Blue Cross Blue Shield FEP Dental
®
www.bcbsfepdental.com
1-855-504-BLUE (2583)
2024
A Nationwide Dental PPO Plan
IMPORTANT
• Rates: Back Cover
• Summary of Benefits: Page 46
Who may enroll in this Plan: All Federal employees, annuitants, and
certain TRICARE beneficiaries in the United States and overseas who
are eligible to enroll in the Federal Employees Dental and Vision
Insurance Program.
Enrollment Options for this Plan:
• High Option – Self Only
• High Option – Self Plus One
• High Option – Self and Family
• Standard Option – Self Only
• Standard Option – Self Plus One
• Standard Option – Self and Family
This Plan has five enrollment regions, including international; please see the end of this brochure to
determine your region and corresponding rates.
Introduction
On December 23, 2004, President George W. Bush signed the Federal Employee Dental and Vision Benefits Enhancement Act of
2004 (Public Law 108-496). The law directed the Office of Personnel Management (OPM) to establish supplemental dental and
vision benefit programs to be made available to Federal employees, annuitants, and their eligible family members. In response to
the legislation, OPM established the Federal Employees Dental and Vision Insurance Program (FEDVIP). OPM has contracted
with dental and vision insurers to offer an array of choices to Federal employees and annuitants. Section 715 of the National
Defense Authorization Act for Fiscal Year 2017 (FY 2017 NDAA), Public Law 114-38, expanded FEDVIP eligibility to certain
TRICARE-eligible individuals.
This brochure describes the benefits of BCBS FEP Dental under the Blue Cross and Blue Shield Association’s contract OPM02-
FEDVIP-02AP-03 with OPM, as authorized by the FEDVIP law. The address for our administrative office is:
Blue Cross Blue Shield FEP Dental
PO Box 75
Minneapolis, MN 55440-0075
1-855-504-BLUE (2583)
www.bcbsfepdental.com
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure. It is your responsibility to be informed about your benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One,
you and your designated family member are entitled to these benefits. If you are enrolled in Self and Family coverage, each of
your eligible family members is also entitled to these benefits, if they are also listed on the coverage. You and your family
members do not have a right to benefits that were available before January 1, 2024 unless those benefits are also shown in
this brochure.
OPM negotiates rates with each carrier annually. Rates are shown at the end of this brochure.
BCBS FEP Dental is responsible for the selection of in-network dentists in your area. Contact us at 1-855-504-BLUE (2583) or
TTY: 711 for the names of participating dentists or to request a Zip code-based dentist directory. Network dentists are listed on
our website at www.bcbsfepdental.com/findadentist and on the BCBS FEP Dental mobile app. Our directory is updated weekly.
You may also contact us at 1-855-504-BLUE (2583) for further assistance. Continued participation of any specific dentist cannot
be guaranteed. Thus, you should choose your plan based on the benefits provided and not on a specific dentist's participation.
When you phone for an appointment, please remember to verify that the dentist is currently in the BCBS FEP Dental network. If
your dentist is not currently participating in the network, you can nominate them to join. Dentist nominations can be submitted
online or via the mobile app. You can also print a nomination form from our website at www.bcbsfepdental.com or call us at
1-855-504-BLUE (2583) and we will send you a form. Bring the form to your dentist and ask them to complete it if they are
interested in participating in our network. You cannot change plans outside of Open Season because of changes to the
dentist network.
The network may be more extensive in some areas than others. We cannot guarantee the availability of every specialty in all
areas. If you require the services of a specialist and one is not available in your area, contact us for assistance. Please be aware
that the BCBS FEP Dental network may be different from your health plan's network.
This BCBS FEP Dental Plan and all other FEDVIP plans are not a part of the Federal Employees Health Benefits (FEHB)
Program.
We want you to know that protecting the confidentiality of your individually identifiable health information is of the utmost
importance to us. To review full details about our privacy practices, our legal duties, and your rights, visit our website at
www.bcbsfepdental.com and link to the “Policies” at the bottom of the page. If you do not have access to the internet or would
like further information, contact us by calling 1-855-504-BLUE (2583) or 711 for TTY relay.
