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

If you sign up for a dental and/or vision plan during the 2023 Open Season, your coverage begins on January 1, 2024.  Premium deductions start with the first full pay period beginning on/after January 1, 2024.  You may use your benefits as soon as your enrollment is confirmed.

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

Each year, an Open Season will be held, during which you may enroll or change your dental and/or vision plan enrollment.  This year, Open Season runs from November 13, 2023 through midnight EST  December 11, 2023.  You do not need to re-enroll each Open Season unless you wish to change plans or plan options; your coverage will continue from the previous year.  In addition to the annual Open Season, there are certain events that allow you to make specific types of enrollment changes throughout the year.  Please see Section 2, Enrollment, for more information.

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

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

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

You are eligible to enroll if you:

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

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

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

An individual who is eligible for FEDVIP dental coverage based on the individual's eligibility to previously be covered under the TRICARE Retiree Dental Program or an individual eligible for FEDVIP vision coverage based on the individual's enrollment in a specified TRICARE health plan. Retired members of uniformed services and National Guard/Reserve components, including "gray-area" retirees under age 60 and their families are eligible for FEDVIP dental coverage. These individuals, if enrolled in a TRICARE health plan, are also eligible for FEDVIP vision coverage. In addition, uniformed services active duty family members who are enrolled in a TRICARE health plan are eligible for FEDVIP vision coverage.

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

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

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

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

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

If you are currently enrolled in FEDVIP and do not want to change plans, your enrollment will continue automatically.  Please Note:  your plans’ premiums may change for 2024.

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

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

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

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

Open Season

If you are an eligible employee, annuitant, or TRICARE-eligible individual, you may enroll in a dental and/or vision plan during the November 13, through midnight EST, December 11, 2023 Open Season.  Coverage is effective January 1, 2024.

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

New hire/Newly eligible

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

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

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

Qualifying Life Event

A qualifying life event (QLE) is an event that allows you to enroll or change your enrollment outside of an Open Season.  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

New hire/Newly eligible 

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

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

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

Qualifying Life Event 

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

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

Qualifying Life Event: From Not Enrolled to Enrolled: Yes 

Increase Enrollment Type: Yes  

Decrease Enrollment Type: No  

Cancel: No  

Change from One Plan to Another: No  

Qualifying Life Event: Moving out of regional plan's service area 

From Not Enrolled to Enrolled: No  

Increase Enrollment Type: No  

Decrease Enrollment Type: No  

Cancel: No  

Change from One Plan to Another: Yes  

Qualifying Life Event: Going on active military duty, non- pay status (enrollee or spouse) 

From Not Enrolled to Enrolled: No  

Increase Enrollment Type: No  

Decrease Enrollment Type: No  

Cancel: Yes  

Change from One Plan to Another: No  

Qualifying Life Event: Returning to pay status from active military duty (enrollee or spouse) 

From Not Enrolled to Enrolled: Yes  

Increase Enrollment Type: No  

Decrease Enrollment Type: No  

Cancel: No  

Change from One Plan to Another: No  

Qualifying Life Event: Returning to pay status from Leave without pay 

From Not Enrolled to Enrolled: Yes (if enrollment cancelled during LWOP)  

Increase Enrollment Type: No  

Decrease Enrollment Type: No  

Cancel: No  

Change from One Plan to Another: Yes (if enrollment cancelled during LWOP)  

Qualifying Life Event: Annuity/ compensation restored 

From Not Enrolled to Enrolled: Yes  

Increase Enrollment Type: No  

Decrease Enrollment Type: No  

Cancel: No  

Change from One Plan to Another: No  

Qualifying Life Event: Transferring to an eligible position* 

From Not Enrolled to Enrolled: No  

Increase Enrollment Type: No  

Decrease Enrollment Type: No  

Cancel: Yes  

Change from One Plan to Another: No  

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

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

• There is no time limit for a change based on moving from a regional plan’s service area; and  

• You cannot request a new enrollment based on a QLE before the QLE occurs, except for enrollment because of a loss of dental or vision insurance. You must make the change no later than 60 days after the event.  

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

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

VA Exception for Cancellation 

Generally, you may cancel your enrollment only during the annual Open Season. However, if you are a FEDVIP enrollee paying premiums on a post-tax basis, and you, your family member, or TEI family member becomes eligible for VA dental or vision benefits, then you may change your enrollment type or cancel your enrollment within 60 days of receiving notification of VA dental or vision eligibility. This 60-day period may fall outside of open season. VA dental or vision eligibility documentation must be submitted to OPM via the BENEFEDS mailbox (benefedsportal@opm.gov) within 60 days of notification to support the FEDVIP enrollment change or cancellation. 

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

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

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

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

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

Coverage for a family member ends when:

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

Under FEDVIP, there is no 31-day extension of coverage. The following are also

NOT available under the FEDVIP plans

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

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

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

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

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

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

You receive an identification card (two cards if you enroll under the Self Plus One or Self and Family options), which will serve as confirmation of your enrollment.  The ID card is neither a guarantee of benefits nor does your provider need it to render dental services.  Your dentist may call 1-877-394-8224 to confirm your enrollment in the plan and the benefits available to you.  You may print an ID card at www.uccifedvip.com.

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

In-network care is provided by a participating dentist in United Concordia’s Federal Dental Program Network. You can locate a participating provider by visiting our website at www.uccifedvip.com, or by calling FEDVIP customer service at 1-877-FYI-UCCI (1-877-394-8224)  

When you visit a provider who participates with both, your FEHB plan and your FEDVIP plan, the FEHB plan will pay benefits first.  The FEDVIP plan allowance will be the prevailing charge in these cases.  You are responsible for the difference between the FEHB and FEDVIP benefit payments and the FEDVIP plan allowance.  United Concordia Dental is responsible for facilitating the process with the FEHB first payor. United Concordia will coordinate benefits not to exceed members responsibility and will not pay more than the member is responsible for.

Please ask your dentist to submit the charges to your FEHB plan.  Please note that it is not your responsibility to submit any claim information or an explanation of benefits (EOB) to United Concordia Dental.

