Benefit

D7252 Partial extraction for immediate implant placement

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

D6193 Replacement of an implant screw

D8091 Comprehensive orthodontic treatment with orthognathic surgery

D8671 Periodic orthodontic treatment visit associated with orthognathic surgery

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

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

If you sign up for a dental and/or vision plan during the 2024 Open Season, your coverage will begin on January 1, 2025.  Premium deductions will start with the first full pay period beginning on/after January 1, 2025.  You 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 11, 2024, through midnight EST December 9, 2024.  You do not need to re-enroll each open season, unless you wish to change plans or plan options; your coverage will continue from the previous year.  In addition to the annual open season, there are certain events that allow you to make specific types of enrollment changes throughout the year.  Please see Section 2, Enrollment, for more information.

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

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

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

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

You are eligible to enroll if you:

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

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

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

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/PSHB rules for family member eligibility are NOT the same.  For more information on family member eligibility visit the website at www.opm.gov/healthcare-insurance/dental-vision/ or contact your employing agency or retirement system.

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

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

• Deferred annuitants
• Former spouses of employees or annuitants.  Note:  Former spouses of TRICARE-eligible individuals may enroll in a FEDVIP vision plan.
• FEHB/PSHB Temporary Continuation of Coverage (TCC) 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.gov) sponsored by OPM.  If you do not have access to a computer, call 1-877-888-FEDS (1-877-888-3337), to enroll or change your enrollment. 

Hearing and Speech impaired individuals may communicate using a text telephone device and Relay Services by dialing the MetLife Federal Dental number of “888-865-6854”. Relay services is immediate assistance. The Message Relay Service enables customers who are deaf, hard of hearing, or speech impaired, and who use a Teletypewriter (TTY), to communicate with others via the telephone. You simply type your conversation to a Relay Agent who then reads the typed conversation to the other party. The text telephone is used through a caller's wireless provider as long as they have a TTY compatible phone.

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

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

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

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

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.

Open Season

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

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

New hire/Newly eligible

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

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

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

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

The following chart lists the QLE’s 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

Opportunities to Enroll or Change Enrollment  

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 11, 2024 through midnight EST December 9, 2024, Open Season. Coverage is effective January 1, 2025. 

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

New hire/Newly eligible 

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

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

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

Qualifying Life Event 

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

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

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.

Note: Coverage ends for a covered individual when MetLife does not receive premium payment for that covered individual.

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

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

However, we will pay benefits for a 31 day period after your insurance ends if before coverage ends the dentist:

• prepared the abutment teeth for the completion of installation of prosthetic devices; 
• made an impression;
• prepared the tooth for cast restoration; or
• your dentist opened the pulp chamber before your insurance ends and the device is installed or treatment was finished within 31 days after the termination of coverage.

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

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

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

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

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

When you enroll for the first time, you will receive a welcome letter along with an identification card ("ID Card"). It is important to bring your FEDVIP and FEHB/PSHB ID card to every dental appointment because most FEHB/PSHB 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 require a replacement ID card, you will be able to view and print your ID card via MyBenefits after entering www.MetLife.com/FEDVIP-Dental.  An ID card is neither a guarantee of benefits nor does your provider need it to render dental services. Your dentist may call (877) 638-3379 to confirm your enrollment in the Plan and the benefits available to you.

If you were enrolled in the MetLife Federal Dental Plan in 2024 and continue coverage for 2025, MetLife will provide you with a confirmation letter only.  

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

We list our Plan providers on our website at: www.MetLife.com/FEDVIP-Dental which we update weekly. When you make your appointment please inform the dental office you are enrolled in the FEDVIP plan and that you wish to use your In-Network benefits. This will also serve to confirm that the dentist is a MetLife provider. You may also contact customer service at (888) 865-6854.

Care that you receive from a MetLife Preferred Dentist Program (PPO) provider is considered In-Network. Plan participants are not required to select a primary care dentist and are free to select the dentist of their choice. MetLife’s PPO network consists of independently credentialed and contracted providers. To find a dentist in your area go to: www.MetLife.com/FEDVIP-Dental. You may also contact customer service at (888) 865-6854.

Care that you receive from a licensed provider that does not participate in the MetLife Preferred Dentist Program (PPO) is considered Out-of-Network. You are responsible for any difference between the plan payment and the amount billed.

The plan allowance is the maximum amount we will consider for payment for a specific procedure. The actual benefit will be a specified percentage of the plan allowance. When you use a participating (in-network) provider, your out-of-pocket cost is limited to the difference between the plan allowance and our payment. When you use services provided by a provider that does not participate in our network of providers, they are considered out-of-network services.

The Plan Allowance for Out-of-Network services will be equal to the In-Network Plan Allowance for the covered service (see page 59 for further details). 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. Out-of-Network providers may charge their normal fees which may be greater than the Plan Allowance.

The Plan Allowance may very by geographic location and/or a participating provider's contracted fee schedule.

A pre-treatment estimate of benefits is recommended for any procedure which is anticipated to cost at least $300 or which involves mandatory consultant review. Mandatory consultant review applies to services such as but not limited to, periodontal services, crowns, bridges, inlays/onlays (when performed together) veneers, implants (when a plan provides benefits for these procedures) and overdentures, among other services. When your dentist suggests treatment, have them send a claim form, along with the proposed treatment plan and supporting documentation to MetLife. An explanation of benefits (EOB) will be sent to you and the dentist detailing an estimate of what services MetLife will cover and at what payment level. Actual payments may vary from the pre-treatment estimate depending upon annual maximums, deductibles, plan frequency limits and other plan provisions at time of payment.

Alternate benefits applicable to your treatment plan will be determined during Pre-certification. However, should the services billed differ from those pre-certified, MetLife reserves the right to determine if an Alternate Benefit is applicable to the actual services rendered.

If MetLife determines that a less costly covered service other than the covered service the dentist performed could have been performed to treat a dental condition we will pay benefits based upon the less costly service if such service would produce a professionally acceptable result under generally accepted dental standards

For example, when an amalgam filling and a composite filling are both professionally acceptable methods for filling a molar, or when a partial denture and fixed bridgework are both professionally acceptable methods for replacing multiple missing teeth in an arch we may base our benefit determination upon the amalgam filling or partial denture which is the less costly service.

MetLife's claim review is conducted by licensed dentist consultants who review the clinical documentation submitted by your treating dentist.  These dentist consultants review this material checking for dental necessity for certain procedures such as crowns, bridges, onlays, implants, periodontal treatments, as well as other services. The dentist consultants may also recommend that an alternate benefit be applied to a service in accordance with the terms of the plan. Therefore, we strongly recommend that you or your dentist request a pre-treatment estimate for services that are expected to cost at least $300, so that, you and your dentist are aware of the coverage terms and benefits before services are performed.

If you have dental coverage through your FEHB/PSHB plan and coverage under FEDVIP, your FEHB/PSHB plan will be the first payor of any benefit payments.  When services are rendered by a provider, who participates with both your FEHB/PSHB and your FEDVIP plan, the FEDVIP Plan Allowance will prevail. We are responsible for facilitating the process with the primary FEHB/PSHB payor. You are responsible for the difference if any between the FEHB/PSHB and FEDVIP benefit payments and the FEDVIP Plan Allowance subject to any deductibles and benefits maximums. See examples 1 and 2 below. 

It is important to bring your FEDVIP and FEHB/PSHB identification cards to every dental appointment because most FEHB/PSHB 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.

When the covered individual has FEHB/PSHB coverage that offers dental benefits, FEHB/PSHB is always First Payor.

Services are provided by an In-Network Provider

Provider submitted charge for a one surface amalgam filling*: $108.00
In-Network fee: $60.00
FEHB/PSHB paid as first-payor (or MetLife's estimate): $16.00
MetLife benefits payable in the absence of FEHB/PSHB coverage: $42.00 ($60.00 at 70%).
Payment by MetLife: $42.00

Patient's responsibility to the provider: $2.00 ($60.00-$16.00-$42.00=$2.00).

*This example assumes all deductibles have been met and annual maximums have not been reached.

When the covered individual has FEHB/PSHB coverage that offers dental benefits, FEHB/PSHB is always First Payor.