Discrimination is Against the Law
BCBS FEP Dental complies with all applicable Federal civil rights laws, to include both Title VII of the Civil Rights Act of 1964
and Section 1557 of the Affordable Care Act. Pursuant to Section 1557, BCBS FEP Dental does not discriminate, exclude people,
or treat them differently on the basis of race, color, national origin, age, disability, or sex.
1 2024 Blue Cross Blue Shield FEP Dental®
Table of Contents
Introduction ...................................................................................................................................................................................1
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) ...............................................................................................5
Section 1 Eligibility ......................................................................................................................................................................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 .....................................................................................................................................................................8
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 .................................................................................................................................................12
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 .................................................................................................................................15
Deductible .........................................................................................................................................................................15
Coinsurance .......................................................................................................................................................................15
Annual Benefit Maximum ................................................................................................................................................16
2 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
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 ...............................................................................................................17
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
Tools and Resources ....................................................................................................................................................................45
Summary of Benefits ..................................................................................................................................................................46
Stop Health Care Fraud! .............................................................................................................................................................48
Rate Information .........................................................................................................................................................................50
Rates ............................................................................................................................................................................................51
3 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Changes for 2024
Benefit Changes:
Changes for both High and Standard Options
•We will cover two routine oral exams and one additional exam if a problem happens between checkups. We previously
covered just two oral exams.
•We will cover nitrous oxide (laughing gas) for children 5 and under and other individuals with a medical condition that
may require it.
We've added the following procedure codes:
•D2989 Excavation of a tooth resulting in the determination of non-restorability
•D6089 Accessing and retorquing loose implant screw - per screw
4 2024 Blue Cross Blue Shield FEP Dental®
FEDVIP Program Highlights
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.
A Choice of Plans and
Options
You enroll online at www.BENEFEDS.com. Please see Section 2, Enrollment, for more
information.
Enroll Through
BENEFEDS
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.
Dual Enrollment
If you sign up for a dental and/or vision plan during the 2023 Open Season, your coverage
will begin on January 1, 2024. Premium deductions will start with the first full pay period
beginning on/after January 1, 2024. You may use your benefits as soon as your enrollment
is confirmed.
Coverage Effective Date
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.
Pre-Tax Salary Deduction
for Employees
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.
Annual Enrollment
Opportunity
Your enrollment or your eligibility to enroll may continue after retirement. You do not
need to be enrolled in FEDVIP for any length of time to continue enrollment into
retirement. Your family members may also be able to continue enrollment after your
death. Please see Section 1, Eligibility, for more information.
Continued Group
Coverage After
Retirement
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.
Compliance with the
American Dental
Association (ADA)
5 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Section 1 Eligibility
If you are a Federal or U.S. Postal Service employee, you are eligible to enroll in FEDVIP, if
you are eligible for the Federal Employees Health Benefits (FEHB) Program or the Health
Insurance Marketplace (Exchange) and your position is not excluded by law or regulation, you
are eligible to enroll in FEDVIP. Enrollment in the FEHB Program or a Health Insurance
Marketplace (Exchange) plan is not required.
Federal Employees
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.
Temporary /
Seasonal
Employees
You are eligible to enroll if you:
• retired on an immediate annuity under the Civil Service Retirement System (CSRS), the
Federal Employees Retirement System (FERS) or another retirement system for employees
of the Federal Government;
• retired for disability under CSRS, FERS, or another retirement system for employees of the
Federal Government.
Your FEDVIP enrollment will continue into retirement if you retire on an immediate annuity or
for disability under CSRS, FERS or another retirement system for employees of the
Government, regardless of the length of time you had FEDVIP coverage as an employee. There
is no requirement to have coverage for 5 years of service prior to retirement in order to continue
coverage into retirement, as there is with the FEHB Program.
Your FEDVIP coverage will end if you retire on a Minimum Retirement Age (MRA) + 10
retirement and postpone receipt of your annuity. You may enroll in FEDVIP again when you
begin to receive your annuity.
Federal Annuitants
If you are a survivor of a deceased Federal/U.S. Postal Service employee or annuitant and you
are receiving an annuity, you may enroll or continue the existing enrollment.
Survivor
Annuitants
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.
Compensationers
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.
TRICARE-eligible
individual
6 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
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.