United Concordia Dental may send you a letter asking for other insurance carrier information if we have an indication of other insurance (but not the carrier details) in order to determine the first payor.  Any claims received during the questionnaire process are pended for return of the letter providing other insurance information.

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

First Payor Example:

When the covered individual has FEHB coverage that offers dental benefits, United Concordia is always secondary to the FEHB carrier

Services were performed by an In-Network provider

Dentist submitted charge for a one surface amalgam filling: $105.00
In-Network allowance of the Primary Plan: $65.00
FEHB paid as primary carrier ($24.00 applied to coinsurance): $41.00 ($65.00 - $24.00)
United Concordia Allowance: $60.00
United Concordia benefits payable in the absence of other insurance (United Concordia as primary): $48.00 ($60.00 at 80%)
Payment by United Concordia: $19.00 ($60.00 - $41.00)
Patient’s responsibility to the dentist: $0.00 ($60.00 - $41.00 - $19.00)

United Concordia Dental coordinates benefit payments with non-FEHB carriers.  If you are the policy holder for both FEDVIP and a commercial carrier, the plan that has been in effect the longest is primary.  We also coordinate benefit payments with any other group health benefits coverage you may have and the payment of dental costs under no-fault insurance that pays benefits without regard to fault. 

United Concordia Dental is the primary payor if we do not have an indication of other insurance on our enrollment files and there is no indication of other insurance on the claim form. 

COB In-Network Examples:

When United Concordia is secondary to a Non-FEHB dental carrier

Services were performed by an In-Network provider

Provider submitted charge for a two surface amalgam filling: $131.00
In Network allowance of the Primary Plan: $70.00
Payable by Primary Carrier ($5.00 applied to coinsurance): $65.00 ($70.00 - $5.00)
United Concordia Allowance: $60.00
United Concordia benefit in absence of other insurance (United Concordia as primary): $48.00 ($60.00 at 80%)
Payable by United Concordia (The total payment by the primary and secondary plan cannot exceed the provider charge): $5.00 ($70.00 - $65.00)
Patient responsibility: $0.00 ($70.00 - $65.00 - $5.00)

COB Out-of-Network Examples:

When the covered individual has FEHB coverage that offers dental benefits, United Concordia is always secondary to the FEHB carrier

Services were performed by an Out-of-Network Provider.

Provider submitted charge for a one surface amalgam filling: $105.00
In Network allowance of the Primary Plan: N/A
FEHB paid as primary carrier ($24.00 applied to coinsurance): $41.00
United Concordia's Maximum Allowable Charge: $80.00
United Concordia benefits payable in the absence of other insurance (United Concordia as primary): $48.00 ($80.00 at 60%)
Payment by United Concordia: $48.00
Patient’s responsibility to the provider: $16.00 ($105.00 - $41.00 - $48.00). Since the provider does not participate in either network, the provider is allowed to balance bill the member.

When United Concordia is secondary to a Non-FEHB dental carrier

Services were performed by an Out-of-Network provider

Provider submitted charge for a two surface amalgam filling: $131.00
In Network allowance of the Primary Plan: N/A
Payable by Primary Carrier ($5.00 applied to coinsurance): $65.00
United Concordia's Maximum Allowable Charge: $80.00
United Concordia benefit in absence of other insurance (United Concordia as primary): $48.00 ($80.00 at 60%)
Payable by United Concordia (The total payment by the primary and secondary plan cannot exceed the provider charge): $48.00
Patient responsibility: $18.00 ($131.00 - $65.00 - $48.00). Since the provider does not participate in either network, the provider is allowed to balance bill the member.

If you live in a limited access area and you receive covered services from an out-of-network provider, we could pay benefits based on our in network plan allowance and coinsurance.  This is dependent on the applicable co-insurance, plan maximums and other benefit features that apply.  You are responsible for any difference between the amount billed and our payment.  To find out if you are in a limited access area, please call United Concordia's customer service representatives at 1-877-FYI-UCCI (1-877-394-8224) Monday - Friday, 8 a.m. to 8 p.m., ET.

The alternate benefit provision determines how payment is made when there are two or more clinically acceptable covered dental services available to satisfactorily correct the same dental condition.  This provision states that United Concordia provides the allowance for the less expensive service available, while still ensuring that you receive the quality care you need.  Should the member and the dentist choose the more expensive treatment, the member is responsible for the additional charges beyond the allowance for the alternate service, even if an in-network provider.

Situations where this provision may apply include a composite filling may be the alternate benefit for a porcelain/ceramic inlay. 

United Concordia Dental reviews claims that report single crowns, onlays, fixed bridgework, impacted third molars, operative periodontics, scaling and root planing or services that are of a complex or questionable nature.  Your dentist must submit supporting documentation such as x-rays or charting that are required for certain services.

All claims submitted for periodontal soft tissue grafts will require submission of diagnostic materials and Advisor review. The following diagnostic materials must be submitted for review:

1. Periodontal charting completed within the past 12 months of the areas(s) being treated, which must include:

    a. Pocket depths; b. Amount of recession measured from the CEJ to the gingival margin; c.An indication of the amount of keratinized gingiva remaining.

2. A narrative (statement) explaining the reason why the graft(s) is needed.

Coinsurance is the percentage of our allowance that you must pay for your care.  The allowance will be based on United Concordia Dental’s Maximum Allowable Charge. 

For the High Option your coinsurance is as follows:

Class A
In-Network High Option: 0%
Out-of-Network Standard Option: 20%

Class B
In-Network High Option: 20%
Out-of-Network High Option: 40%

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

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

For the Standard Option your coinsurance is as follows:

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

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

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

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

For the High Option our Plan includes an Unlimited annual benefit maximum per covered person for combined Class A, B and C covered services, excluding implant related services. Implant related Services have a $2500 annual maximum per covered person.  

For the Standard Option our Plan includes a $1,500 annual benefit maximum per covered person for combined Class A, B and C covered services. 