Services are provided by an Out-of-Network Provider

Provider submitted charge for one surface amalgam filling*: $108.00
Plan Allowance**: $90.00
FEHB/PSHB payment as first payor (or MetLife's estimate): $16.00
MetLife benefits payable in the absence of FEHB/PSHB coverage: $54.00 ($90.00 x 60%).
Payment by MetLife**: $54.00

Patient's responsibility to the provider**: $38.00 ($108.00-$16.00-$54.00=$38.00)

*This example assumes all deductibles have been met and annual maximums have not been reached.

**Assumes the provider charge is higher than MetLife's plan allowance. The plan allowance may vary by geographic location and/or a participating provider's contracted fee schedule. 

If you are covered under a non-FEHB/non-PSHB plan, your MetLife Federal Dental benefits will be coordinated using traditional COB provisions for determining payment. Please see examples 1 and 2 below.

When benefits are coordinated between MetLife and a non-FEHB/non-PSHB carrier, the maximum allowable charge may vary depending upon the contractual relationship and contracted fee between MetLife and non-FEHB/non-PSHB carrier. The participant may be responsible for the difference between the combined non-FEHB/non-PSHB and MetLife benefit payment and the providers’ allowable charge.

When MetLife is secondary to a non-FEHB/non-PSHB dental carrier.

Services are provided by an In-Network Provider

Provider submitted charge for two surface amalgam filling: $121.00
In-Network Fee: $73.00
Payable by Primary Carrier: $60.50
MetLife benefits payable in the absences of other insurance*: $51.10 ($73.00 at 70%)
Payment by MetLife: $12.50
Patient’s responsibility to the provider **: $0 ($73.00 - $60.50 - $12.50 = $0.00)

*This example assumes all deductibles have been met and annual maximums have not been reached.

** Assumes the provider has no other contractual relationship regarding negotiated fees with the primary carrier.

When MetLife is secondary to a non-FEHB/non-PSHB carrier

Services are provided by an Out-of-Network Provider

Provider submitted charge for 2 surface amalgam fillings: $113.00
Plan Allowance** $113.00: 
Payment of Primary Carrier: $96.80
MetLife benefits payable in the absence of other insurance*: $67.80 ($113.00 x 60%)
Payment by MetLife: $16.20
Patient’s responsibility to the provider **: $0 ($113.00 - $96.80 - $16.20 = $0)

*This example assumes all deductibles have been met and annual maximums have not been reached.

**Assumes the provider charge is within MetLife’s plan allowance. The plan allowance may vary be geographic location and/or a participating provider's contracted fee schedule. 

If the amount we pay is more than we should have paid under the First Payor provision or when benefits are coordinated we may recover the excess from one or more of:

• the person we have paid;
• insurance companies; or
• other organizations.

The amount of the payment includes the reasonable cash value of any benefits provided in the form of services. However, in no circumstance will the member be responsible for a greater out of pocket amount then they would have been responsible for had there been no overpayment.

If you live in a limited access area and you receive covered services from an Out-of- Network provider, we will pay benefits based on our In-Network Plan Allowances.  The determination of network adequacy is based on a ratio of Federal eligibles to network and general dentistry providers in a particular area.  To determine if you are in a limited access area or specialty services are needed, please contact MetLife at (888) 865-6854*. MetLife reviews the limited access areas quarterly to ensure you have adequate access to our general dentistry In-Network providers.  Therefore, we recommend you call (888) 865-6854 to confirm if you are still in a limited access area as your claim payment may be impacted.  The limited access rule applies to general dentistry providers and specialty services.  If the services must be provided by a specialist and one is not available in your area, please call us for assistance.  If an In-Network provider (general or specialist) can perform a specialty service, then that service will be covered at the In-Network benefit. Please contact MetLife at (888) 865-6854 or visit our website at MetLife.com/FEDVIP-Dental to obtain a list of In-Network general dentists in your area, who may be able to perform specialty services.

*Hearing and Speech impaired individuals may communicate using a text telephone device and Relay Services by dialing the MetLife Federal Dental number of “888-865-6854”. Relay Services is immediate assistance. The Message Relay Service enables customers who are deaf, hard of hearing, or speech impaired, and who use a Teletypewriter (TTY), to communicate with others via the telephone. You simply type your conversation to a Relay Agent who then reads the typed conversation to the other party. The text telephone is used through a callers wireless provider as long as they have a TTY compatible phone.

Should you experience a lapse in coverage during the calendar year, any benefits paid after reinstatement will be accrued to the maximums applicable to that same calendar year.

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

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

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

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

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

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

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

Class B
In-Network High Option: 30%
In-Network Standard Option: 45%
Out-of-Network High Option: 40%
Out-of-Network Standard Option: 60%

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

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

Once you reach this amount, you are responsible for all additional charges. The Annual Benefit Maximums within each option are combined between In and Out-of-Network services. The total Annual Benefit Maximum will never be greater than the In-Network Annual Benefit Maximum.

Annual Benefits Maximum
In-Network High Option: Unlimited
In-Network Standard Option: $2,000
Out-of-Network High Option: Unlimited
Out-of-Network Standard Option: $2,000

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

Lifetime Orthodontia Maximum
In-Network High Option: $3,500 (child)/ $3,000 (adult)
In-Network Standard Option: $1,500
Out-of-Network High Option: $3,500 (child)/ $3,000 (adult)
Out-of-Network Standard Option: $1,500

Care that you receive from a MetLife Preferred Dentist Program (PPO) provider is considered In-Network. Plan participants are not required to select a primary care dentist and are free to select the dentist of their choice. No referral process is needed for access to specialty care.  In most cases, use of In-Network providers results in a lower out-of-pocket expense to you. 

If you reside in a limited access area your benefits will be paid at the In-Network benefit level. For additional information on limited access areas, please see Section 3, How You Obtain Care.

Remember, for In-Network services you only pay the difference between the Plan Allowance for the covered service and the plan's benefit payment subject to any deductibles and benefits maximums.

All services rendered by an Out-of-Network dentist will be paid as Out-of-Network benefits. except for limited access benefits.

The plan allowance for Out-of-Network services will be equal to the In-Network Plan Allowance for the covered service. The Out-of-Network Plan Allowance may vary be geographic location and/or a participating provider's contracted fee schedule.

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.

The calendar year refers to the plan year, which is defined as January 1, 2025, to December 31, 2025.

If orthodontia services are initiated prior to the effective date of coverage, we will prorate benefits. Twenty-five percent (25%) of the Plan Allowance is considered as the fee for initial placement of the appliance. Because this occurred prior to the effective date of coverage, it is considered a non- covered expense. The balance of the Plan Allowance, 75%, will be divided by the total number of monthly visits provided in the orthodontist's treatment plan. Benefits are payable at 50% of the Plan Allowance.

Actual Fee: $6,400

Treatment Plan: 24 visits
Number of monthly visits (not covered): 14, Provided prior to being eligible for orthodontia benefits.
Number of monthly visits (covered): 10, 24 total visits minus 14 provided prior to being eligible for orthodontia benefits.
Plan Allowance for initial placement: $1,600, $6,400 x 25% = $1,600 (This is a non-covered expense as it occurred prior to being eligible for orthodontia benefits
Plan Allowance for monthly visits: $4,800, $6,400 - $1,600 = $4,800
Plan Allowance per visit: $200, $4,800 divided by 24
Total Plan Allowance for covered visits: $2,000, $200 times 10 covered visits
Total plan payment: $1,000, Benefit is 50% of Plan Allowance for covered services

Actual Fee: $6,400

Treatment Plan: 24 visits
Number of monthly visits (not covered): 14, Provided prior to being eligible for orthodontia benefits.
Number of monthly visits (covered): 10, 24 total visits minus 14 provided prior to being eligible for orthodontia benefits.
Plan Allowance for initial placement: $1,600, $6,400 x 25% = $1,600. (This is a non-covered expense as it occurred prior to being eligible for orthodontia benefits)
Plan Allowance for monthly visits: $4,800, $6,400 - $1,600 = $4,800
Plan Allowance per visit: $200, $4,800 divided by 24
Total Plan Allowance for covered visits: $2,000, $200 x 10 covered visits
Total Plan Payment: $1,000, Benefit is 50% of Plan Allowance for covered orthodontia services

