maintainer – mandibular - Limited to children age 15 and younger

D1553 - Re-cement or re-bond unilateral space maintainer – per quadrant - Limited to children age 15 and younger

D1556 - Removal of fixed unilateral space maintainer – per quadrant - Limited to children age 15 and younger

D1557 - Removal of fixed bilateral space maintainer – maxillary - Limited to children age 15 and younger

D1558 - Removal of fixed bilateral space maintainer – mandibular - Limited to children age 15 and younger

D1575 Distal shoe space maintainer – fixed – unilateral - Limited to children age 15 and younger

D4910 - Periodontal maintenance following active periodontal therapy – Limited to four per calendar year

D9311 Consultation with a medical health care professional

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

D2140 Amalgam - one surface, primary or permanent - (D2140-D2394 share frequency of 1 per tooth per 2 year period)

D2150 Amalgam - two surfaces, primary or permanent - (D2140-D2394 share frequency of 1 per tooth per 2 year period)

D2160 Amalgam - three surfaces, primary or permanent - (D2140-D2394 share frequency of 1 per tooth per 2 year period)

D2161 Amalgam - four or more surfaces, primary or permanent - (D2140-D2394 share frequency of 1 per tooth per 2 year period)

D2330 Resin–based composite - one surface, anterior - (D2140-D2394 share frequency of 1 per tooth per 2 year period)

D2331 Resin-based composite - two surfaces, anterior - (D2140-D2394 share frequency of 1 per tooth per 2 year period)

D2332 Resin-based composite - three surfaces, anterior - (D2140-D2394 share frequency of 1 per tooth per 2 year period)

D2335 Resin-based composite - four or more surfaces (anterior) - (D2140-D2394 share frequency of 1 per tooth per 2 year period)

D2390 Resin based composite crown – anterior (D2140-D2394 share frequency of 1 per tooth per 2 year period)

D2391 Resin-based composite - one surface posterior - alternate benefit of amalgam will be provided on posterior teeth - (D2140-D2394 share frequency of 1 per tooth per 2 year period)

D2392 Resin-based composite - two surface posterior - alternate benefit of amalgam will be provided on posterior teeth - (D2140-D2394 share frequency of 1 per tooth per 2 year period)

D2393 Resin-based composite - three surface posterior - alternate benefit of amalgam will be provided on posterior teeth - (D2140-D2394 share frequency of 1 per tooth per 2 year period)

D2394 Resin-based composite - four or more surface posterior - alternate benefit of amalgam will be provided on posterior teeth - (D2140-D2394 share frequency of 1 per tooth per 2 year period)

D2910 Re-cement inlay

D2915 Re-cement cast or prefab post and core

D2920 Re-cement crown

D2921 Reattachment of tooth fragment - incisal edge or cusp

D2930 Prefabricated stainless steel crown - primary tooth

D2931 Prefabricated stainless steel crown - permanent tooth

D3220 Therapeutic pulpotomy (excluding final restoration) allowed on primary teeth only

D3222 Partial pulpotomy for apexogenesis permanent teeth with incomplete root development

D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration). Incomplete endodontic treatment when you discontinue treatment

D3355 Pulpal regeneration - initial visit 

D3356 Pulpal regeneration - interim medication replacement 

D3357 Pulpal regeneration - completion of treatment (does not include final restoration) 

D4341 Periodontal scaling and root planning-four or more teeth per quadrant – Limited to a maximum of once per quadrant in a three year period

D4342 Periodontal scaling and root planning-one to three teeth, per quadrant – Limited to a maximum of once per quadrant in a three year period

D4346 Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation - Limited to one per year and cross reduces with codes D1110 and D1120

D5410 Adjust complete denture - maxillary - not covered if done within 6 months of installation

D5411 Adjust complete denture - mandibular - not covered if done within 6 months of installation

D5421 Adjust partial denture - maxillary - not covered if done within 6 months of installation

D5422 Adjust partial denture - mandibular - not covered if done within 6 months of installation

D5710 Rebase complete maxillary denture – not covered within first six months of placement, limited to once in a 3 year period

D5711 Rebase lower complete denture - not covered within first six months of placement, limited to once in a 3 year period

D5720 Rebase maxillary partial denture – not covered within first six months of placement, limited to once in a 3 year period

D5721 Rebase mandibular partial denture – not covered within first six months of placement, limited to once in a 3 year period