Family Members
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 dental plan
• FEHB Temporary Continuation of Coverage (TCC) enrollees
• Anyone receiving an insurable interest annuity who is not also an eligible family member
• Active-duty uniformed service members
Note: If you are an active-duty uniformed service member, your dental and vision coverage will
be provided by TRICARE. Your family members will still be eligible to enroll in the TRICARE
Dental Plan (TDP)
• Temporary/seasonal employees who do not meet the 130 hours per calendar month for 90
days
Not Eligible
7 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Section 2 Enrollment
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 (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.
Enroll Through
BENEFEDS
Self Only: A Self Only enrollment covers only you as the enrolled employee or annuitant. You
may choose a Self Only enrollment even though you have a family; however, your family members
will not be covered under FEDVIP.
Self Plus One: A Self Plus One enrollment covers you as the enrolled employee or annuitant plus
one eligible family member whom you specify. You may choose a Self Plus One enrollment even
though you have additional eligible family members, but the additional family members will not be
covered under FEDVIP.
Self and Family: A Self and Family enrollment covers you as the enrolled employee or annuitant
and all of your eligible family members. You must list all eligible family members when enrolling.
Enrollment
Types
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.
Dual Enrollment
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;
• an employee returning to service following a break in service of at least 31 days; or
• a TRICARE-eligible individual.
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.
8 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
The following 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 (LWOP)
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)
Opportunities to
Enroll or Change
Enrollment
9 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
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 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
([email protected]) within 60 days of notification to support the FEDVIP enrollment
change or 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 employees, 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;
• the sponsor or primary enrollee leaves active duty
When Coverage
Stops
10 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
• you 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;
• you are making direct premium payments to BENEFEDS and you stop making the payments;
• you cancel the enrollment during Open Season.
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 BCBS FEP Dental 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).
Continuation of
Coverage
FSAFEDS/High Deductible Health Plans and FEDVIP
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.
FSAFEDS/High
Deductible
Health Plans and
FEDVIP
11 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Section 3 How You Obtain Care
When you enroll for the first time, you will receive a welcome letter along with an
identification (ID) card which will serve as confirmation of your enrollment. Each
contract holder will receive two BCBS FEP Dental ID cards. The ID cards will only have
the contract holder's name on them. Since most FEHB plans offer some level of dental
benefits separate from your FEDVIP coverage, presenting both ID cards can ensure that
you receive the maximum allowable benefit under each program along with accurate and
timely claims processing.
Existing members who were previously issued ID cards will not receive new ID cards
unless otherwise requested. You may order a replacement ID card via
www.bcbsfepdental.com or by calling customer service at 1-855-504-BLUE (2583).
An ID card is neither a guarantee of benefits nor does your dentist need it to render dental
services. Your dentist may call 1-855-504-BLUE (2583) to confirm your enrollment and
the benefits available to you.
Identification Cards/
Enrollment
Confirmation
You can obtain care from any licensed dentist in the United States or overseas. Where You Get Covered
Care
Network dentist are listed on our website at www.bcbsfepdental.com/findadentist and on
the BCBS FEP Dental mobile app. Our directory is updated weekly. You may also contact
us at 1-855-504-BLUE (2583) for further assistance.
Plan Dentists
BCBS FEP Dental negotiates rates with dentists to help reduce your costs. We refer to
these dentists as in-network. If you use one of these dentists, benefits are paid at the in-
network level. To find a dentist in your area go to www.bcbsfepdental.com/findadentist or
contact customer service at 1-855-504-BLUE (2583).
Note: The BCBS FEP Dental dentist network may be different from the BCBS
Federal Employee Program (FEP) medical network.
Before each appointment, verify the dentist is in-network at the service location.
In-Network
You may obtain care from any licensed dentist. If the dentist you use is not part of our
network, we will pay for their services based on an out-of-network benefit level and plan
allowance, resulting in a lower annual maximum benefit. You are responsible for the
difference between our payment and the amount billed. If you choose to go out of
network, we will pay our portion to the contract holder directly.
Out-of-Network
Emergency services are defined as those dental services needed to relieve pain or prevent
the worsening of a condition that would be caused by a delay.
Emergency Services
Pre-treatment estimates are not mandatory. However, we do recommend that your dentist
submits a pre-treatment estimate if you are considering major or extensive dental care.
Pre-treatment estimates should include a comprehensive treatment plan and necessary
supporting documentation such as, chart notes, radiographic images, and photos.
Benefits may be alternated to a least costly procedure that meets broadly accepted national
standards of dental practice.