For the High Option, our Plan includes a lifetime benefit maximum of $3,000 per covered person for Class D orthodontic services and a lifetime benefit maximum of $2,000 per covered person for dental accident services.  Once you reach this amount, you are responsible for all charges for these services.

For the Standard Option, our Plan includes a lifetime benefit maximum of $2,000 per covered person for Class D orthodontic services and a lifetime benefit maximum of $2,000 per covered person for dental accident services.  Once you reach this amount, you are responsible for all charges for these services.

In-network services are services performed by a dentist who is part of United Concordia’s Federal Dental Program Network. Using a participating dentist may result in lower out-of pocket-costs. You can locate a participating dentist by visiting our website at 
www.uccifedvip.com or by calling 1-877-FYI-UCCI (1-877-394-8224).

You may use any licensed dentist; however, benefits received out-of-network could result in higher out-of-pocket costs. A member will pay the coinsurance plus the difference between the allowance amount and the out of network providers charge. 

If you live in a limited access area, your benefits will be paid at the in-network coinsurance level for covered services. You are responsible  for any difference between the amount billed and our payment. You can determine if you live in an underserved area by visiting our website at www.uccifedvip.com or by calling 1-877-FYI-UCCI (1-877-394-8224). 

A dental accident is an injury to sound natural teeth and supporting structures caused by a violent external force such as a fall or blow to the mouth.

United Concordia pays 100% of the program allowance for covered services specifically related to accidental dental injuries up to a lifetime maximum of $2,000.  This benefit is separate from the services through the High Option unlimited annual maximum and the Standard Option $1,500 annual maximum.  Further, benefits paid for covered services related to the accident(s) in excess of $2,000 accrue to the annual benefit maximum. 

For a complete list of services covered as dental accident services, call 1-877-FYI-UCCI (1-877-394-8224).

The amount we use to determine our payment for covered services. We determine our Plan allowance as follows: for care rendered to members who reside in limited access areas, the 75^th percentile of Ingenix data for the provider’s location; for care provided to members who live outside of the 50 states, the District of Columbia or Puerto Rico, the 90^th percentile of Ingenix data for the District of Columbia.

In-progress treatment for dependents of retiring active-duty service members who were enrolled in the TRICARE Dental Program (TDP) will be covered for the 2024 plan year; regardless of any current plan exclusion for care initiated prior to the enrollee's effective date.

This requirement includes assumption of payments for covered orthodontia services up to the FEDVIP policy limits, and full payment where applicable up to the terms of FEDVIP policy for covered services completed (but not initiated) in the 2024 plan year such as crowns and implants.

D0120 Periodic oral evaluation – Limited to two per calendar year in combination with D0150, D0180, D0145

D0140 Limited oral evaluation – problem focused – Limited to one per patient per provider every 12 months

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

D0150 Comprehensive oral evaluation – new or established patient – two per calendar year in combination with D0120, D0180, D0145

D0170 Re-evaluation - limited, problem focused, integral to diagnostic procedures 

D0171 Re-evaluation - post operative office visit, integral to diagnostic procedures

D0180 Comprehensive periodontal evaluation – new or established patient – two per calendar year in combination with D0120, D0150, D0145

D0210 Intraoral – comprehensive series of radiographic images

D0251 Extraoral-Posterior Dental Radiograph - Limited to 1 per 12 month period. Not covered if related to TMJ.

D0330 Panoramic radiographic image

Current Dental Terminology © American Dental Association

D0372 Intraoral tomosynthesis - comprehensive series of radiographic images - alternate benefit of a D0210

D0373 Intraoral tomosynthesis - bitewing radiographic image -alternate benefit of a D0270

D0374 Intraoral tomosynthesis - periapical radiographic image - alternate benefit of a D0220

D0396 3D printing of a 3D dental surface scan - Limited to one per lifetime

D0425 Caries susceptibility tests

D0460 Pulp vitality tests - integral to diagnostic services 

D0470 Diagnostic casts - Limited to one per lifetime

D0601 Caries risk assessment and documentation, with a finding of low risk - integral to diagnostic services 

D0602 Caries risk assessment and documentation, with a finding of moderate risk - integral to diagnostic services 

D0603 Caries risk assessment and documentation, with a finding of high risk - integral to diagnostic services 

D0999 Unspecified diagnostic procedure

D1110 Prophylaxis – adult – Limited to two per calendar year; one additional cleaning during pregnancy when registered in MyDentalBenefits

D1120 Prophylaxis – child – Limited to two per calendar year

D1301 Immunization Counseling - Integral to preventive procedures 

D1351 Sealant – per tooth – Limited to permanent molars through age 18. One sealant per tooth in a 3-year period

D1353 Sealant repair (per tooth)- Limited to through age 18 on  permanent molars and 1 per tooth per 3 years.

D1354 application of caries arresting medication application - Limited to members age 1 through 6,  2 treatments per tooth per 12 months; age 7 through 12, 1 treatment per 12 months

D1510 Space maintainer – fixed – unilateral, per quadrant, excludes distal shoe space maintainer – Limited to one per three years for members under age 19

D1516 Space maintainer-fixed-bilateral,maxillary- Limited to one per three years for members under age 19

D1517 Space maintainer-fixed-bilateral,mandibular- Limited to one per three years for members under age 19

D1520 Space maintainer – removable – unilateral, per quadrant – Limited to one per three years for members under age 19

D1526 Space maintainer-removable-bilateral,maxillary – Limited to one per three years for members under age 19

D1527 Space maintainer-removable-bilateral,mandibular – Limited to one per three years for members under age 19

D1551 Re-cement or re-bond bilateral space maintainer, maxillary - One per six months for members under age 19

D1552 Re-cement or re-bond bilateral space maintainer, mandibular - One per six months for members under age 19

D1553 Re-cement or re-bond unilateral space maintainer, per quadrant - One per six months for members under age 19

D1575 Distal shoe space maintainer- fixed unilateral,per quadrant - Limited to one per three years for members under age 19