D5730 Reline complete maxillary denture (direct) – not covered within first six months of placement, limited to once in a 3 year period

D5731 Reline complete mandibular denture (direct) – not covered within first six months of placement, limited to once in a 3 year period

D5740 Reline maxillary partial denture (direct) – not covered within first six months of placement, limited to once in a 3 year period

D5741 Reline mandibular partial denture (direct) – not covered within first six months of placement, limited to once in a 3 year period

D5750 Reline complete maxillary denture (indirect) – not covered within first six months of placement, limited to once in a 3 year period

D5751 Reline complete mandibular denture (indirect) – not covered within first six months of placement, limited to once in a 3 year period

D5760 Reline maxillary partial denture (indirect) – not covered within first six months of placement, limited to once in a 3 year period

D5761 Reline mandibular partial denture (indirect) – not covered within first six months of placement, limited to once in a 3 year period

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

D7251 Coronectomy – intentional partial tooth removal, impacted teeth only

D7509 - marsupialization of odontogenic cyst

D7956 - guided tissue regeneration, edentulous area – resorbable barrier, per site

D7957 - guided tissue regeneration, edentulous area – non-resorbable barrier, per site

D6092 Re-cement Implant / Abutment supported crown

Not Covered:

• Restorations for cosmetic purposes only

D2610 Inlay - porcelain/ceramic, one surface - Limited 1 every 5 years

D2620 Inlay - porcelain/ceramic, two surfaces - Limited 1 every 5 years

D2630 Inlay - porcelain/ceramic, three or more surfaces - Limited 1 every 5 years

D3310 Anterior root canal (excluding final restoration) - Limited to 1 per tooth per lifetime

D3320 Premolar root canal (excluding final restoration) - Limited to 1 per tooth per lifetime

D3330 Molar root canal (excluding final restoration) - Limited to 1 per tooth per lifetime

D3346 Retreatment of previous root canal therapy - anterior - Limited to 1 per tooth per lifetime

D3347 Retreatment of previous root canal therapy - premolar - Limited to 1 per tooth per lifetime

D3348 Retreatment of previous root canal therapy - molar - Limited to 1 per tooth per lifetime

D3471 Surgical repair of root resorption - anterior

D3472 Surgical repair of root resorption – premolar

D3473 Surgical repair of root resorption – molar

D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces, per quadrant - Limited to once in a 3 year period

D4211 Gingivectomy or gingivoplasty - one to three teeth, per quadrant - Limited to 1 per tooth per lifetime

D4212 Gingivectomy or gingivoplasty - with restorative procedures, per tooth - Limited to once in a 3 year period

D4240 Gingival flap procedure, including root planing, four of more contiguous teeth or bounded teeth spaces per quadrant - Limited to once in a 3 year period

D4241 Gingival flap procedure, including root planning - one to three teeth per quadrant - Limited to once in a 3 year period

D4249 Clinical crown lengthening-hard tissue - Limited to once in a 3 year period

D4260 Osseous surgery (including flap entry and closure), four or more contiguous teeth or bounded teeth spaces per quadrant - Limited to once in a 3 year period

D4261 Osseous surgery (including flap entry and closure) - one to three teeth per quadrant - Limited to once in a 3 year period

D4268 Surgical revision procedure, per tooth - Limited to once in a 3 year period

D4270 Pedicle soft tissue graft procedure - Limited to once in a 3 year period

D4273 Subepithelial connective tissue graft procedures (including donor site surgery) - Limited to once in a 3 year period

D4275 Soft tissue allograft - Limited to once in a 3 year period

D4276 Combined connective tissue and double pedicle graft, per tooth - Limited to once in a 3 year period

D4277 Free soft tissue graft procedure, first tooth or edentulous tooth position in a graft - Limited to once in a 3 year period

D4278 Free soft tissue graft procedure, each additional contiguous tooth or edentulous tooth position in a graft - Limited to once in a 3 year period

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 - Limited to once in a 3 year period

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 - Limited to once in a 3 year period

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

D5225 Maxillary partial denture, flexible base

D5226 Mandibular partial denture, flexible base

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

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

D5725 Rebase hybrid prosthesis

D5765 Soft liner for complete or partial removable denture – indirect

D6013 Surgical placement of mini implant

D6040 Subperiosteal implant

D6050 Transosseous mandibular implant

D6066 Implant supported single porcelain fused to metal crown titanium, titanium alloy, high noble metal

D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surface, without flap entry and closure - limited to 1 per tooth every 3 years