We will provide a non-binding, explanation of benefits to both you and your dentist that
will indicate if procedures are covered and an estimate of what we will pay for those
specific services. The estimated plan allowance is based on your current eligibility and
benefits in effect at the time of the pre-treatment estimate. Submission of other claims or
changes in eligibility or benefits may alter final payment. A pretreatment estimate is not a
guarantee of benefits.
Pre-treatment Estimate
12 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Pre-treatment estimates are valid through the calendar year in which they are processed, or
12 months, subject to eligibility and plan limitations.
Submit pre-treatment estimates to BCBS FEP Dental at the address below. Do not send
pre-treatment estimates to your medical plan.
BCBS FEP Dental
P.O. Box 75
Minneapolis, MN 55440-0075
If more than one service or procedure can be used to treat the dental condition, we reserve
the right to authorize an alternate, less costly covered service as deemed by a dental
professional to be appropriate and to meet broadly accepted national standards of dental
practice.
If you and your dentist choose the more expensive treatment instead of the alternate
benefit, you are responsible for the additional charges beyond the plan allowance for the
alternate service.
Example: If a dental professional determines an implant is not dentally necessary or a less
expensive appropriate treatment is available, no benefits will be allowed for the individual
implant or implant related procedures, and the allowance for the less expensive treatment
may be approved.
Alternate Benefit
Some dental services submitted on a claim may be reviewed for benefit determination and
dental necessity. This review is conducted by licensed dental professionals who will
review the clinical documentation and diagnostic images submitted by your treating
dentist.
There may be situations resulting from the dental review where an alternate benefit is
applied that meets broadly accepted national standards of dental practice. This review
applies to procedures including but not limited to, onlays, crowns, buildups, bridges,
implants, periodontal treatment, extractions and anesthesia.
Dental Review
It is important to know that, per FEDVIP requirements, the FEHB plan will always be the
first payor when you are also covered under BCBS FEP Dental. Therefore, always provide
your dental office with both your FEHB and BCBS FEP Dental ID cards at each
appointment. Your dental office should submit your claim(s) to the FEHB carrier first.
When you visit a provider who participates with both your FEHB plan and your FEDVIP
plan, the FEHB plan will pay benefits first.
In these cases, the BCBS FEP Dental plan allowance will be the negotiated allowable
charge between the plan and the dentist. You are responsible for the difference between
the total FEHB and BCBS FEP Dental payment and the plan allowance.
We are responsible for facilitating the process if the primary FEHB payor is FEP medical.
If you are covered under the Blue Cross Blue Shield Service Benefit Plan Basic Option
and BCBS FEP Dental, you are not responsible for the $30 co-pay (up to 2 evaluations per
year). If your dentist collects the co-pay upfront, they are required to reimburse the co-
pay in full once the claim has processed under BCBS FEP Dental.
Please see the following examples that assume all deductibles have been met and annual
maximums have not been reached.
FEHB First Payor
13 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Example 1: High Option coverage (In-Network dentist)
Class B dentist fee: $108.00
FEHB payment: $16.00
BCBS FEP Dental plan allowance: $60.00
BCBS FEP Dental payment: $42.00 ($60.00 at 70%)
Member’s responsibility*: $2.00 ($60-$16-$42)
Example 2: High Option coverage (Out-of-Network dentist).
Class B dentist fee: $108.00
FEHB payment: $16.00
BCBS FEP Dental payment: $64.80 ($108.00 at 60%)
Member’s responsibility*: $27.20 ($108-$16-$64.80)
*Assumes dentist charge is within the plan allowance
If you are covered under a non-FEHB plan, your BCBS FEP Dental benefits will be
coordinated using traditional COB provisions for determining payment. We will
coordinate benefit payments with the payment of benefits under other group health
benefits coverage (non-FEHB) you may have and the payment of dental costs under no-
fault insurance that pays benefits without regard to fault. Please see the following
examples that assume all deductibles have been met and annual maximums have not been
reached.