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

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

D0120 Periodic oral evaluation - established patient - Limited to 1 every 6 months

D0140 Limited oral evaluation - problem focused - Limited to 1 every 6 months

D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver

D0150 Comprehensive oral evaluation - new or established patient - Limited to 1 every 6 months

D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) 

D0180 Comprehensive periodontal evaluation - new or established patient - Limited to 1 every 6 months

D0210 Intraoral – comprehensive series of radiographic images - Limited to 1 every 60 (sixty) months

D0220 Intraoral - periapical first radiographic image

D0230 Intraoral - periapical each additional radiographic image

D0240 Intraoral - occlusal radiographic image

D0270 Bitewing - single radiographic image - Adult - 1 set every calendar year/Children - 1 set every 6 months              

D0272 Bitewings - two radiographic images - Adult - 1 set every calendar year/Children - 1 set every 6 months 

D0273 Bitewings - three radiographic images

D0274 Bitewings - four radiographic images - Adult - 1 set every calendar year/Children - 1 set every 6 months 

D0277 Vertical bitewings - 7 to 8 radiographic images – Adult - 1 set every calendar year/Children - 1 set every 6 months 

D0330 Panoramic radiographic image – Limited to 1 image every 60 (sixty) months

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

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

D0372 Intraoral tomosynthesis – comprehensive series of radiographic images - Limited to 1 every 60 (sixty) months

D0373 Intraoral tomosynthesis- bitewing radiographic image - Limited to 1 set every 6 months

D0374 Intraoral tomosynthesis – periapical radiographic image

D0396 3D printing of a 3D dental surface scan

D0415 Collection of microorganisms for culture and sensitivity 

D0422 Collection and preparation of genetic sample material for laboratory analysis and report - Limited to 1 per lifetime

D0423 Genetic test for susceptibility to diseases – specimen analysis - Limited to 1 per lifetime.

D0470 Diagnostic casts

D1110 Prophylaxis – adult - Limited to 1 every 6 months

D1120 Prophylaxis – child - Limited to 1 every 6 months

D1206 Topical application of fluoride varnish - Limited to 1 in 12 months for adults, 2 every 12 months for dependent children based on age limits.

D1208 Topical application of fluoride – excluding varnish - Limited to 2 every 12 months for dependent children based on age limits.

D1351 Sealant - per tooth - Limited to unrestored permanent molars - Less than age 19. 1 sealant per tooth every 36 months

D1352 Preventive resin restoration in a moderate to high caries risk patient – permanent tooth - Limited to 1 sealant per tooth every 36 months.

D1353 Sealant repair –per tooth - Limited to permanent teeth, 1 every 36 months

D1354 Application of caries arresting medicament – per tooth - Limited to permanent teeth 1 per tooth every 36 months (Molars/Bicuspids excluding Wisdom Teeth).

D1355 Caries preventive medicament application – per tooth - Limited to 1 every 36 months

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.

D1517 Space maintainer - fixed - bilateral, mandibular - Limited to children under age 19.

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

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

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

D1575 Distal shoe space maintainer - fixed, unilateral - per quadrant

D1999 Unspecified preventive procedure, by report 

D9110 Palliative treatment of dental pain – per visit

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

D9311 Consultation with a medical health care professional

D9440 Office visit - after regularly scheduled hours

D0320 Temporomandibular joint arthrogram, including injection

D0321 Other temporomandibular joint radiographic images, by report

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

D0388 Intraoral tomosynthesis – bitewing radiographic image – image capture only

D0389 Intraoral tomosynthesis – periapical radiographic image – image capture only

D0414 Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation and transmission of written report

D0418 Analysis of saliva sample

D0419 Assessment of salivary flow by measurement

D0425 Caries susceptibility tests

D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures   

D0475 Decalcification procedure

D0477 Special stains, not for microorganisms

D0479 Tissue in-situ hybridization, including interpretation

D0483 Indirect immunofluorescence

D0485 Consultation, including preparation of slides from biopsy material supplied by referring source

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

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

D0604 Antigen testing for a public health related pathogen, including coronavirus 

D0605 Antibody testing for a public health related pathogen, including coronavirus

D0606 Molecular testing for a public health related pathogen, including coronavirus

D0701 Panoramic radiographic image – image capture only

D0702 2-D cephalometric radiographic image – image capture only

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

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

D0706 Intraoral – occlusal radiographic image – image capture only

D0707 Intraoral – periapical radiographic image – image capture only

D0708 Intraoral – bitewing radiographic image – image capture only

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

D0801 3D intraoral surface scan – direct

D0802 3D dental surface scan – indirect

D0803 3D facial surface scan – direct

D0804 3D facial surface scan – indirect

D1301 Immunization counseling

D1310 Nutritional counseling for control of dental disease

D1320 Tobacco counseling for the control and prevention of oral disease

D1321 Counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use

D1330 Oral hygiene instructions

D1556 Removal of fixed unilateral space maintainer - per quadrant

D1557 Removal of fixed bilateral space maintainer - maxillary

D1558 Removal of fixed bilateral space maintainer - mandibular

D1701 Pfizer-BioNTech Covid-19 vaccine administration – first dose

D1702 Pfizer-BioNTech Covid-19 vaccine administration – second dose

D1703 Moderna Covid-19 vaccine administration – first dose

D1704 Moderna Covid-19 vaccine administration – second dose

D1705 AstraZeneca Covid-19 vaccine administration – first dose

D1706 AstraZeneca Covid-19 vaccine administration – second dose

D1707 Janssen Covid-19 vaccine administration

D1708 Pfizer-BioNTech Covid-19 vaccine administration – third dose

D1709 Pfizer-BioNTech Covid-19 vaccine administration – booster dose

D1710 Moderna Covid-19 vaccine administration – third dose

D1711 Moderna Covid-19 vaccine administration – booster dose

D1712 Janssen Covid-19 vaccine administration - booster dose

D1713 Pfizer-BioNTech Covid-19 vaccine administration tris-sucrose pediatric – first dose

D1714 Pfizer-BioNTech Covid-19 vaccine administration tris-sucrose pediatric – second dose

D1781 Vaccine administration – human papillomavirus – Dose 1

D1782 Vaccine administration – human papillomavirus – Dose 2

D1783 Vaccine administration – human papillomavirus – Dose 3

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

D2140 Amalgam - one surface, primary or permanent

D2150 Amalgam - two surfaces, primary or permanent

D2160 Amalgam - three surfaces, primary or permanent

D2161 Amalgam - four or more surfaces, primary or permanent

D2330 Resin–based composite - one surface, anterior 

D2331 Resin-based composite - two surfaces, anterior 

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

D2390 Resin-based composite crown, anterior - Limited to 1 every 60 months

D2391 Resin-based composite - one surface, posterior

D2392 Resin-based composite - two surfaces, posterior

D2393 Resin-based composite - three surfaces, posterior

D2394 Resin-based composite - four or more surfaces, posterior

D2610 Inlay - porcelain/ceramic - one surface - Limited to 1 every 60 months

D2620 Inlay - porcelain/ceramic - two surfaces - Limited to 1 every 60 months

D2630 Inlay - porcelain/ceramic - three or more surfaces - Limited to 1 every 60 months

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

D2921 Reattachment of tooth fragment, incisal edge or cusp

D2929 Prefabricated porcelain/ceramic crown – primary tooth - Limited to 1 every 60 months

D2930 Prefabricated stainless steel crown - primary tooth – Under age 15 - Limited to 1 per tooth in 60 months

D2931 Prefabricated stainless steel crown - permanent tooth - Under age 15 - Limited to 1 per tooth in 60 months

D2940 Placement of interim direct restoration

D2951 Pin retention - per tooth, in addition to restoration

D2976 Band stabilization – per tooth - Limited to 1 every 60 months

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

D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament -  If a root canal is within 45 days of the pulpotomy, the pulpotomy is not a covered service since it is considered a part of the root canal procedure and benefits are not payable separately.