D6089 – Accessing and retorquing loose implant screw - per screw

D6090 Repair implant prosthesis

D6091 Replacement of replaceable part of semi-precision or precision attachment

D6100 Implant removal

D6102 Debridement of peri-implant defect

D6106 - guided tissue regeneration – resorbable barrier, per implant

D6107 - guided tissue regeneration – non-resorbable barrier, per implant

D6191 Semi-precision abutment – placement

D6192 Semi-precision attachment – placement

D6605 Retainer inlay – cast predominantly base metal, 3 or more surfaces (limited to 1 per tooth every 5 years)

D9932 Cleaning and inspection of removable complete denture, maxillary

D9933 Cleaning and inspection of removable complete denture, mandibular

D9934 Cleaning and inspection of removable partial denture, maxillary

D9935 Cleaning and inspection of removable partial denture, mandibular

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

Not Covered:

• Restoration for cosmetic purposes only
• Precision attachments, personalization, precious metal bases, and other specialized techniques
• Replacement of dentures that have been lost, stolen, or misplaced
• Removable or fixed prostheses initiated prior to the effective date of coverage or inserted/cemented after the coverage ending date

D0340 Cephalometric film

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

D0372 - intraoral tomosynthesis - comprehensive series of radiographic images

D0373 - intraoral tomosynthesis - bitewing radiographic image

D0374 - intraoral tomosynthesis - periapical radiographic image

D0470 Diagnostic casts

D8040 Limited orthodontic treatment of adult dentition (limited to 1 treatment per lifetime)

D8210 Removable appliance therapy - Limited to 14 years or younger, 1 per lifetime

D8220 Fixed appliance therapy - Limited to 14 years or younger, 1 per lifetime

D8681 Removable orthodontic retainer adjustment

D9219 Evaluation for moderate sedation, deep sedation or general anesthesia

D9230 – Inhalation of nitrous oxide/analgesia, anxiolysis; covered when necessary in conjunction with covered dental services; once per date of service

D9613 Infiltration of sustained release therapeutic drug – single or multiple sites

D0120 Periodic oral evaluation – established patient – (limited to 3 per calendar year)

D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver (limited to 1 per patient per lifetime)

D0210 Intraoral – comprehensive series of radiographic images (limited to 1 every 3 years)

D0340 Cephalometric film

$0

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

$0

D0372 - intraoral tomosynthesis - comprehensive series of radiographic images

$0

D0373 - intraoral tomosynthesis - bitewing radiographic image

$0

D0374 - intraoral tomosynthesis - periapical radiographic image

$0

D0425 Caries susceptibility tests

$0

D0470 Diagnostic casts

$0

D1110 Prophylaxis – adult (limited to 3 per calendar year)

D1120 Prophylaxis – child (limited to 3 per calendar year)

D1353 Sealant Repair - (Per tooth) Permanent tooth-1 every 3 year period

$0

D1354 Interim caries arresting medicament application - Permanent tooth 1 every 3 years

$0

D1510 Space maintainer – fixed – unilateral, per quadrant (limited to children under age 19)

D1516 Space maintainer – fixed – bilateral, maxillary (limited to children under age 19)

$0

D1517 Space maintainer – fixed – bilateral, mandibular (limited to children under age 19)

$0

D1520 Space maintainer – removable – unilateral, per quadrant (limited to children under age 19)

D1526 Space maintainer – removable – bilateral, maxillary (limited to children under age 19)

D1527 Space maintainer – removable – bilateral, mandibular (limited to children under age 19)

D1551 Re-cement or re-bond bilateral space maintainer, maxillary (limited to children under age 19)

$0

D1552 Re-cement or re-bond bilateral space maintainer, mandibular (limited to children under age 19)

$0

D1553 Re-cement or re-bond unilateral space maintainer, per quadrant (limited to children under age 19)

$0

D1556 Removal of fixed unilateral space maintainer - per quadrant (Limited to children under 19)

$0

D1557 Removal of fixed bilateral space maintainer - maxillary per quadrant (Limited to children under 19)

$0

D1558 Removal of fixed bilateral space maintainer - mandibular (Limited to children under 19)

$0

D1575 Distal shoe space maintainer – fixed – unilateral

$0

D9311 Consultation with a medical health care professional

$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

N/A

D2335 Resin-based composite - four or more surfaces anterior (limited to 1 per tooth every 24 months)