Example 1: High Option coverage (In-Network dentist)
Class B dentist fee: $121.00
FEHB payment: $60.50
BCBS FEP Dental plan allowance: $73.00
BCBS FEP Dental payment: $51.10 ($73.00 at 70%)
Payment by BCBS FEP Dental: $12.50
Member’s responsibility*: $0.00 ($73-$60.50-$12.50)
Example 2: High Option coverage (Out-of-Network dentist)
Class B dentist fee: $121.00
FEHB payment: $96.80
BCBS FEP Dental payment: $72.60 ($121.00 at 60%)
Payment by BCBS FEP Dental: $24.20 ($121-$96.80)
Member’s responsibility*: $27.20 ($121-$96.80-$24.20)
*Assumes dentist charge is within the plan allowance
Coordination of Benefits
(COB)
Your rates are determined based on where you live. This is called a rating area. If you
move, you must update your address through BENEFEDS at www.BENEFEDS.com or by
phone at 877-888-FEDS (3337). Your rates might change because of the move. Your rates
will not be impacted if you temporarily reside at another location.
Rating Areas
If you live in an area with limited access to a network dentist and you receive covered
services from an out-of-network dentist, we will pay the same benefit level as if you
utilized the services of an in-network dentist. A limited access area is a driving distance
greater than 15 miles in urban areas, or greater than 35 miles in rural areas. You are
responsible for any difference between the amount billed and our payment.
If you need assistance locating an in-network dentist in your area, please call us at
1-855-504-BLUE (2583).
Limited Access Area
14 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Section 4 Your Cost For Covered Services
This is what you will pay out-of-pocket for covered care:
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: $75
Class B
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $50
Out-of-Network Standard Option: $75
Class C
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $50
Out-of-Network Standard Option: $75
Orthodontics
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $0
Out-of-Network Standard Option: $0
Deductible
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%
Coinsurance
15 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Once you reach this amount, you are responsible for all additional charges. The Annual
Benefit Maximums within each plan 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 Benefit Maximum:
In-Network High Option: Unlimited
In-Network Standard Option: $1,500
Out-of-Network High Option: $3,000
Out-of-Network Standard Option: $750
Annual Benefit
Maximum
The Lifetime Benefit Maximum is applicable to orthodontia benefits only. There are no
other Lifetime Benefit Maximums under this Plan.
Lifetime Benefit Maximum
In-Network High Option: up to $3,500
In-Network Standard Option: up to $2,500
Out-of-Network High Option: up to $3,500
Out-of-Network Standard Option: up to $1,250
Lifetime Benefit
Maximum
You pay the coinsurance percentage of our plan allowance for covered services. Before
each appointment, verify the dentist is in-network at the service location.
Only dentists listed with their corresponding locations are in network. Not all dentists at a
location may be in network and the same dentist at a different location may not be in
network. It is your responsibility to ensure that the listed dentist is active and in network
at the time and location at which you receive services.
In-Network Services
If the dentist you use is not part of our network, benefits will be considered at the out-of-
network level. All services provided by an out-of-network dentist will be paid at out-of-
network levels, except for limited access benefits. We pay for services rendered by an out-
of-network dentist based on an out-of-network plan allowance. You will be responsible
for your co-insurance percentage plus the billed amount over plan allowance.
Out-of-Network Services
Our plan allowance is the amount we use to determine our payment and your coinsurance
for covered services. We determine our allowance as follows:
• For in-network dentists, based on our contracted dental rates. The member is not
responsible for billed amounts that are more than the plan allowance.
• For out-of-network dentists, based on the out-of-network plan allowance. FAIR Health
(a non-profit, non-insurance operation) data is utilized to determine the out-of-network
plan allowance. The member is responsible for any amounts billed by out-of-network
dentists that are above the plan allowance, plus their coinsurance amount.
Plan Allowance
The calendar year refers to the plan year, which is defined as January 1, 2024 to December
31, 2024.
Calendar Year
Emergency or accident related services are covered the same as any other benefit. Emergency 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 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.
In-Progress Treatment
16 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Section 5 Dental Services and Supplies
Class A Basic
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when determined to be necessary for the prevention, diagnosis, care, or treatment of a
covered condition and if they are determined to meet broadly accepted national standards of practice.
•The calendar year deductible is $0 if you use an in-network dentist. If you elect to use an out-of-network
dentist, Standard Option has a $75 deductible per person; High Option has a $50 deductible per person.
Neither option contains a family deductible; each enrolled covered person must satisfy their own deductible.
•There is no High Option Annual Benefit Maximum for non-orthodontic in-network services, and $3,000 for
out-of-network services.