D2991 Application of hydroxyapatite - regeneration medicament per tooth - Two per tooth per 12 months ages 1 thru 6; 1 per tooth per 12 months ages 7 thru 12

D9110 Palliative treatment of dental pain – per visit

D9310 Consultation - Diagnostic service provided by dentist or physician other than requesting dentist or physician - Limited to one per patient per Provider per 12 months in combination with limited evaluation (D0140)

D9311 Consultation with a medical health care professional - Combination of D9310 and D9311 limited to one per patient per Provider per 12 months

Current Dental Terminology © American Dental Association

Not covered:

• Plaque control programs
• Oral hygiene instruction
• Dietary instructions
• Sealants for teeth other than permanent molars
• Over-the-counter dental products, such as teeth whiteners,toothpaste,dental floss,special mouth rinses,fluoride rinses
• Exams are allowed 2 in calendar year but they cannot be done on the same day by same provider

Current Dental Terminology © American Dental Association

D2140 Amalgam – one surface, primary or permanent – Limited to one in 24 months for replacement restorations

D2150 Amalgam – two surfaces, primary or permanent – Limited to one in 24 months for replacement restorations

D2160 Amalgam – three surfaces, primary or permanent – Limited to one in 24 months for replacement restorations

D2161 Amalgam – four or more surfaces, primary or permanent – Limited to one in 24 months for replacement restorations

D2330 Resin–based composite – one surface, anterior – Limited to one in 24 months for replacement restorations

D2331 Resin-based composite – two surfaces, anterior – Limited to one in 24 months for replacement restorations

D2332 Resin-based composite – three surfaces, anterior – Limited to one in 24 months for replacement restorations

D2335 Resin-based composite – four or more surfaces (anterior) – Limited to one in 24 months for replacement restorations

D2390 Resin based composite crown-anterior - Limited to one per 24 months for replacement restorations

D2391 Resin-based composite-one surface-posterior -Limited to one in 24 months for replacement restorations

D2392 Resin-based composite- two surfaces- posterior- Limited to one in 24 months for replacement restorations

D2393 Resin-based composite- three surfaces- posterior- Limited to one in 24 months for replacement restorations

D2394 Resin-based composite–four or more surfaces-posterior- Limited to one in 24 months for replacement restorations

D2610 Inlay porcelain/ceramic one surface - Alternate benefit applies ( See Section 4 How to Obtain Care, for definition)

D2620 Inlay porcelain/ceramic two surfaces - Alternate benefit applies(see Section 4 How to Obtain Care, for definition)

D2630 Inlay/porcelain/ceramic three surfaces or more - Alternate benefit applies(see Section 4 How to Obtain Care, for definition)

Current Dental Terminology © American Dental Association

D2910 Re-cement or re-bond inlay, onlay, partial coverage restoration – One per 6 month period; integral within 12 months of the placement of prosthesis

D2915 Re-cement Inlay-  Limited to one per 3 years

D2920 Re-cement or re-bond crown – One per 6 month period; integral within 12 months of the placement of prosthesis

D2921 Reattachment of tooth fragment - Limited to one every 24 months

D2949 Restorative foundation for an indirect restoration - integral 

D2951 Pin retention – per tooth, in addition to restoration

Not Covered:

• Restorations, including veneers, which are placed for cosmetic purposes only 
• Gold foil restorations

D3220 Therapeutic pulpotomy (excluding final restoration)

D4341 Periodontal scaling and root planing – four or more teeth per quadrant – Limited to one periodontal surgical procedure per 24 months per area of the mouth; requires submission of diagnostic materials

D4342 Periodontal scaling and root planing – one to three teeth per quadrant – Limited to one periodontal surgical procedure per 24 months per area of the mouth; requires submission of diagnostic materials

D4346 Scaling in presence of generalized moderate or severe gingival inflammation-full mouth oral evaluation-Covered age 16 and older; once per 24 months. Combination of scaling with gingival inflammation and routine prophylaxis cannot exceed 2 per calendar year. 

D4910 Periodontal maintenance – Limited to 4 periodontal cleanings and 2 routine cleanings within a calendar year period; the total cannot exceed 4 in a calendar year.

D4921 Gingival irrigation with a medicinal agent - per quadrant - integral to periodontal services 

D4999 Unspecified periodontal procedure

Smile for Health®-Wellness is included in the High and Standard Options. This provides enhanced benefits for members with a qualifying condition. This includes coverage at 100% of our plan allowance for the following procedures: D4240, D4241, D4260,D4261, D4341, D4342, D4346, and D4910. One additional service is allowed for D4910 and all other frequency limitations apply. Members with the following conditions are eligible: Diabetes, Heart Disease, Cerebrovascular Disease (Stroke), Oral Cancer, Lupus, Organ Transplant, and Rheumatoid Arthritis. Members with those specific conditions must be registered prior to receiving services and can register at www.uccifedvip.com under MyDentalBenefits. Pregnancy benefit allows the same enhanced benefits during pregnancy for member who are registered in MyDentalBenefits. All other frequency limitations apply. 

Current Dental Terminology © American Dental Association

D5410 Adjust complete denture – maxillary – Integral within 6 months of the initial or replacement denture

D5411 Adjust complete denture – mandibular – Integral within 6 months of the initial or replacement denture

D5421 Adjust partial denture – maxillary – Integral within 6 months of the initial or replacement denture

D5422 Adjust partial denture – mandibular – Integral within 6 months of the initial or replacement denture

D5511 Repair broken complete denture base, mandibular

D5520 Replace missing or broken teeth – complete denture (each tooth)

D5611 Repair resin partial denture base, mandibular

D5621 Repair cast partial framework, mandibular

D5630 Repair or replace broken retentive clasping materials - per tooth

D5640 Replace broken teeth – per tooth

D5650 Add tooth to existing partial denture - one per arch per 36 months

D5660 Add clasp to existing partial denture- per tooth - one per arch per 36 months

D5670 Replace all teeth and acrylic on cast metal framework (maxillary)- one per 5 years 

D5671 Replace all teeth and acrylic on cast metal framework (mandibular) - one per 5 years 