D2390 Resin based composite crown – anterior

$90

D2915 Re-cement cast or prefab post and core

$24

D2921 Reattachment of tooth fragment - incisal edge or cusp

$50

D3222 Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development (limited to 1 per tooth per lifetime)

$22

D5511 Repair broken complete denture base, mandibular

$44

D5512 Repair broken complete denture base, maxillary

$44

D5611 Repair resin partial denture base, mandibular

D5612 Repair resin partial denture base, maxillary

$46

D5621 Repair cast partial framework, mandibular

D5622 Repair cast partial framework, maxillary

$49

D5630 Repair or replace broken retentive clasping materials - per tooth

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

$44

D7111 Extraction, coronal remnants – primary deciduous tooth

D7251 Coronectomy – intentional partial tooth removal, impacted tooth only (limited to 1 per tooth per lifetime)

Not Covered:

• Gold foil restorations
• Restorations for cosmetic purposes only

N/A

D2510 Inlay - metallic - one surface - (limited to 1 per tooth every 5 years)

$353

D2520 Inlay - metallic - two surfaces- (limited to 1 per tooth every 5 years)

$341

D2530 Inlay - metallic - three or more surfaces- (limited to 1 per tooth every 5 years)

$432

D2542 Onlay - metallic - two surfaces (limited to 1 per tooth every 5 years)

$315

D2543 Onlay - metallic - three surfaces (limited to 1 per tooth every 5 years)

D2544 Onlay - metallic - four or more surfaces (limited to 1 per tooth every 5 years)

D2610 Inlay – porcelain/ceramic, one surface (limited to 1 per tooth every 5 years)

$335

D2620 Inlay – porcelain/ceramic, two surfaces (limited to 1 per tooth every 5 years)

$324

D2630 Inlay – porcelain/ceramic, three or more surfaces (limited to 1 per tooth every 5 years)

$410

D2740 Crown - Crown - porcelain/ceramic substrate (limited to 1 per tooth every 5 years)

D2750 Crown – porcelain fused to high noble metal (limited to 1 per tooth every 5 years)

D2751 Crown – porcelain fused to predominately base metal (limited to 1 per tooth every 5 years)

D2752 Crown – porcelain fused to noble metal (limited to 1 per tooth every 5 years)

D2753 Crown – porcelain fused to titanium and titanium alloys (limited to 1 per tooth every 5 years)

$437

D2794 Crown – titanium and titanium alloy (limited to 1 per tooth every 5 years)

D3320 Endodontic therapy, premolar bicuspid tooth (excluding final restorations) - (limited to 1 per tooth per lifetime)

D3330 Endodontic therapy, molar tooth (excluding final restorations) - (limited to 1 per tooth per lifetime)

D3347 Retreatment of previous root canal therapy – bicuspid premolar

D3355 Pulpal regeneration - initial visit (limited to 1 per tooth per lifetime)

$210

D3356 Pulpal regeneration - interim medication replacement (limited to 1 per tooth per lifetime)

$100

D3357 Pulpal regeneration - completion of treatment (limited to 1 per tooth per lifetime)

$260

D3421 Apicoectomy – bicuspid premolar (first root)

D3426 Apicoectomy – (each additional root)

D3471 Surgical repair of root resorption – anterior

$270

D3472 Surgical repair of root resorption – premolar

$270

D3473 Surgical repair of root resorption – molar

$270

D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit (limited to 1 per lifetime)

D5110 Complete denture – maxillary (limited 1 per 5 years)

D5120 Complete denture – mandibular (limited 1 per 5 years)

D5130 Immediate denture – maxillary (limited 1 per 5 years)

D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) - (limited 1 per 5 years)

D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) - (limited 1 per 5 years)

D5214 Mandibular partial denture - cast metal framework with resin denture base (including retentive/clasping materials, rests and teeth) – (limited 1 per 5 years)

D5213 Maxillary partial denture - cast metal framework with resin denture base (including retentive/clasping materials, rests and teeth) – (limited 1 per 5 years)

D5221 Immediate maxillary partial denture – resin base (including retentive/clasping materials, rests and teeth) - (limited 1 per 5 years)

D5222 Immediate mandibular partial denture – resin base (including retentive/clasping materials, rests and teeth) - (limited  1 per 5 years)

D5223 Immediate maxillary partial denture - cast metal framework with resin denture base (including retentive/clasping materials, rests and teeth) – (limited 1 per 5 years)

