Blue Cross Blue Shield FEP Dental
Table of Contents
Table of Contents
Table of Contents
Introduction 1
Table of Contents 2
Changes for 2024 4
FEDVIP Program Highlights 5
Class B Intermediate 20
Class C Major 25
Class D Orthodontic 34
General Services 36
Section 6 International Services and Supplies 38
Section 7 General Exclusions – Things We Do Not Cover 39
Section 8 Claims Filing and Disputed Claims Processes 41
Section 9 Definitions of Terms We Use in This Brochure 42
Discounts 44
Tool and Resources 45
Summary of Benefits 46
Stop Health Care Fraud! 48
Rate Information 50
Rates 51
Table of Contents 2
Changes for 2024 4
FEDVIP Program Highlights 5
A Choice of Plans and Options 5
Enroll Through BENEFEDS 5
Dual Enrollment 5
Coverage Effective Date 5
Pre-Tax Salary Deduction for Employees 5
Annual Enrollment Opportunity 5
Continued Group Coverage After Retirement 5
Compliance with the American Dental Association (ADA) 6
Section 1 Eligibility 6Enroll Through BENEFEDS 5
Dual Enrollment 5
Coverage Effective Date 5
Pre-Tax Salary Deduction for Employees 5
Annual Enrollment Opportunity 5
Continued Group Coverage After Retirement 5
Compliance with the American Dental Association (ADA) 6
Federal Employees 6
Federal Annuitants 6
Survivor Annuitants 6
Compensationers 6
TRICARE-eligible individual 6
Family Members 7
Not Eligible 7
Section 2 Enrollment 8Federal Annuitants 6
Survivor Annuitants 6
Compensationers 6
TRICARE-eligible individual 6
Family Members 7
Not Eligible 7
Enroll Through BENEFEDS 8
Enrollment Types 8
Dual Enrollment 8
Opportunities to Enroll or Change Enrollment 9
When Coverage Stops 10
Continuation of Coverage 11
FSAFEDS/High Deductible Health Plans and FEDVIP 11
Section 3 How You Obtain Care 12Enrollment Types 8
Dual Enrollment 8
Opportunities to Enroll or Change Enrollment 9
When Coverage Stops 10
Continuation of Coverage 11
FSAFEDS/High Deductible Health Plans and FEDVIP 11
Identification Cards/Enrollment Confirmation 12
Where You Get Covered Care 12
Plan Dentists 12
In-Network 12
Out-of-Network 12
Emergency Services 12
Pre-treatment Estimate 12
Alternate Benefit 13
Dental Review 13
FEHB First Payor 13
Coordination of Benefits (COB) 14
Rating Areas 14
Limited Access Area 14
Section 4 Your Cost For Covered Services 15Where You Get Covered Care 12
Plan Dentists 12
In-Network 12
Out-of-Network 12
Emergency Services 12
Pre-treatment Estimate 12
Alternate Benefit 13
Dental Review 13
FEHB First Payor 13
Coordination of Benefits (COB) 14
Rating Areas 14
Limited Access Area 14
Deductible 15
Coinsurance 15
Annual Benefit Maximum 16
Lifetime Benefit Maximum 16
In-Network Services 16
Out-of-Network Services 16
Plan Allowance 16
Calendar Year 16
Emergency Services 16
In-Progress Treatment 16
Section 5 Dental Services and Supplies Class A Basic 17Coinsurance 15
Annual Benefit Maximum 16
Lifetime Benefit Maximum 16
In-Network Services 16
Out-of-Network Services 16
Plan Allowance 16
Calendar Year 16
Emergency Services 16
In-Progress Treatment 16
Class B Intermediate 20
Class C Major 25
Class D Orthodontic 34
General Services 36
Section 6 International Services and Supplies 38
Section 7 General Exclusions – Things We Do Not Cover 39
Section 8 Claims Filing and Disputed Claims Processes 41
Section 9 Definitions of Terms We Use in This Brochure 42
Discounts 44
Tool and Resources 45
Summary of Benefits 46
Stop Health Care Fraud! 48
Rate Information 50
Rates 51