D5710 Rebase complete maxillary denture – Limited to one in 36 months; integral within 6 months of the insertion of the initial or replacement denture

D5711 Rebase complete mandibular denture – Limited to one in 36 months; integral within 6 months of the insertion of the initial or replacement denture

D5720 Rebase maxillary partial denture – Limited to one in 36 months; integral within 6 months of the insertion of the initial or replacement denture

D5721 Rebase mandibular partial denture – Limited to one in 36 months; integral within 6 months of the insertion of the initial or replacement denture

D5725 Rebase hybrid prosthesis - Limited to one in 36 months; integral within 6 months of the insertion of the initial or replacement denture

D5730 Reline complete maxillary denture (direct) – Limited to one in 36 months; integral within 6 months of the insertion of the initial or replacement denture

D5731 Reline complete mandibular denture (direct) – Limited to one in 36 months; integral within 6 months of the insertion of the initial or replacement denture

D5740 Reline maxillary partial denture (direct) – Limited to one in 36 months; integral within 6 months of the insertion of the initial or replacement denture

D5741 Reline mandibular partial denture (direct) – Limited to one in 36 months; integral within 6 months of the insertion of the initial or replacement denture

D5750 Reline complete maxillary denture (indirect) – Limited to one in 36 months; integral within 6 months of the insertion of the initial or replacement denture

D5751 Reline complete mandibular denture (indirect) – Limited to one in 36 months; integral within 6 months of the insertion of the initial or replacement denture

D5760 Reline maxillary partial denture (indirect) – Limited to one in 36 months; integral within 6 months of the insertion of the initial or replacement denture

D5761 Reline mandibular partial denture (indirect) – Limited to one in 36 months; integral within 6 months of the insertion of the initial or replacement denture

D5765 Soft liner for complete or partial removable denture-indirect - Limited to one in 36 months; integral within 6 months of the insertion of the initial or replacement denture

D5850 Tissue conditioning (maxillary)

Current Dental Terminology © American Dental Association

D5851 Tissue conditioning (mandibular)

D6089 Accessing and retorquing loose implant screw - per screw 

D6092 Re-cement or re-bond implant/abutment support -Limited to one per 6 month period; integral within 12 months of the placement of prosthesis.

D6093 Re-cement or re-bond implant abutment supported fixed partial dentures -Limited to one per 6 month period; integral within 12 months of the placement of the prosthesis

D6980 Fixed partial denture repair, by report

D3921 Decoronation or submergence of erupted tooth

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

D7220 Removal of impacted tooth – soft tissue

D7230 Removal of impacted tooth – partially bony

D7240 Removal of impacted tooth – completely bony

D7250 Removal of residual tooth roots (cutting procedure)

D7251 Coronectomy – intentional partial tooth removal, impacted teeth only

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

D7280 Exposure of an unerupted tooth, one per tooth per lifetime. 

D7310 Alveoloplasty in conjunction with extractions – per quadrant

D7320 Alveoloplasty not in conjunction with extractions – per quadrant

D7471 Removal of exostosis

D7510 Incision and drainage of abscess – intraoral soft tissue

D7910 Suture of recent small wounds up to 5 cm

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

D7971 Excision of pericoronal gingiva

Current Dental Terminology © American Dental Association 

D0160 Detailed and extensive oral evaluation – problem focused, by report – Limited to one per patient per provider per lifetime

D2510 Inlays – metallic – one surface – Limited to one per 5 years, per tooth

D2520 Inlays – metallic – two surfaces – Limited to one per 5 years, per tooth

D2530 Inlays-metallic – three or more surfaces – Limited to one per 5 years, per tooth

D2542 Onlay – metallic – two surfaces – Limited to one per 5 years, per tooth

D2543 Onlay – metallic – three surfaces – Limited to one per 5 years,per tooth

D2544 Onlay – metallic – four or more surfaces – Limited to one per 5 years, per tooth

D2740 Crown – porcelain/ceramic – Limited to one per 5 years, per tooth

D2750 Crown – porcelain fused to high noble metal – Limited to one per 5 years, per tooth

D2751 Crown – porcelain fused to predominately base metal – Limited to one per 5 years, per tooth

D2752 Crown – porcelain fused to noble metal – Limited to one per 5 years, per tooth

D2753 Crown - porcelain fused to titanium and titanium alloys - Limited to one in 5 years, per tooth

D2780 Crown – 3/4 cast high noble metal – Limited to one per 5 years, per tooth

D2781 Crown – 3/4 cast predominately base metal – Limited to one per 5 years, per tooth

D2782 Crown – 3/4 cast noble metal – Limited to one per 5 years, per tooth

D2783 Crown – 3/4 porcelain/ceramic – Limited to one per 5 years, per tooth

D2790 Crown – full cast high noble metal – Limited to one per 5 years, per tooth

D2791 Crown – full cast predominately base metal – Limited to one per 5 years, per tooth

D2792 Crown – full cast noble metal – Limited to one per 5 years, per tooth

D2794 Crown – titanium and titanium alloys – Limited to one per 5 years, per tooth

D2950 Core buildup, including any pins – Limited to one per 5 years, per tooth

D2954 Prefabricated post and core, in addition to crown – Limited to one per 5 years, per tooth

D2980 Crown repair

D2981 Inlay repair necessitated by restorative material failure

D2982 Onlay repair necessitated by restorative material failure

D2983 Veneer repair

D2999 Unspecified restorative procedure, by report

Not covered:

• Gold foil restorations
• Sedative restorations
• Restorations for cosmetic purposes only
• Composite resin inlays

D3310 Anterior root canal (excluding final restoration)

D3320 Endodontic therapy, premolar tooth(excluding final restoration)

D3330 Endodontic therapy, molar tooth (excluding final restoration)

D3331 Treatment of root canal obstruction, non-surgical access, integral 

D3332 Incomplete endodontic therapy – By report and is not covered when the patient discontinues treatment

D3346 Retreatment of previous root canal therapy-anterior

D3347 Retreatment of previous root canal therapy-premolar

D3348 Retreatment of previous root canal therapy-molar

Current Dental Terminology © American Dental Association

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

D3357 Pulpal regeneration – completion of treatment -one per tooth per lifetime 

D3450 Root amputation – per root

D3471 Surgical repair of root resorption-anterior - Integral if reported with an apicoectomy by the same dentist on the same date of service

D3472 Surgical repair of root resorption-premolar - Integral if reported with an apicoectomy by the same dentist on the same date of service

D3473 Surgical repair of root resorption-molar - Integral if reported  with an apicoectomy by the same dentist on the same date of service

D3501 Surgical exposure of root surface without apicoectomy or repair of root resorption-anterior - Intergral if reported with a apicoectomy by the same dentist on the same date of service.