D5224 Immediate mandibular partial denture - cast metal framework with resin denture base (including retentive/clasping materials, rests and teeth) – (limited 1 per 5 years)

D5225 Maxillary partial denture - flexible base (including any retentive/clasping materials, rests, and teeth) - (limited 1 per 5 years)

$575

D5226 Mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth) - (limited 1 per 5 years)

$584

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

$575

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

$584

D5282 Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests and teeth), maxillary - (limited to 1 per arch every 5 years)

D5283 Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests and teeth), mandibular - (limited to 1 per arch every 5 years)

$295

D5284 Removable unilateral partial denture – one piece flexible base (including retentive/clasping materials, rests, and teeth), per quadrant (limited to 1 per quadrant every 5 years)

$295

D5286 Removable unilateral partial denture – one piece resin (including retentive/clasping materials, rests, and teeth), per quadrant (limited to 1 per quadrant every 5 years)

$295

D5725 Rebase hybrid prosthesis

$124

D5765 Soft liner for complete or partial removable denture – indirect

$112

D6010 Surgical placement of implant body: endosteal implant (limited to 1 per tooth per lifetime)

$980

D6013 Surgical placement of mini implant (limited to 1 per tooth per lifetime)

$600

D6040 Subperiosteal implant (limited to 1 per tooth per lifetime)

$980

D6050 Transosseous mandibular implant (limited to 1 per tooth per lifetime)

$895

D6055 Connecting Bar – implant supported or abutment supported (limited to 1 per tooth every 5 years)

D6056 Prefabricated abutment – includes modification and placement (limited to 1 per tooth every 5 years)

D6057 Custom fabricated abutment – includes modification and placement (limited to 1 per tooth every 5 years)

D6058 Abutment supported porcelain/ceramic crown (limited to 1 per tooth every 5 years)

D6059 Abutment supported porcelain fused to metal crown – high noble metal (limited to 1 per tooth every 5 years)

D6060 Abutment supported porcelain fused to metal crown – predominantly based metal (limited to 1 per tooth every 5 years)

D6061 Abutment supported porcelain fused to metal crown – noble metal (limited to 1 per tooth every 5 years)

D6062 Abutment supported cast metal crown – high noble metal (limited to 1 per tooth every 5 years)

D6063 Abutment supported cast metal crown – predominantly based metal (limited to 1 per tooth every 5 years)

D6064 Abutment supported cast metal crown – noble metal (limited to 1 per tooth every 5 years)

D6065 Implant supported porcelain/ceramic crown (limited to 1 per tooth every 5 years)

D6066 Implant supported porcelain, high noble alloys (limited to 1  per tooth every 5 years)

$731

D6067 Implant supported crown, high noble alloys (limited to 1 per tooth every 5 years)

$635

D6068 Abutment supported retainer for porcelain/ceramic FPD (limited to 1 per tooth every 5 years)

D6069 Abutment supported retainer for porcelain fused to metal FPD – high noble metal (limited to 1 per tooth every 5 years)

D6070 Abutment supported retainer for porcelain fused to metal FPD – predominantly base metal (limited to 1 per tooth every 5 years)

D6071 Abutment supported retainer for porcelain fused to metal FPD – noble metal (limited to 1  per tooth every 5 years)

D6072 Abutment supported retainer for cast metal FPD – high noble metal (limited to 1 per tooth every 5 years)

D6073 Abutment supported retainer for cast metal FPD – predominantly base metal (limited to 1 per tooth every 5 years)

D6074 Abutment supported retainer for cast metal FPD – noble metal (limited to 1 per tooth every 5 years)

D6075 Implant supported retainer for ceramic FPD (limited to 1 per tooth every 5 years)

D6076 Implant supported retainer FPD high noble alloys (limited to 1 per tooth every 5 years)

$604

D6077 Implant supported retainer for FPD high noble alloys (limited to 1 per tooth every 5 years)

$466

D6080 Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis (limited to 1 per tooth every 5 years)

D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surface, without flap entry and closure (limited to 1 per tooth every 3 years)

D6082 Implant supported crown – porcelain fused to predominantly base alloys (limited to 1 per tooth every 5 years)

$676

D6084 Implant supported crown – porcelain fused to titanium and titanium alloys (limited to 1 per tooth every 5 years)

$740

D6083 Implant supported crown – porcelain fused to predominantly base alloys (limited to 1 per tooth every 5 years)

$690

D6086 Implant supported crown – predominantly base alloys (limited to 1 per tooth every 5 years)