D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development - If a root canal is within 45 days of the pulpotomy, the pulpotomy is not a covered service since it is considered a part of the root canal procedure and benefits are not payable separately.

D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) - Limited to primary incisor teeth for members up to age 6 and for primary molars and cuspids up to age 11 and is limited to once per tooth per lifetime.

D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) - Limited to primary incisor teeth for members up to age 6 and for primary molars and cuspids up to age 11 and is limited to once per tooth per lifetime.

D3355 Pulpal regeneration – initial visit - Limited to 1 per lifetime.

D3356 Pulpal regeneration – interim medication replacement - Limited to 1 per lifetime.

D3357 Pulpal regeneration – completion of treatment - Limited to 1 per lifetime

D4341 Periodontal scaling and root planing - four or more teeth per quadrant – Limited to 1 every 24 months

D4342 Periodontal scaling and root planing - one to three teeth per quadrant – Limited to 1 every 24 months.

D4346 Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation - Limited to 1 every 6 months combined with prophylaxis and periodontal maintenance.

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

D4910 Periodontal maintenance – Limited to 4 in 12 months combined with adult prophylaxis after the completion of active periodontal therapy

D5410 Adjust complete denture – maxillary

D5411 Adjust complete denture – mandibular

D5421 Adjust partial denture – maxillary

D5422 Adjust partial denture - mandibular

D5511 Repair broken complete denture base, mandibular

D5512 Repair broken complete denture base, maxillary

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

D5611 Repair resin partial denture base, mandibular

D5612 Repair resin partial denture base, maxillary

D5621 Repair cast partial framework, mandibular

D5622 Repair cast partial framework, maxillary

D5630 Repair or replace broken retentive clasping materials – per tooth

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

D5650 Add tooth to existing partial denture – per tooth

D5660 Add clasp to existing partial denture - per tooth

D5710 Rebase complete maxillary denture - Limited to 1 in a 36-month period 6 months after the initial installation

D5720 Rebase maxillary partial denture - Limited to 1 in a 36-month period 6 months after the initial installation

D5721 Rebase mandibular partial denture - Limited to 1 in a 36-month period 6 months after the initial installation

D5725 Rebase hybrid prosthesis - Limited to a 1 in a 36-month period 6 months after the initial installation

D5730 Reline complete maxillary denture (direct) - Limited to 1 in a 36-month period 6 months after the initial installation

D5731 Reline complete mandibular denture (direct) - Limited to 1 in a 36-month period 6 months after the initial installation

D5740 Reline maxillary partial denture (direct) - Limited to 1 in a 36-month period 6 months after the initial installation

D5741 Reline mandibular partial denture (direct) - Limited to 1 in a 36-month period 6 months after the initial installation

D5750 Reline complete maxillary denture (indirect) - Limited to 1 in a 36-month period 6 months after the initial installation

D5751 Reline complete mandibular denture (indirect) - Limited to 1 in a 36-month period 6 months after the initial installation

D5760 Reline maxillary partial denture (indirect) - Limited to 1 in a 36-month period 6 months after the initial installation

D5761 Reline mandibular partial denture (indirect) - Limited to 1 in a 36-month period 6 months after the initial installation.

D5765 Soft liner for complete or partial removable denture – indirect - Limited to a 1 in 36-month period 6 months after the initial installation

D5850 Tissue conditioning, maxillary

D5851 Tissue conditioning, mandibular

D6930 Re-cement or re-bond fixed partial denture

D6980 Fixed partial denture repair necessitated by restorative material failure

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

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

D7220 Removal of impacted tooth - soft tissue

D7230 Removal of impacted tooth – partially bony

D7240 Removal of impacted tooth - completely bony

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

D7250 Removal of residual tooth roots (cutting procedure)

D7251 Coronectomy – intentional partial tooth removal, impacted teeth only

D7252 Partial extraction for immediate implant placement

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

D7280 Exposure of an unerupted tooth

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

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

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

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

D7471 Removal of lateral exostosis (maxilla or mandible)

D7510 Incision and drainage of abscess - intraoral soft tissue

D7910 Suture of recent small wounds up to 5 cm

D7921 Collection and application of autologous blood concentrate product - Limited to 1 every 36 months.

D7953 Bone replacement graft for ridge preservation - per site

D7961 Buccal / labial frenectomy (frenulectomy)

D7962 Lingual frenectomy (frenulectomy)

D7971 Excision of pericoronal gingiva

D7999 Unspecified oral surgery procedure, by report

D9230 Inhalation of nitrous oxide/analgesia, anxiolysis - Limited to when medically or dentally necessary 

D7292 Placement of temporary anchorage device [screw retained plate] requiring flap 

D7293 Placement of temporary anchorage device requiring flap

D7294 Placement of temporary anchorage device without flap

D7298 Removal of temporary anchorage device [screw retained plate], requiring flap

D7299 Removal of temporary anchorage device, requiring flap

D7300 Removal of temporary anchorage device without flap

D7880 Occlusal orthotic device, by report

D7881 Occlusal orthotic device adjustment

D7899 Unspecified TMD therapy, by report

D7922 Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site

D7951 Sinus augmentation with bone or bone substitutes via a lateral open approach

D7952 Sinus augmentation via a vertical approach

D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar

D7998 Intraoral placement of a fixation device not in conjunction with a fracture

D0160 Detailed and extensive oral evaluation - problem focused, by report

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

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

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

D2542 Onlay - metallic - two surfaces – Limited to 1 per tooth every 60 months

D2543 Onlay - metallic - three surfaces – Limited to 1 per tooth every 60 months

D2544 Onlay - metallic - four or more surfaces – Limited to 1 per tooth every 60 months

D2740 Crown - porcelain/ceramic - Limited to 1 per tooth every 60 months

D2750 Crown - porcelain fused to high noble metal - Limited to 1 per tooth every 60 months

D2751 Crown - porcelain fused to predominantly base metal – Limited to 1 per tooth every 60 months

D2752 Crown - porcelain fused to noble metal – Limited to 1 per tooth every 60 months

D2753 Crown - porcelain fused to titanium and titanium alloys - Limited to 1 per tooth every 60 months.

D2780 Crown - 3/4 cast high noble metal – Limited to 1 per tooth every 60 months

D2781 Crown - 3/4 cast predominantly base metal – Limited to 1 per tooth every 60 months

D2783 Crown - 3/4 porcelain/ceramic – Limited to 1 per tooth every 60 months

D2790 Crown - full cast high noble metal – Limited to 1 per tooth every 60 months

D2791 Crown - full cast predominantly base metal – Limited to 1 per tooth every 60 months

D2792 Crown - full cast noble metal – Limited to 1 per tooth every 60 months

D2794 Crown - titanium and titanium alloys – Limited to 1 per tooth every 60 months

D2928 Prefabricated porcelain/ceramic crown – permanent tooth - Limited to 1 per tooth every 60 months

D2932 Prefabricated resin crown - Limited to 1 per tooth every 60 months.

D2950 Core buildup, including any pins when required – Limited to 1 per tooth every 60 months

D2952 Post and core in addition to crown, indirectly fabricated - Limited to 1 per tooth every 60 months.