D3502 Surgical exposure of root surface without apicoectomy or repair of root resorption- premolar- Integral if reported with an apicoectomy by the same dentist on the same date of service

D3503 Surgical exposure of root surface without apicoectomy or repair of root resorption- molar- Integral if reported with an apicoectomy by the same dentist on the same dated of service

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

D3999 Unspecified endodontic procedure, by report 

D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces, per quadrant – Limited to one periodontal surgical procedure per 24 months per area of the mouth

D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces, per quadrant – Limited to one periodontal surgical procedure per 24 months per area of the mouth

D4212 Gingivectomy or gingivoplasty to allow access for restorative procedures per tooth - Integral and ineligible as a separate service

D4240 Gingival flap procedure, including root planing, four of more contiguous teeth or bounded teeth spaces per quadrant – Limited to one periodontal surgical procedure per 24 months per area of the mouth

D4249 Clinical crown lengthening-hard tissue – Limited to one per tooth per lifetime

D4268 Surgical revision procedures, per tooth - Integral and not eligible as a separate service

Current Dental Terminology © American Dental Association

D4276 Combined connective tissue and pedicle graft, per tooth Limited to one periodontal surgical procedure per 24 months per area of the mouth

D4286 Removal of non-resorbable barrier - integral to periodontic services 

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

D5110 Complete denture – maxillary – Limited to one in 5 years

D5120 Complete denture – mandibular – Limited to one in 5 years

D5130 Immediate denture – maxillary – Limited to one in 5 years

D5140 Immediate denture – mandibular – Limited to one in 5 years

D5211 Maxillary partial denture – resin base (including retentive clasping material, rests and teeth) – Limited to one in 5 years

D5212 Mandibular partial denture – resin base (including retentive clasping material, rests and teeth) – Limited to one in 5 years

D5213 Maxillary partial denture – cast metal framework with resin denture base (including retentive/clasping materials, rests and teeth) – Limited to one in 5 years

D5214 Mandibular partial denture – cast metal framework with resin denture base (including retentive/clasping materials,rests and teeth) – Limited to one in 5 years

D5221 Immediate maxillary partial denture- resin base(including retentive/clasping materials,rests, and teeth) Limited to one in 5 years

D5222 Immediate mandibular partial denture-resin based(including retentive/clasping materials, rests, and teeth) Limited to one in 5 years

D5223 Immediate maxillary partial denture-cast metal framework with resin denture bases(including retentive/clasping materials, rests, and teeth) Limited to one in 5 years

D5224 Immediate mandibular partial denture-cast metal framework with resin denture bases(including retentive/clasping materials, rests, and teeth) Limited to one in 5 years

D5225 Maxillary partial denture, flexible base - Limited to one in 5 years

D5226 Mandibular partial denture, flexible base - Limited to one in 5 years

D5227 immediate mandibular partial denture-flexible base(including clasps,rests, teeth)- Limited to one in 5 years

Current Dental Terminology © American Dental Association

D5228 Immediate mandibular partial denture-flexible base(including clasps,rests,teeth)- Limited to one in 5 years

D5282 Removable unilateral partial denture-one piece cast metal(including retentive/clasping materials, rests and teeth), maxillary - Limited to one in 5 years

D5283 Removable unilateral partial denture-one piece cast metal(including retentive/clasping materials, rests and teeth), mandibular- Limited to one in 5 years

D5284 Removable unilateral partial denture-one piece flexible base(including retentive/clasping materials, rests and teeth) per quadrant - Limited to one in 5 years

D5286 Removable unilateral partial denture- one piece resin(including retentive/clasping materials, rests and teeth) per quadrant - Limited to one in 5 years

D5863 Overdentures complete maxillary - Limited to one in 5 years 

D5864 Overdentures partial maxillary - Limited to one in 5 years

D5865 Overdentures complete mandibular- Limited to one in 5 years

D5866 Overdentures partial mandibular- Limited to one in 5 years

D5876 Add metal substructure to acrylic full denture - Limited to one in 5 years

D5899 Unspecified removable prosthodontic procedure, by report

D6066 Implant supported porcelain crown/fused to high noble alloys – Limited to one in 5 years

D6067 Implant supported crown high noble alloys – Limited to one in 5 years

D6080 Implant maintenance procedures when prostheses are removed and reinserted, cleansing of prosthesis, and abutments- Dentally necessary only – Limited to one in 5 years

D6082 Implant supported crown- porcelain fused to predominantly base alloys - Limited to one in 5 years

D6083 Implant supported crown-porcelain fused to noble alloys - Limited to one in 5 years

D6084 Implant supported crown-porcelain fused to titanium and titanium alloys - Limited to one in 5 years

D6086 Implant supported crown, predominantly base alloys - Limited to one in 5 years

D6087 Implant supported crown,noble alloys - Limited to one in 5 years

D6088 Implant supported crown, titanium and titanium alloys - Limited to one in 5 years

D6091 Replacement of replaceable part of semi-precision or precision attachment – Limited to one in 5 years 

D6094 Abutment supported crown, titanium and titanium alloys – Limited to one in 5 years

D6097 Abutment supported crown, porcelain fused to titanium and titanium alloys - Limited to one in 5 years