$588

D6087 Implant supported crown – noble alloys (limited to 1 per tooth every 5 years)

$600

D6088 Implant supported crown – titanium and titanium alloys (limited to 1 per tooth every 5 years)

$643

D6089 – Accessing and retorquing loose implant screw - per screw

$55

D6090 Repair implant supported prosthesis, by report (limited to 1 every 5 years)

D6091 Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment (limited to 1 per tooth every 5 years)

D6094 Abutment supported crown – titanium (limited to 1 per tooth every 5 years)

D6095 Repair Implant Abutment (limited to 1 per tooth every 5 years)

D6097 Abutment supported crown – porcelain fused to titanium and titanium alloys (limited to 1 per tooth every 5 years)

$638

D6098 Implant supported retainer - porcelain fused to predominantly base alloys (limited to 1 per tooth every 5 years)

$558

D6099 Implant supported retainer FPD - porcelain fused to noble alloys (limited to 1 per tooth every 5 years)

$570

D6100 Implant Removal (limited to 1 per tooth every 5 years)

D6102 Debridement of peri-implant defect (limited to 1 per tooth every 5 years)

$375

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

$118

D6110 implant /abutment supported removable denture for edentulous arch – Maxillary (limited to 1 every 5 years)

D6111 implant /abutment supported removable denture for edentulous arch – mandibular (limited to 1 per tooth every 5 years)

D6112 implant /abutment supported removable denture for partially edentulous arch – maxillary (limited to 1 per tooth every 5 years)

D6113 implant /abutment supported removable denture for partially edentulous arch – mandibular (limited to 1 per tooth every 5 years)

D6114 implant /abutment supported fixed denture for edentulous arch – maxillary (limited to 1 per tooth every 5 years)

D6115 implant /abutment supported fixed denture for edentulous arch – mandibular (limited to 1 per tooth every 5 years)

D6116 implant /abutment supported fixed denture for partially edentulous arch – maxillary (limited to 1 per tooth every 5 years)

D6117 implant /abutment supported fixed denture for partially edentulous arch – mandibular (limited to 1 per tooth every 5 years)

D6120 Implant supported retainer - porcelain fused to titanium and titanium alloys (limited to 1 per tooth every 5 years)

$611

D6121 Implant supported retainer for metal FPD - predominantly base alloys (limited to 1 per tooth every 5 years)

$431

D6122 Implant supported retainer for metal FPD - noble alloys (limited to 1 per tooth every 5 years)

$440

D6123 Implant supported retainer for metal FPD - titanium and titanium alloys (limited to 1 per tooth every 5 years)

$472

D6191 Semi-precision abutment – placement

$300

D6192 Semi-precision attachment – placement

$300

D6194 Abutment supported retainer crown for FPD – titanium and titanium alloys (limited to 1 per year every 5 years)

$630

D6195 Abutment supported retainer - porcelain fused to titanium and titanium alloys (limited to 1 per tooth every 5 years)

$630

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

$47

D6214 Pontic – titanium and titanium alloys (limited to 1 per tooth every 5 years)

D6243 Pontic - porcelain fused to titanium and titanium alloys (limited to 1 per tooth every 5 years)

$416

D6753 Retainer crown - porcelain fused to titanium and titanium alloys (limited to 1 per tooth every 5 years)

$441

D6784 Retainer crown ¾ - titanium and titanium alloys (limited to 1 per tooth every 5 years)

$420

D6794 Retainer crown – titanium and titanium alloys (limited to 1 per tooth every 5 years)

$416

D9941 Fabrication of athletic mouth guard

$95

D9943 Occlusal guard adjustment

$60

D9944 Occlusal guard – hard appliance, full arch (limited to 1 arch-maxillary or mandibular every 5 years)

D9945 Occlusal guard – soft appliance, full arch (limited to 1 arch-maxillary or mandibular every 5 years)

$155

D9946 Occlusal guard – hard appliance, partial arch (limited to 1 arch-maxillary or mandibular every 5 years)

$155

D8010 Limited orthodontic treatment of the primary dentition (limited to 1 treatment per lifetime)

$685

D8020 Limited orthodontic treatment of the transitional dentition (limited to 1 treatment per lifetime)

$894

D8030 Limited orthodontic treatment of the adolescent dentition (limited to 1 treatment per lifetime)

$1,007

D8040 Limited orthodontic treatment of adult dentition (limited to 1 treatment per lifetime)