D2954 Prefabricated post and core in addition to crown – Limited to 1 per tooth every 60 months

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

D2990 Resin infiltration of incipient smooth surface lesions - Limited to 1 in 36 months

D2991 Application of hydroxyapatite regeneration medicament – per tooth – Limited to 1 in 36 months

D2999 Unspecified restorative procedure, by report 

D3310 Endodontic therapy, anterior tooth (excluding final restoration)

D3320 Endodontic therapy, premolar tooth (excluding final restoration)

D3330 Endodontic therapy, molar tooth (excluding final restoration)

D3346 Retreatment of previous root canal therapy - anterior

D3347 Retreatment of previous root canal therapy - premolar

D3348 Retreatment of previous root canal therapy - molar

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

D3352 Apexification/recalcification – interim medication replacement 

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

D3410 Apicoectomy - anterior

D3421 Apicoectomy - premolar (first root)

D3425 Apicoectomy - molar (first root)

D3426 Apicoectomy (each additional root)

D3450 Root amputation - per root

D3471 Surgical repair of root resorption - anterior

D3472 Surgical repair of root resorption – premolar

D3473 Surgical repair of root resorption – molar

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

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

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

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

D3921 Decoronation or submergence of an erupted tooth 

D3999 Unspecified endodontic procedure, by report

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

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

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

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

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

D4249 Clinical crown lengthening - hard tissue

D4260 Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant – Limited to 1 every 36 months

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

D4263 Bone replacement graft – retained natural tooth – first site in quadrant - Limited to 1 every 36 months

D4270 Pedicle soft tissue graft procedure

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

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

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

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

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

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 1 every 36 months

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 to 1 every 60 months

D5120 Complete denture - mandibular – Limited to 1 every 60 months

D5130 Immediate denture - maxillary – Limited to 1 every 60 months

D5140 Immediate denture - mandibular – Limited to 1 every 60 months

D5211 Maxillary partial denture – resin base (including, retentive/clasping materials, rests, and teeth) – Limited to 1 every 60 months

D5212 Mandibular partial denture – resin base (including, retentive/clasping materials, rests, and teeth) – Limited to 1 every 60 months

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

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

D5221 Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) - Limited to 1 every 60 months.

D5222 Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) - Limited to 1 every 60 months.

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

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

D5227 Immediate maxillary partial denture - flexible base (including any clasps, rests and teeth) - Limited to 1 every 60 months

D5228 Immediate mandibular partial denture - flexible base (including any clasps, rests and teeth) - Limited to 1 every 60 months

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

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

D5284 Removable unilateral partial denture – one piece flexible base (including retentive/clasping materials, rests, and teeth) – per quadrant - Limited to 1 every 60 months.

D5286 Removable unilateral partial denture – one piece resin (including retentive/clasping materials, rests, and teeth) – per quadrant - Limited to 1 every 60 months.

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

D5899 Unspecified removable prosthodontic procedure, by report

D6010 Surgical placement of implant body: endosteal implant - Limited to 1 every 60 months

D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant - Limited to 1 every 60 months

D6040 Surgical placement: eposteal implant – Limited to 1 every 60 months

D6050 Surgical placement: transosteal implant – Limited to 1 every 60 months

D6055 Connecting bar – implant supported or abutment supported - Limited to 1 every 60 months

D6056 Prefabricated abutment – includes modification and placement – Limited to 1 every 60 months

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

D6058 Abutment supported porcelain/ceramic crown - Limited to 1 every 60 months

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

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

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

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

D6063 Abutment supported cast metal crown (predominantly base metal) - Limited to 1 every 60 months

D6064 Abutment supported cast metal crown (noble metal) - Limited to 1 every 60 months

D6065 Implant supported porcelain/ceramic crown - Limited to 1 every 60 months

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

D6067 Implant supported crown - high noble alloys - Limited to 1 every 60 months

D6068 Abutment supported retainer for porcelain/ceramic FPD - Limited to 1 every 60 months

D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) - Limited to 1 every 60 months

D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) - Limited to 1 every 60 months

D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) - Limited to 1 every 60 months

D6072 Abutment supported retainer for cast metal FPD (high noble metal) - Limited to 1 every 60 months

D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) - Limited to 1 every 60 months

D6074 Abutment supported retainer for cast metal FPD (noble metal) - Limited to 1 every 60 months

D6075 Implant supported retainer for ceramic FPD - Limited to 1 every 60 months

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

D6077 Implant supported retainer for metal FPD - high noble alloys - Limited to 1 every 60 months

D6080 Implant maintenance procedures when a full arch fixed hybrid prosthesis is removed and reinserted, including cleansing of prosthesis and abutments - Limited to 1 every 60 months

D6081 Scaling and debridement of a single implant in the presence of mucositis, including inflammation, bleeding upon probing and increased pocket depths; includes cleaning of the implant surfaces, without flap entry and closure - Limited to 1 every 60 months

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

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

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

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

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

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

D6089 Accessing and retorquing loose implant screw – per screw

D6090 Repair of implant/abutment supported prosthesis - Limited to 1 every 60 months

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

D6096 Remove broken implant retaining screw - Limited to 1 every 12 months

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

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

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

D6100 Surgical removal of implant body - Limited to 1 every 60 months

D6101 Debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure - Limited to 1 every 60 months

D6102 Debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant and includes surface cleaning of the exposed implant surfaces, including flap entry and closure - Limited to 1 every 60 months

D6103 Bone graft for repair of peri-implant defect – does not include flap entry and closure

D6104 Bone graft at time of implant placement

D6105 Removal of implant body not requiring bone removal or flap elevation - Limited to 1 every 60 months

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

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

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

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

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

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

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

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

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

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

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

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

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

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

D6180 Implant maintenance procedures when a full arch fixed hybrid prosthesis is not removed, including cleansing of prosthesis and abutments - Limited to 1 every 60 months 

D6190 Radiographic/surgical implant index, by report - Limited to 1 every 60 months

D6191 Semi-precision abutment – placement - Limited to 1 every 60 months

D6192 Semi-precision attachment – placement - Limited to 1 every 60 months

D6193 Replacement of an implant screw - Limited to 1 every 12 months

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

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

D6210 Pontic - cast high noble metal – Limited to 1 every 60 months

D6211 Pontic - cast predominantly base metal – Limited to 1 every 60 months

D6212 Pontic - cast noble metal – Limited to 1 every 60 months

D6214 Pontic - titanium and titanium alloys – Limited to 1 every 60 months

D6240 Pontic - porcelain fused to high noble metal – Limited to 1 every 60 months

D6241 Pontic - porcelain fused to predominantly base metal – Limited to 1 every 60 months

D6242 Pontic - porcelain fused to noble metal – Limited to 1 every 60 months

D6243 Pontic – porcelain fused to titanium and titanium alloys - Limited to 1 every 60 months

D6245 Pontic - porcelain/ceramic – Limited to 1 every 60 months

D6545 Retainer - cast metal for resin bonded fixed prosthesis - Limited to 1 every 60 months

D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis - Limited to 1 every 60 months

D6549 Retainer – resin bonded fixed prosthesis - Limited to 1 every 60 months

D6740 Retainer crown - porcelain/ceramic - Limited to 1 every 60 months

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

D6751 Retainer crown - porcelain fused to predominantly base metal - Limited to 1 every 60 months

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

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

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

D6781 Retainer crown - 3/4 cast predominantly base metal - Limited to 1 every 60 months

D6782 Retainer crown - 3/4 cast noble metal - Limited to 1 every 60 months

D6783 Retainer crown - 3/4 porcelain/ceramic - Limited to 1 every 60 months

D6784 Retainer crown ¾ - titanium and titanium alloys - Limited to 1 every 60 months

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

D6791 Retainer crown - full cast predominantly base metal - Limited to 1 every 60 months

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

D6794 Retainer crown - titanium and titanium alloys

D6999 Unspecified fixed prosthodontic procedure, by report

D9932 Cleaning and inspection of removable complete denture, maxillary - Limited to 1 every 6 months

D9933 Cleaning and inspection of removable complete denture, mandibular - Limited to 1 every 6 months

D9934 Cleaning and inspection of removable partial denture, maxillary - Limited to 1 every 6 months

D9935 Cleaning and inspection of removable partial denture, mandibular - Limited to 1 every 6 months

D9942 Repair and/or reline of occlusal guard - Limited to 1 every 24 months for patients 13 and older.

D9943 Occlusal guard adjustment - Limited to 1 every 24 months for patients 13 and older.

D9944 Occlusal guard - hard appliance, full arch - Limited to 1 in 12 months for patients 13 and older.

D9945 Occlusal guard - soft appliance, full arch - Limited to 1 in 12 months for patients 13 and older.

D9946 Occlusal guard - hard appliance, partial arch - Limited to 1 in 12 months for patients 13 and older.

D9954 Fabrication and delivery of oral appliance therapy (OAT) morning repositioning device – Limited to 1 in 12 months

D9955 Oral appliance therapy (OAT) titration visit – Limited to 1 in 12 months.