•The Standard Option Annual Benefit Maximum for non-orthodontic services is $1,500 for in-network
services and $750 for out-of-network services. In no instance will BCBS FEP Dental allow more than
$1,500 in combined benefits under Standard Option in any plan year.
•The frequencies between your FEHB and BCBS FEP Dental policy are combined, not separate. (ex. If 2 oral
exams are covered under your FEHB policy, and 2 oral exams are covered under BCBS FEP Dental a total of
2 oral exams will be covered and coverage will coordinate between policies)
•The following is an all-inclusive list of covered services.
You Pay:
High Option
•In-Network: Preventive and Diagnostic services - $0 for covered services as defined by the plan, subject to
plan maximums.
•Out-of-Network: Preventive and Diagnostic services – $50 deductible and then you pay 10% of the plan
allowance, subject to plan maximums. You are responsible for any difference between our allowance and the
billed amount.
Standard Option
•In-Network: Preventive and Diagnostic services - $0 for covered services as defined by the plan, subject to
plan maximums.
•Out-of-Network: $75 deductible and then you pay 40% of the plan allowance, subject to plan maximums.
You are responsible for any difference between our allowance and the billed amount.
Diagnostic Services
D0120 Periodic oral evaluation - established patient - Limit 2 per calendar year - see additional benefit limitations at the end of this
section
D0140 Limited oral evaluation - problem focused - Limit 1 per calendar year - see additional limitations at the end of this section
D0145 Oral evaluation for a patient under 3 years of age and counseling with a primary caregiver. Limit 2 per calendar year – see
additional benefit limitations at the end of this section
D0150 Comprehensive oral evaluation - new or established patient - Limit 1 per calendar year - see additional benefit limitations at
the end of this section
D0160 Detailed and extensive oral evaluation - problem focused, by report - Limit 1 per calendar year - see additional limitations at
the end of this section
D0180 Comprehensive periodontal evaluation - new or established patient - Limit 1 per calendar year - see additional benefit
limitations at the end of this section. If billed with a D4910, the D0180 will alternate to a D0120.
D0210 Intraoral - comprehensive series of radiographic images including bitewings - Limit 1 every 60 months for any combination
of comprehensive series of radiographic images
Diagnostic Services - continued on next page
17 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Diagnostic Services (cont.)
D0220 Intraoral - periapical radiographic image
D0230 Intraoral - periapical each additional radiographic image
D0240 Intraoral - occlusal radiographic image
D0250 Extraoral - 2D projection radiographic image created using a stationary radiation source, and detector
D0251 Extra-oral - posterior dental radiographic image
D0270 Bitewing - single - radiographic image - Limit 2 per calendar year of any combination of bitewings for patients up to age 22,
1 per calendar year of any combination ofbitewings for all others
D0272 Bitewings - two radiographic images - Limit 2 per calendar year of any combination of bitewings for patients up to age 22, 1
per calendar year of any combination of bitewings for all others.
D0273 Bitewings - three radiographic images Limit - 2 per calendar year of any combination of bitewings for patients up to age 22,
1 per calendar year of any combination of bitewings for all others.
D0274 Bitewings - four radiographic images - Limit 2 per calendar year of any combination of bitewings for patients up to age 22,
1 per calendar year of any combination of bitewings for all others.
D0277 Bitewings - Seven to eight radiographic images - Limit 2 per calendar year for any combination of bitewings for patients up
to age 22, 1 per calendar year for any combination of bitewings for all others.
D0330 Panoramic radiographic image - Limit 1 every 60 months
D0372 Intraoral tomosynthesis – comprehensive series of radiographic images - Limit 1 every 60 months for any combination of
comprehensive series of radiographic images
D0373 Intraoral tomosynthesis – bitewing radiographic image - Limit 2 per calendar year of any combination of bitewings for
patients up to age 22, 1 per calendar year of any combination of bitewings for all others
D0374 Intraoral tomosynthesis – periapical radiographic image
D0425 Caries susceptibility tests
D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written
report
Class A Diagnostic Services Notes and Limitations:
Non-problem focused exams – Limit 2 per year
• Periodic oral evaluation (D0120), oral evaluation for a child under age 3 (D0145), comprehensive oral evaluation (D0150) and
comprehensive periodontal evaluation (D0180) are combined and limited to a total of 2 per year
- Comprehensive oral evaluation (D0150) and comprehensive periodontal evaluation(D0180) are combined and limited to 1 per
year
- Comprehensive oral evaluations in excess of the 1 per year limit will be processed as a periodic evaluation
Problem-focused exams – Limit 1 per year
• Limited oral evaluation (D0140) and detailed and extensive oral evaluation (D0160) are combined and limited to 1 per year
Diagnostic Imaging
• 14 or more radiographic images on the same date of service will be processed as a D0210 (complete set of radiographic images)
• Bitewing radiographic images with the same date of service as a panoramic radiographic image will be processed as a D0210
Preventive Services
D1110 Prophylaxis – Adult: Limit 3 during the calendar year. Age 13 and under will be processed as D1120 - additional
information on the following page.