$1,143

D8070 Comprehensive orthodontic treatment of the transitional dentition (Limited to 1 treatment per lifetime)

$2,765

D8080 Comprehensive orthodontic treatment of the adolescent dentition (limited to 1 treatment per lifetime)

$2,820

D8090 Comprehensive orthodontic treatment of the adult dentition (limited to 1 treatment per lifetime)

$2,820

D8210 Removable appliance therapy (limited to 1 treatment per lifetime)

$583

D8220 Fixed appliance therapy (limited to 1 treatment per lifetime)

$662

D8660 Pre-orthodontic treatment visit (limited to 1 treatment per lifetime)

$35

D8670 Periodic orthodontic treatment visit (as part of contract)

$116

D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) - (limited to 1 treatment per lifetime)

$286

D8681 Removable orthodontic retainer adjustment

$75

D9219 Evaluation for moderate sedation, deep sedation or general anesthesia

$30

D9222 Deep sedation/general anesthesia – first 15 minutes

$70

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

$60

D9230 – Inhalation of nitrous oxide/analgesia, anxiolysis; covered when necessary in conjunction with covered dental services; once per date of service

$15

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

$62

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

$53

D9613 Infiltration of sustained release therapeutic drug – single or multiple sites

$38

D9932 Cleaning and inspection of removable complete denture, maxillary

$0

D9933 Cleaning and inspection of removable complete denture, mandibular

$0

D9934 Cleaning and inspection of removable partial denture, maxillary

$0

D9935 Cleaning and inspection of removable partial denture, mandibular

$0

This plan provides a benefit for emergency services when overseas. Emergency services are defined as treatment due to injury, accident or severe pain requiring the services of a dentist which occurs under circumstances where it is neither medically or physically possible for you to be treated by an in-network plan provider. For the High PPO option, if you utilize the services of an out-of-network dentist for emergency services, benefits will be paid under the out-of-network plan provisions. All expenses for emergency services are payable as any other expense and are subject to plan limitations such as frequencies, deductibles, and maximums. You are responsible for the difference between our payment and billed charges. For the Standard Advantage EPO option, you will be reimbursed for emergency services up to $100 per member per year.

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 http://your.humana.com/feds.

You may also contact us by phone at 877-692-2468.

To obtain claim forms or other claim filing advice or answers about your benefits, contact us at 877-692-2468 or go to our web site at http://your.humana.com/feds.

For emergency and international claims, you have one year from the date of service to file your claim.

The date of loss is 12 months on fully insured commercial plans plus 90 days after the date of loss to give proof.

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

Disputed Claim Steps

1. Ask us in writing to reconsider our initial decision. You must submit a formal written statement to our Grievance and Appeals Department at: PO Box 14638 Lexington, KY 40512-4638 within one (1) year from occurrence of the events upon which the grievance is based, and must contain a statement of the action requested, your name, address, telephone number, Member number, signature and the date.

2. We have 60 days from the date we received your request to render a decision to either pay or deny the claim and communicate such decision back to you. However, if the grievance involves collection of information from outside our service area, an additional thirty (30) days will be allowed for processing.

3. If the dispute is not resolved through the reconsideration process, you may request a review of the denial. You must request reconsideration by the Grievance Panel within sixty (60) days after receipt of the initial grievance written decision by submitting a written request to the our Grievance and Appeals Department at: PO Box 14638 Lexington, KY 40512-4638.

4. If you do not agree with our final decision, you may request an independent third party, mutually agreed upon by us and OPM, review the decision. The decision of the independent third party is binding and is the final review of your claim. To request a third-party review, you must submit a written request to our Grievance and Appeals Department at: PO Box 14638 Lexington, KY 40512-4638.

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.

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

Note: Coinsurance only applies to the High PPO option.

Co-pay or co-payment is a fixed amount of money you pay directly to the dentist when you receive covered services.

Note: Co-pay only applies to the Standard Advantage EPO option.

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

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

The amount we use to determine our payment for services.

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.

Humana Dental Company.

Class A (Basic) Services – preventive and diagnostic

0%, no deductible                                    

Class B (Intermediate) Services – includes minor restorative services

20%, after deductible                              

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

50%, after deductible                              

Class D Services – orthodontic

Note: Up to $2,500 lifetime orthodontic maximum

50%, no deductible

Class A (Basic) Services – preventive and diagnostic

Class D Services – orthodontic