D6102 Debridement of periimplant defect- Limited to one per tooth per lifetime

D6191 Semi-precision abutment - placement

D6192 Semi-precision attachment - placement

D6210 Pontic – cast high noble metal – Limited to one in 5 years

D6211 Pontic – cast predominately base metal – Limited to one in 5 years

D6212 Pontic – cast noble metal – Limited to one in 5 years

Current Dental Terminology © American Dental Association

D6214 Pontic – titanium and titanium alloys – Limited to one in 5 years

D6240 Pontic – porcelain fused to high noble metal – Limited to one in 5 years

D6241 Pontic – porcelain fused to predominately base metal – Limited to one in 5 years

D6242 Pontic – porcelain fused to noble metal – Limited to one in 5 years

D6243 Pontic, porcelain fused to titanium and titanium alloys - Limited to one in 5 years

D6245 Pontic – porcelain/ceramic – Limited to one in 5 years

D6545 Retainer – cast metal for resin bonded fixed prosthesis – Limited to one in 5 years

D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis – Limited to one in 5 years

D6549 Resin retainer - for resin bonded fixed prosthesis - Limited to one in 5 years

D6613 Onlay, cast predominantly base metal, three or more surfaces – Limited to one in 5 years

D6615 Onlay, cast noble metal, three or more surfaces – Limited to one in 5 years

D6753 Retainer crown, porcelain fused to titanium and titanium alloys - Limited to one in 5 years

D6784 Retainer crown 3/4, titanium and titanium alloys -Limited to one in 5 years 

D6794 Retainer crown, titanium and titanium alloys – Limited to one in 5 years

D7994 Surgical placement: zygomatic implant - Limited to one in 5 years

D7999 Unspecified oral surgery, by report 

D9932 Cleaning and inspection of removable complete denture, maxillary- Limited to one in a 12 month period

D9933 Cleaning and inspection of removable complete denture, mandibular - Limited to one in a 12 month period

D9934 Cleaning and inspection of removable partial denture,maxillary - Limited to one in a 12 month period

D9935 Cleaning and inspection of removable partial denture,mandibular - Limited to one per 12 month period

Current Dental Terminology © American Dental Association

Implant services may be allowed under the benefit plan. For the High Option we will limit payment on covered implant services to a calendar year maximum of $2,500. Replacement implant services are limited to one per 5 years after initial placement.

D6010 Surgical placement of implant body:endosteal implant- Limited to one in 5 years

D6011 Second stage implant surgery – Limited to one in 5 years

D6013 Surgical placement of mini implant – Limited to one in 5 years

D6040 Surgical placement; eposteal implant – Limited to one in 5 years

D6050 Surgical placement; transosteal implant – Limited to one in 5 years

D6055 Dental implant supported connecting bar- Limited to one in 5 years

D6056 Prefabricated abutment – includes modification and placement – Limited to one in 5 years

D6057 Custom fabricated abutment – includes placement – Limited to one in 5 years

D6068 Abutment supported retainer/porcelain/ceramic fixed partial denture – Limited to one in 5 years

D6069 Abutment supported retainer/porcelain/fused to metal (high noble) – Limited to one in 5 years

D6070 Abutment supported retainer/porcelain/fused to metal fixed partial denture – Limited to one in 5 years

D6071 Abutment support retainer/porcelain/fused to metal fixed partial denture(noble metal) – Limited to one in 5 years

D6072 Abutment supported retainer/cast metal fixed partial denture(high noble) – Limited to one in 5 years

D6073 Abutment supported retainer/cast metal fixed partial denture (base metal) – Limited to one in 5 years

D6074 Abutment supported retainer/cast metal fixed partial denture (noble metal) – Limited to one in 5 years

D6075 Implant supported retainer/ceramic fixed partial denture – Limited to one in 5 years

D6076 Implant supported retainer fixed partial denture, porcelain fused to alloys - Limited to one in 5 years

D6077 Implant supported retainer for metal fixed partial denture, high noble alloys – Limited to one in 5 years

D6090 Repair implant supported prosthesis, by report – Limited to one in 5 years

D6095 Repair implant abutment, by report – Limited to one in 5 years

D6096 Remove broken implant retaining screw

D6098 Implant supported retainer, porcelain fused to predominantly base alloys - Limited to one in 5 years

D6099 Implant supported retainer for fixed partial denture, porcelain fused to noble alloys - Limited to one in 5 years

D6100 Surgical removal of Implant, by report – Limited to one in 5 years

D6104 Bone graft at time of placement - Limited to one per tooth per lifetime

D6105 Removal of implant body not requiring bone removal nor flap elevation - Limited to one in 5 years

D6110 Implant/abutment support supported removable denture edentulous arch-maxillary-Limited to one in 5 years

D6111 Implant/abutment supported removable denture for edentulous arch mandibular-Limited to one in 5 years

D6112 Implant/abutment supported removable denture for partially edentulous arch-maxillary-Limited to one in 5 years

D6113 Implant/abutment supported removable denture for partially edentulous arch-mandibular-Limited to one in 5 years

D6114 Implant/abutment supported fixed denture for edentulous arch- maxillary – Limited to one in 5 years

D6115 Implant/abutment supported fixed denture for edentulous arch-mandibular – Limited to one in 5 years

D6116 Implant/abutment supported fixed denture for partially edentulous arch-maxillary – Limited to one in 5 years

D6117 Implant/abutment supported fixed denture for partially edentulous arch- mandibular – Limited to one in 5 years

D6120 Implant supported retainer, porcelain fused to titanium and titanium alloys - Limited to one in 5 years

D6121 Implant supported retainer for metal fixed partial denture, predominantly base alloy - Limited to one in 5 years

D6122 Implant supported retainer for metal fixed partial denture, noble alloys - Limited to one in 5 years

D6123 Implant supported retainer for metal fixed partial denture, titanium and titanium alloys - Limited to one in 5 years

D6194 Abutment supported retainer crown for fixed partial denture – titanium and titanium alloys  – Limited to one in 5 years

D6195 Abutment supported retainer, porcelain fused to titanium and titanium alloys - Limited to one in 5 years