D1120 Prophylaxis – Child: Limit 3 during the calendar year. Age 14 and over will be processed as D1110 - additional information
on the following page.
D1206 Topical application of fluoride varnish - Limit 2 during the calendar year for patients up to age 22 in combination with
D1208
D1208 Topical application of fluoride -excluding varnish - Limit 2 during the calendar year for patients up to age 22 in combination
with D1206
Preventive Services - continued on next page
18 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Preventive Services (cont.)
D1351 Sealant - per tooth - unrestored 1st and 2nd permanent molars for patient up to age 22 - any combination of a sealant or a
preventive resin restoration - Limit 1 every 36 months
D1352 Preventive resin restoration in a moderate to high caries risk patient - unrestored 1st and 2nd permanent tooth for patient up
to age 22 - any combination of a sealant or a preventive resin restoration - Limit 1 every 36 months
D1353 Sealant repair - per unrestored 1st and 2nd permanent molar for patient up to age 22 - any combination of a sealant or
preventive resin restoration - Limit 1 every 36 months
D1354 Application of caries arresting medicament - per tooth
D1510 Space maintainer - fixed - unilateral - per quadrant - Limited to patients up to age 22
D1516 Space maintainer – fixed – bilateral, maxillary- Limited to patients up to age 22
D1517 Space maintainer – fixed – bilateral, mandibular - Limited to patients up to age 22
D1520 Space maintainer - removable - unilateral - per quadrant - Limited to patients up to age 22
D1526 Space maintainer – removable – bilateral, maxillary - Limited to patients up to age 22
D1527 Space maintainer – removable – bilateral, mandibular - Limited to patients up to age 22
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
D1556 Removal of fixed unilateral space maintainer – per quadrant. Allowed if removed by dentist or dental practice that did not
originally place the appliance
D1557 Removal of fixed bilateral space maintainer – maxillary. Allowed if removed by dentist or dental practice that did not
originally place the appliance
D1558 Removal of fixed bilateral space maintainer – mandibular. Allowed if removed by dentist or dental practice that did not
originally place the appliance
D1575 Distal shoe space maintainer - Fixed – Unilateral - per quadrant - Limited to patients up to age 22
Class A Preventive Services Notes:
• Prophylaxis and scaling in presence of generalized moderate or severe gingival inflammation: Limit 3 per calendar year for any
combination of D1110, D1120, and D4346, age 13 and under will be processed as D1120 and age 14 and over will be processed
as D1110
• Treatments such as fluorides are combined under one limitation by the plan. For example, topical application of fluoride –
varnish (D1206) and topical application of fluoride - excluding varnish (D1208) are combined and limited to 2 per calendar year
for patients up to age 22
Additional Procedures Covered as Basic Services
D9110 Palliative treatment of dental pain – per visit - Not covered the same day as final treatment
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
Services Not Covered
Refer to Section 7 for a list of general exclusions
19 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Class B Intermediate
Important things you should keep in mind about these benefits:
•Please remember that 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 broadly accepted national standards of practice.
•The calendar year deductible is $0 if you use an in-network dentist.
•If you elect to use an out-of-network dentist, Standard Option has a $75 deductible per person; High
Option has a $50 deductible per person. Neither option contains a family deductible; each enrolled
covered person must satisfy their own deductible.
•There is no High Option Annual Benefit Maximum for non-orthodontic in-network services, and
$3,000 for out-of-network services. However, alternate benefits may be applied. See Section 7 –
Things We Do Not Cover, for a list of exclusions and limitations.