D0171 Re-evaluation - post-operative office visit

D2410 Gold foil - one surface

D2420 Gold foil - two surfaces

D2430 Gold foil - three surfaces

D2799 Interim crown – further treatment or completion of diagnosis necessary prior to final impression

D2955 Post removal 

D2975 Coping

D3460 Endodontic endosseous implant

D3470 Intentional re-implantation (including necessary splinting)

D3910 Surgical procedure for isolation of tooth with rubber dam

D3911 Intraorifice barrier  

D3950 Canal preparation and fitting of preformed dowel or post

D4230 Anatomical crown exposure – four or more contiguous teeth or tooth bounded spaces per quadrant

D4231 Anatomical crown exposure – one to three teeth or tooth bounded spaces per quadrant

D4286 Removal of non-resorbable barrier

D4322 Splint – intra-coronal; natural teeth or prosthetic crowns

D4323 Splint – extra-coronal; natural teeth or prosthetic crowns

D5810 Interim complete denture (maxillary)

D5811 Interim complete denture (mandibular)

D5820 Interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary

D5821 Interim partial denture (including retentive/clasping materials, rests, and teeth), mandibular

D5862 Precision attachment, by report

D5867 Replacement of replaceable part of semi-precision or precision attachment, per attachment

D5986 Fluoride gel carrier

D6051 Placement of interim implant abutment

D6085 Interim implant crown

D6118 Implant/abutment supported interim fixed denture for edentulous arch – mandibular

D6119 Implant/abutment supported interim fixed denture for edentulous arch – maxillary

D6198 Remove interim implant component

D6199 Unspecified implant procedure, by report

D6253 Interim pontic - further treatment or completion of diagnosis necessary prior to final impression

D6793 Interim retainer crown - further treatment or completion of diagnosis necessary prior to final impression

D6920 Connector bar

D6940 Stress breaker

D6950 Precision attachment

D9219 Evaluation for moderate sedation, deep sedation or general anesthesia

D9986 Missed appointment

D9987 Cancelled appointment

D9991 Dental case management - addressing appointment compliance barriers

D9992 Dental case management - care coordination

D9993 Dental case management - motivational interviewing

D9994 Dental case management - patient education to improve oral health literacy

D9997 Dental case management – patients with special health care needs

D8010 Limited orthodontic treatment of the primary dentition

D8020 Limited orthodontic treatment of the transitional dentition

D8070 Comprehensive orthodontic treatment of the transitional dentition

D8080 Comprehensive orthodontic treatment of the adolescent dentition

D8091 Comprehensive orthodontic treatment with orthognathic surgery

D8210 Removable appliance therapy

D8220 Fixed appliance therapy

D8670 Periodic orthodontic treatment visit

D8671 Periodic orthodontic treatment visit associated with orthognathic surgery

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

Services Not Covered:

(Please refer to Section 7 for a list of General Exclusions)

• Repair of orthodontic appliance/retainer.
• Removable orthodontic retainer adjustment.
• Replacement of lost or broken appliance/retainer.
• Re-cement or re-bond retainer.
• Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth.
• Removal of fixed orthodontic appliances for reasons other than completion of treatment

• Orthodontic care for dependent children age 22 and over for Federal civilian employees.

• Orthodontic care for dependent children age 21 and over OR full-time students age 23 and over for TRICARE eligible enrollees.

D9222 Deep sedation/general anesthesia - first 15 minutes

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

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

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

D9610 Therapeutic parenteral drug, single administration

D9613 Infiltration of sustained release therapeutic drug, per quadrant

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

D0472 Accession of tissue, gross examination, preparation and transmission of written report

D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report

D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report

D0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report

D0502 Other oral pathology procedures, by report

D5911 Facial moulage (sectional)

D5912 Facial moulage (complete)

D5913 Nasal prosthesis

D5914 Auricular prosthesis

D5915 Orbital prosthesis

D5916 Ocular prosthesis

D5919 Facial prosthesis

D5922 Nasal septal prosthesis

D5923 Ocular prosthesis, interim

D5924 Cranial prosthesis

D5925 Facial augmentation implant prosthesis

D5926 Nasal prosthesis, replacement

D5927 Auricular prosthesis, replacement

D5928 Orbital prosthesis, replacement

D5929 Facial prosthesis, replacement

D5931 Obturator prosthesis, surgical

D5932 Obturator prosthesis, definitive

D5933 Obturator prosthesis, modification

D5934 Mandibular resection prosthesis with guide flange

D5935 Mandibular resection prosthesis without guide flange

D5936 Obturator prosthesis, interim

D5937 Trismus appliance (not for TMD treatment)

D5951 Feeding aid

D5952 Speech aid prosthesis, pediatric

D5953 Speech aid prosthesis, adult

D5954 Palatal augmentation prosthesis

D5955 Palatal lift prosthesis, definitive

D5958 Palatal lift prosthesis, interim

D5959 Palatal lift prosthesis, modification

D5960 Speech aid prosthesis, modification

D5982 Surgical stent

D5983 Radiation carrier

D5984 Radiation shield

D5985 Radiation cone locator

D5987 Commissure splint

D5988 Surgical splint

D5993 Maintenance and cleaning of a maxillofacial prosthesis (extra- or intra-oral) other than required adjustments, by report

D7284 Excisional biopsy of minor salivary glands

D7285 Incisional biopsy of oral tissue-hard (bone, tooth)

D7286 Incisional biopsy of oral tissue-soft

D7295 Harvest of bone for use in autogenous grafting procedure

D7410 Excision of benign lesion up to 1.25 cm

D7411 Excision of benign lesion greater than 1.25 cm

D7412 Excision of benign lesion, complicated 

D7413 Excision of malignant lesion up to 1.25 cm

D7414 Excision of malignant lesion greater than 1.25 cm

D7415 Excision of malignant lesion, complicated 

D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm

D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm

D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm

D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm

D7465 Destruction of lesion(s) by physical or chemical method, by report

D7490 Radical resection of maxilla or mandible 

D7509 Marsupialization of odontogenic cyst

D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue

D7540 Removal of reaction producing foreign bodies, musculoskeletal system

D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone

D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body

D7610 Maxilla - open reduction (teeth immobilized, if present)

D7620 Maxilla - closed reduction (teeth immobilized, if present)

D7630 Mandible - open reduction (teeth immobilized, if present)

D7640 Mandible - closed reduction (teeth immobilized, if present)

D7650 Malar and/or zygomatic arch - open reduction 

D7660 Malar and/or zygomatic arch - closed reduction

D7670 Alveolus - closed reduction, may include stabilization of teeth

D7671 Alveolus - open reduction, may include stabilization of teeth

D7680 Facial bones - complicated reduction with fixation and multiple surgical approaches

D7710 Maxilla - open reduction

D7720 Maxilla - closed reduction

D7730 Mandible - open reduction

D7740 Mandible - closed reduction

D7750 Malar and/or zygomatic arch - open reduction

D7760 Malar and/or zygomatic arch - closed reduction

D7770 Alveolus - open reduction stabilization of teeth

D7771 Alveolus, closed reduction stabilization of teeth 

D7780 Facial bones - complicated reduction with fixation and multiple approaches 

D7810 Open reduction of dislocation

D7820 Closed reduction of dislocation

D7830 Manipulation under anesthesia

D7840 Condylectomy

D7850 Surgical discectomy, with/without implant

D7852 Disc repair

D7854 Synovectomy

D7856 Myotomy

D7858 Joint reconstruction

D7860 Arthrotomy

D7865 Arthroplasty

D7870 Arthrocentesis

D7871 Non-arthroscopic lysis and lavage

D7872 Arthroscopy - diagnosis, with or without biopsy

D7873 Arthroscopy: lavage and lysis of adhesions

D7874 Arthroscopy: disc repositioning and stabilization

D7875 Arthroscopy: synovectomy

D7876 Arthroscopy: discectomy

D7877 Arthroscopy: debridement

D7911 Complicated suture - up to 5 cm

D7912 Complicated suture - greater than 5 cm

D7920 Skin graft (identify defect covered, location and type of graft)

D7939 Indexing for osteotomy using dynamic robotic assisted or dynamic navigation 