Current Dental Terminology © American Dental Association

D6197 Replacement of restorative material used to close an access opening of a screw-retained implant supported prothesis, per implant - Limited to one in 5 years  

D6198 Remove interim implant component - Limited to one in 5 years

D7994 Surgical placement: zygomatic implant - Limited to one in 5 years

Not covered:

• Implant services other than those listed above. 
• Cast unilateral removable partial dentures
• Precision attachments, personalization, precious metal bases, and other specialized techniques
• Replacement of dentures that have been lost, stolen or misplaced
• Removable or fixed prostheses prescribed/initiated prior to the effective date of coverage or inserted/cemented after the coverage ending date

Current Dental Terminology © American Dental Association

D0340 Cephalometric film - Limited to one per patient per lifetime

D0350 Oral/facial images 

D0702 2-D cephalometric radiograhic image- Image capture only - Limited to one per member per lifetime

D8010 Limited orthodontic treatment of the primary dentition

D8020 Limited orthodontic treatment of the transitional dentition

D8030 Limited orthodontic treatment of the adolescent dentition

D8070 Comprehensive orthodontic treatment of the transitional dentition

D8080 Comprehensive orthodontic treatment of the adolescent dentition

D8210 Removable appliance therapy

D8220 Fixed appliance therapy

D8660 Pre-orthodontic treatment examination to monitor growth and development 

Current Dental Terminology © American Dental Association

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

D8681 Removable orthodontic retainer adjustment - Integral, not covered submitted as a separate service

D8999 Unspecified orthodontic procedure, by report 

Not covered:

• Repair of damaged orthodontic appliances
• Replacement of lost or missing appliance
• 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

Current Dental Terminology © American Dental Association

D9210 Local anesthesia not in conjunction with operative or surgical procedures - integral 

D9211 Regional block anesthesia - integral 

D9212 Trigeminal division block anesthesia - integral 

D9215 Local anesthesia in conjunction with operative or surgical procedures - integral 

D9219 Evaluation for moderate sedation, deep sedation or general anesthesia - Integral, limited to third molar extractions only, children up to age 22 and once per lifetime

D9222 Deep sedation/general anesthesia – first 15 minutes – Covered by report

D9230 - Inhalation of nitrous oxide/analgesia, anxiolysis - eligible for children aged 12 and under based on dental necessity and for members over 12 years with special needs/intellectual and developmental disabilities

D9239 Intravenous moderate (conscious) sedation/analgesia – first 15 minutes- Covered by report

Current Dental Terminology © American Dental Association

D9610 Therapeutic drug injection, by report

D9612 Therapeutic parenteral drugs, two or more administrations, different medications - by report 

D9613 Infiltration of sustained release therapeutic drug - per quadrant - covered to age 23 /  one per lifetime

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

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

D9943 Occlusal Guard adjustment - Limited to one per 24 months for patients  age 13 or over; not covered when performed for TMJ

D9944 Occlusal guard, hard appliance,full arch, – Limited to one per 12 month period for patients age 13 or over; not covered when performed for TMJ

D9945 Occlusal guard, soft appliance,full arch, – Limited to one per 12 month period for patients age 13 or over; not covered when performed for TMJ

D9946 Occlusal guard, hard appliance, partial arch, – Limited to one per 12 month period for patients age 13 or over; not covered when performed for TMJ

D9974 Internal bleaching – per tooth – Limited to one per endodontically treated tooth per 3 year period

D9999 Unspecified adjunctive procedure, by report

Not covered:

• Oral sedation
• Repair/reline of occlusal guard

Current Dental Terminology © American Dental Association

If you live overseas, you may visit any dentist.  You are responsible for submitting a claim form with a receipt.

Submit the claim form and receipt to:

United Concordia Companies, Inc.
P.O. Box 69416
Harrisburg, PA 17106-9416

You can download a claim form from our website at www.uccifedvip.com.

You may contact Customer Service at 1-877-394-8224 or by visiting our website at
www.uccifedvip.com.  

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

A United Concordia participating Federal Dental Program Network dentist files the claim for you.  If you do need to file a claim, you and the dentist should complete the appropriate claim form sections, and you should then mail the claim to the address below.  You can download a claim form from our website at www.uccifedvip.com.

United Concordia Companies, Inc.
PO. Box 69416
Harrisburg, PA 17106-9416

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

Disputed Claims Steps

1. Ask us in writing to reconsider our initial decision. You must file an appeal with us within 180 days of receipt of the initial decision. Please submit with your appeal, the appropriate written comments from the treating dentist, supporting documents, dental records and other information relating to the claim(s).
2. We have 60 days from the date we receive your request to review the appeal in a thorough, appropriate and timely manner to ensure that you are afforded a full and fair review of claims for benefits.
3. If the dispute is not resolved through the reconsideration process, you may request a review of the denial. You must file the appeal to us within 30 days of the receipt of the first review decision. Any dentist advisor involved in reviewing the appeal will be different from and not in a subordinate position to the dentist advisor involved in the initial benefit determination.
4. If you do not agree with our final decision, you may request an independent third party, mutually agreed upon by us and OPM, to review the decision. You must file the appeal in writing to United Concordia Dental within 30 days of receipt of the original appeal decision. The appeal should be mailed, with the appropriate written comments from the treating dentist, supporting documents, dental records and other information relating to the claim(s) to:

United Concordia Companies, Inc.
Member Appeals Department
P.O. Box 69420
Harrisburg, PA 17106-9420

The independent third party will thoroughly review the appeal and provide the decision to United Concordia Dental who will in turn respond to you in writing within 60 days of receipt of the third party review request. 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.

The maximum annual benefit that you can receive per person each calendar year. For the High Option our Plan includes an annual benefit maximum of Unlimited and $2,500 annual benefit maximum for Implant Services, per covered person. For the Standard Option our Plan includes $1,500 annual benefit maximum per covered person. Once you reach this amount, you are responsible for all charges.

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

Dental services that initiated/prescribed or performed in 2023 that will be completed in 2024.

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

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

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