D7940 Osteoplasty - for orthognathic deformities

D7941 Osteotomy - mandibular rami

D7943 Osteotomy - mandibular rami with bone graft; includes obtaining the graft

D7944 Osteotomy - segmented or subapical

D7945 Osteotomy - body of mandible

D7946 LeFort I (maxilla - total)

D7947 LeFort I (maxilla - segmented)

D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - without bone graft

D7949 LeFort II or LeFort III - with bone graft

D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report

D7955 Repair of maxillofacial soft and/or hard tissue defect

D7956 Guided tissue regeneration, edentulous area – resorbable barrier, per site

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

D7979 Non-surgical sialolithotomy

D7980 Surgical sialolithotomy

D7981 Excision of salivary gland, by report

D7982 Sialodochoplasty

D7983 Closure of salivary fistula

D7990 Emergency tracheotomy

D7991 Coronoidectomy

D7993 Surgical placement of craniofacial implant – extra oral

D7994 Surgical placement: zygomatic implant

D7995 Synthetic graft - mandible or facial bones, by report

D7996 Implant-mandible for augmentation purposes (excluding alveolar ridge), by report

D9130 Temporomandibular joint dysfunction – non-invasive physical therapies

D9210 Local anesthesia not in conjunction with operative or surgical procedures

D9211 Regional block anesthesia

D9212 Trigeminal division block anesthesia

D9215 Local anesthesia in conjunction with operative or surgical procedures

D9420 Hospital or ambulatory surgical center call

D9450 Case presentation, subsequent to detailed and extensive treatment planning

D9630 Drugs or medicaments dispensed in the office for home use

D9912 Pre-visit patient screening

D9920 Behavior management, by report

D9938 Fabrication of a custom removable clear plastic temporary aesthetic appliance

D9939 Placement of a custom removable clear plastic temporary aesthetic appliance

D9947 Custom sleep apnea appliance fabrication and placement

D9948 Adjustment of custom sleep apnea appliance

D9949 Repair of custom sleep apnea appliance

D9953 Reline custom sleep apnea appliance (indirect)

D9956 Administration of home sleep apnea test

D9957 Screening for sleep related breathing disorders

D9961 Duplicate/copy patient's records

D9971 Odontoplasty - per tooth

D9972 External bleaching - per arch - performed in office

D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays

D9990 Certified translation or sign-language services – per visit

We will pay benefits, subject to plan provisions, in an amount equal to the covered percentage for the charges incurred by you.  All payments will be made in U.S. currency.

International employees and their dependents may contact AXA Assistance USA (AXA) for referral to dental providers outside of the continental United States or may use the dentist of their choice.  The process involves a plan participant calling AXA at (312) 935-9210 collect or (866) 384-2771 to find a local provider in their country.  International participants will receive In-Network benefit when services are performed by an Out-of-Network internationally located provider.

The plan participant will be responsible for paying the dentist and submitting the claims to MetLife for reimbursement at the following address.

Mail completed claim form to:

MetLife Dental Claims

P.O. Box 981282

El Paso, TX 79998-1282

To avoid delay in the payment of your claims please have your dentist submit your claims directly to MetLife for payment.

MetLife’s dental providers may submit their claims directly to MetLife by accessing MetDental.com where we provide them with real-time results.  However, should you wish to send in a paper claim you may download a claim form from the website www.MetLife.com/FEDVIP-Dental

Mail completed claim form to:

MetLife Dental Claims
P.O. Box 981282
El Paso, TX 79998-1282

When a claimant files a claim for dental insurance benefits described in this brochure, both the notice of claim and the required Proof should be sent to us within 90 days of the date of a loss.  If notice of claim or proof is not given within the time limits described in this section, the delay will not cause a claim to be denied or reduced if such notice and Proof are given as soon as is reasonably possible

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

Step 1:

Ask us in writing to reconsider our initial decision.  You must include any pertinent information omitted from the initial claim filing and mail your additional proof to us within 180 days from the date of receipt of our decision.

Step 2:

Send your request for reconsideration to:

MetLife Dental Claims Appeals

P.O. Box 14589

Lexington, KY 40512

We will review your request and provide you with a written or electronic explanation of benefit determination within 30 days of the receipt of your request.

Step 3:

If you disagree with the decision regarding your request for reconsideration, you may request a second review of the denial.  You must submit your request to us in writing to the address shown above along with any additional information you or your dentist can provide to substantiate your claim so that we can reconsider our decision. Failure to do so will disqualify the appeal of your claim.

Step 4:

If you do not agree with our final decision, under certain circumstances you may request an independent third party, mutually agreed upon by MetLife and OPM, review the decision. To qualify for this independent third party review the charge for the procedure in question must be in excess of $300 and the reason for denial must be based on our determination that the rationale for the procedure did not meet our dental necessity criteria or our administration of the plans Alternate Benefit provision, for example, a bridge being given an alternate benefit of a partial denture.

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

If the matter is not eligible for this third level of review, the second level of review is binding and is the final remedy available to you. This decision is not subject to judicial review.

MetLife will review your claim and notify you of its decision to approve or deny your claim.  Such notification will be provided to you within a 30-day period from the date you submitted your claim; except for situations requiring an extension of time of up to 15 days because of matters beyond the control of the Plan.  If MetLife needs such an extension, MetLife will notify you prior to the expiration of the initial 30 day period, state the reason why the extension is needed, and state when it will make its determination.  If an extension is needed because you did not provide sufficient information or filed an incomplete claim, the time from the date of MetLife’s notice requesting further information and an extension until MetLife receives the requested information does not count toward the time period MetLife is allowed to notify you as to its claim decision.  You will have 45 days to provide the requested information from the date you receive the notice requesting further information from MetLife.

We have the right to recover any amount that we determine to be an overpayment, whether for services received by you or your dependents.

An overpayment occurs if we determine that:

• the total amount paid by us on a claim for dental benefits is more than the total of the benefits due to you under this brochure; or
• payment we made should have been made by another group plan

If such overpayment occurs, you have an obligation to reimburse us.

We may recover the overpayment from you by: stopping or reducing any future benefits payable under the MetLife Federal Dental Plan; demanding an immediate refund of the overpayment from you; and/or taking legal action.

We may recover such overpayment in accordance with that agreement.  If the overpayment results from MetLife having made a payment to you that should have been made under another group plan, we may recover such overpayment from one or more of the following:

• any other insurance company;
• any other organization; or
• from you.

This section describes how medical information about you may be used and disclosed and how you can get information.  Please review this section carefully.

MetLife and each member of the MetLife family of companies (an Affiliate”) strongly believe in protecting the confidentiality and security of information we collect about you.  This section refers to MetLife by using the terms “us,” “we,” or “our.”

This section describes how we protect the Personal Health Information we have about you which relates to your coverage under the MetLife Federal Dental Plan (“Personal Health Information”), and how we may use and disclose this information.  Personal Health Information includes individually identifiable information, which relates to your past, present or future health, treatment or payment for health care services.  This section also describes your rights with respect to the Personal Health Information and how you can exercise those rights.

We are required to provide notice of our privacy practices for Personal Health Information to you by the Health Insurance Portability and Accountability Act (“HIPAA”).  For additional information regarding our HIPAA Medical Information Privacy Policy or our general privacy policies, please see the privacy notices contained at our website, MetLife.com/FEDVIP-Dental or www.metlife.com.  You may submit questions to us there or you may write to us directly at MetLife, Americas-U.S. HIPPA Privacy Office PO Box 902, New York, NY 10159-0902 

We are required by law to:

• maintain the privacy of your Personal Health Information;
• provide you notice of our legal duties and privacy practices with respect to your Personal Health Information; and notify affected individuals following a breach of unsecured Personal Health Information and
• follow the terms of our HIPAA privacy practices as explained in this section.

We protect your Personal Health Information from inappropriate use or disclosure. Our employees, and those of companies that help us service your insurance coverage under the MetLife Federal Dental Plan, are required to comply with our requirements that protect the confidentiality of Personal Health Information.  They may look at your Personal Health Information only when there is an appropriate reason to do so, such as to administer our products or services.

We will not sell or disclose your Personal Health Information to any other company for their use in marketing their products to you.  However, as described below, we will use and disclose Personal Health Information about you for business purposes relating to your Dental Insurance coverage. 

The main reason we may use and disclose your Personal Health Information are to evaluate and process any requests for coverage and claims for benefits you may make or in connection with other health-related benefits or services that may be of interest to you.  The following describe these and other uses and disclosures, together with some examples.

We may use and disclose Personal Health Information to pay benefits under the MetLife Federal Dental Plan.  For example, we may review Personal Health Information contained in claims to reimburse providers for services rendered.  We may also disclose Personal Health Information to other insurance carriers to coordinate benefits with respect to a particular claim.  Additionally, we may disclose Personal Health Information to a health plan or an administrator of an employee welfare benefit plan for various payment-related functions, such as eligibility determination, audit and review or to assist you with your inquiries or disputes.

We may also use and disclose Personal Health Information for our insurance operations.  These purposes include evaluating a request for dental insurance products or services, administering those products or services, and processing transactions requested by you.  We may also disclose Personal Health Information to Affiliates, and to business associates outside of the MetLife family of companies, if they need to receive Personal Health Information to provide a service to us and will agree to abide by specific HIPAA rules relating to the protection of Personal Health Information.  Examples of business associates are: billing companies, data processing companies, companies that provide general administrative services, health information organization, e-prescribing gateways or personal health record vendors that provide services to covered entities.  Personal Health Information may be disclosed to reinsurers for underwriting, audit or claim review reasons.  Personal Health Information may also be disclosed as part of a potential merger or acquisition involving our business in order that the parties to the transaction may make an informed business decision.

We may use your Personal Health Information to provide you with information about benefits available to you under your current coverage and, in limited situations, about health-related products or services that may be of interest to you. However, we will not send marketing communications to you in exchange for financial remuneration from a third party without your authorization.

If you or your estate are involved in a lawsuit or a dispute, we may disclose Personal Health Information about you in response to a court or administrative order.  We may also disclose Personal Health Information about you in response to a subpoena, discovery request, or other lawful process. But only if efforts have been made to tell you about the request or to obtain an order protecting the Personal Health Information requested.  We may disclose Personal Health Information to any governmental agency or regulator with whom you have filed a complaint or as part of a regulatory agency examination.

Other uses and disclosures of Personal Health Information not covered by this section and permitted by the laws that apply to us will be made only with your written authorization or that of your legal representative.  If we are authorized to use or disclose Personal Health Information about you, you or your legally authorized representative may revoke that authorization, in writing, at any time, except to the extent that we have taken action relying on the authorization or if the authorization was obtained as a condition of obtaining your dental insurance coverage.  You should understand that we will not be able to take back any disclosures we have already made with authorization.

The following are your various rights as a consumer under HIPAA concerning your Personal Health Information.  Should you have questions about a specific right, please write to us at the location listed in our discussion of that right.

In most cases, you have the right to inspect and obtain a copy of the Personal Health Information that we maintain about you.  To inspect and copy Personal Health Information, you must submit your request in writing to MetLife Dental P.O. Box 14587, Lexington, KY 40512-4587.  If we maintain the requested Personal Health Information electronically, you may ask us to provide you with the Personal Health Information in electronic format if readily producible or if not, in a readable electronic form and format agreed by you and us. To receive a copy of your Personal Health Information, you may be charged a fee for the costs of copying, mailing, electronic media or other supplies associated with your request.  You may also direct us to send the Personal Health Information you have requested to another person designated by you so long as your request is in writing and clearly identifies the designated individual. However, certain types of Personal Health Information will not be made available for inspection and copying.  This includes Personal Health Information collected by us in connection with, or in reasonable anticipation of any claim or legal proceeding. In very limited circumstances, we may deny your request to inspect and obtain a copy of your Personal Health Information.  If we do, you may request that the denial be reviewed.  The review will be conducted by an individual chosen by us who was not involved in the original decision to deny your request.  We will comply with the outcome of that review.

If you believe that your Personal Health Information is incorrect or that an important part of it is missing, you have the right to ask us to amend your Personal Health Information while it is kept by or for us.  You must provide your request and your reason for the request in writing, and submit it to MetLife Dental P.O. Box 14587, Lexington, KY 40512-4587.  We may deny your request if it is not in writing or does not include a reason that supports the request.  In addition, we may deny your request if you ask us to amend Personal Health Information that:

• is accurate and complete;
• was not created by us, unless the person or entity that created the Personal Health Information is no longer available to make the amendment;
• is not part of the Personal Health Information kept by or for us; or
• is not part of the Personal Health Information, which you would be permitted to inspect and copy.

You have the right to request a list of the disclosures we have made of your Personal Health Information.  This list will not include disclosures made for treatment, payment, health care operations, purposes of national security, to law enforcement  to corrections personnel or to your authorization or directly to you.  To request this list, you must submit your request in writing to MetLife Dental P.O. Box 14587, Lexington, KY 40512-4587. Your request must state the time period for which you want to receive a list of disclosures.  You may only request an accounting of disclosures for a period of time less than six years prior to the date of your request. Your request should indicate in what form you want the list (For example, on paper or electronically).  The first list you request within a 12- month period will be free.  We may charge you for responding to any additional requests.  We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before you incur any cost.

You have the right to request a restriction or limitation on Personal Health Information we use or disclose about you for treatment, payment or health care operations, or that we disclose to someone who may be involved in your care or payment for your care, like a family member or friend.  While we will consider your request, we are not required to agree to it.  If we do agree to it, we will comply with your request. To request a restriction, you must make your request in writing to MetLife Dental P.O. Box 14587, Lexington, KY 40512-4587.  In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply  We will not agree to restrictions on Personal Health Information uses or disclosures that are legally required, or which are necessary to administer our business.

You have the right to request that we communicate with you about Personal Health Information in a certain way or at a certain location if you tell us that communication in another manner may endanger you. For example, you can ask that we only contact you at work or by mail.  To request confidential communications, you must make your request in writing to MetLife Dental P.O. Box 14587, Lexington, KY 40512-4587 and specify how or where you wish to be contacted.  We will accommodate all reasonable requests.

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S.Department of Health and Human Services.  To file a complaint with us, please contact MetLife, America's-U.S. HIPPA Privacy Office P.O. Box 902, New York, NY 10159-0902  All complaints must be submitted in writing.  You will not be penalized for filing a complaint.  If you have questions as how to file a complaint please contact us at (212) 578-0299 or at
www.HIPPAprivacyAmericasUS@metlife.com

You may have additional rights under other applicable laws.  For additional information regarding our HIPAA Medical Information Privacy Policy or our general privacy policies please e-mail us at www.HIPAAprivacyAmericasUS@metlife.com or call us at (212) 578-0299, or write to us at MetLife, U.S. HIPAA Privacy Office P.O. Box 902 New York, NY 10159-0902.  

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

From January 1, 2025 through December 31, 2025.  Also referred to as the Plan year. 

Orthodontia services.

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

MetLife Federal Dental Plan

The plan allowance is the maximum amount we will consider for payment for a specific procedure. The actual benefit will be a specified percentage of the plan allowance. When you use a participating (in-network) provider, your out-of-pocket cost is limited to the difference between the plan allowance and our payment. When you use services provided by a provider that does not participate in our network of providers, they are considered out-of-network services.

The Plan Allowance for Out-of-Network services will be equal to the In-Network Plan Allowance for the covered service (see page 18 for further details). 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. Out-of-network providers may charge their normal fees which may be greater than the Plan Allowance.

The plan allowance may vary by geographic location and/or a participating provider’s contracted fee schedule.

All benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are necessary for the prevention, diagnosis, care, or treatment of a covered condition and meet generally accepted dental protocols.

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.

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

0%

10% 

30%

40%

50%

60%

Class A, B, and C Services are subject to an unlimited maximum benefit

Class D Services – orthodontic

$3,500 Child Lifetime Maximum, $3,000 Adult Lifetime Maximum

50%

50%

0%

40%

45%

60%

65%

80%

Class A, B, and C Services are subject to a $2,000 annual maximum benefit for the In-Network benefits and $2,000 for the Out-of-Network benefits

Class D Services – orthodontic

$1,500 Child Lifetime Maximum, $1,500 Adult Lifetime Maximum.

50%

50%