•The Standard Option Annual Benefit Maximum for non-orthodontic services is $1,500 for in-
network services and $750 for out-of-network services. In no instance will BCBS FEP Dental allow
more than $1,500 in combined benefits under Standard Option in any plan year.
•For inlay services, if you decide to have the alternate benefit of a filling done, the time limitation
would be 1 every 24 months.
•In-progress treatment for dependents of retiring TDP enrollees will be covered for the 2024 plan
year. This is regardless of any current plan exclusions for care initiated prior to the enrollee’s
effective date.
•The following is an all-inclusive list of covered services.
You Pay:
High Option
•In-Network: No deductible; you pay 30% of the plan allowance for covered services as defined by
the plan, subject to plan maximums. For children age 13 and under you pay $0 for covered services
as defined by the plan, subject to plan maximums.
•Out-of-Network: $50 deductible; you pay 40% of the plan allowance for covered services as
defined by the plan, subject to plan maximums and any difference between our allowance and the
billed amount.
Standard Option
•In-Network: No deductible; you pay 45% of the plan allowance for covered services as defined by
the plan, subject to plan maximums. For children age 13 and under, you pay $0 for covered services
as defined by the plan, subject to plan maximums.
•Out-of-Network: $75 deductible; you pay 60% of the plan allowance for covered services as
defined by the plan, subject to plan maximums and any difference between our allowance and the
billed amount.
20 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Minor Restorative Services
D2140 Amalgam – one surface, primary or permanent - Limit 1 every 24 months per surface per tooth
D2150 Amalgam – two surfaces, primary or permanent - Limit 1 every 24 month per surface per tooth
D2160 Amalgam – three surfaces, primary or permanent - Limit 1 every 24 months per surface per tooth
D2161 Amalgam – four or more surfaces, primary or permanent - Limit 1 every 24 months per surface per tooth
D2330 Resin-based composite – one surface, anterior - Limit 1 every 24 months per surface per tooth
D2331 Resin-based composite – two surfaces, anterior - Limit 1 every 24 months per surface per tooth
D2332 Resin-based composite – three surfaces, anterior - Limit 1 every 24 months per surface per tooth
D2335 Resin-based composite – four or more surfaces (anterior) - Limit 1 every 24 months per surface per tooth
D2390 Resin-based composite - resin crown anterior - Limit every 24 months per tooth
D2391 Resin-based composite – one surface, posterior - Limit 1 every 24 months per surface per tooth
D2392 Resin-based composite – two surfaces, posterior - Limit 1 every 24 months per surface per tooth
D2393 Resin-based composite – three surfaces, posterior - Limit 1 every 24 months per surface per tooth
D2394 Resin-based composite – four or more surfaces, posterior - Limit 1 every 24 months per surface per tooth
D2610 Inlay-porcelain/ceramic - one surface - Limit 1 every 60 months - An alternate benefit will be provided
D2620 Inlay-porcelain/ceramic - two surfaces - Limit 1 every 60 months - An alternate benefit will be provided
D2630 Inlay-porcelain/ceramic - three or more surfaces - Limit 1 every 60 months - An alternate benefit will be
provided
D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration - Limit 1 every 6 months after initial
installation, if less than 6 months from installation, no patient liability
D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core - Limit 1 every 6 months after initial
installation, if less than 6 months from installation, no patient liability
D2920 Re-cement or re-bond crown - Limit 1 every 6 months after initial installation, if less than 6 months from
installation, no patient liability
D2921 Re-attachment of tooth fragment, incisal edge or cusp - Limit to 1 every 24 months per surface per tooth, included
with fillings
D2928 Prefabricated porcelain/ceramic crown – permanent tooth – Limit 1 every tooth every 60 months for patients up to
age 15 – an alternate benefit will be provided
D2929 Prefabricated porcelain/ceramic crown – primary tooth – Limit 1 per tooth every 60 months for patients up to age
15 - an alternate benefit will be provided
D2930 Prefabricated stainless steel crown - primary tooth – Limit 1 per tooth every 60 months for patients up to age 15,
including crowns, bridges, prosthetics
D2931 Prefabricated stainless steel crown – permanent tooth – Limit 1 per tooth every 60 months for patients up to age 15,
including crowns, bridges, prosthetics
D2940 Protective Restoration
D2941 Interim therapeutic restoration - primary dentition
D2951 Pin retention – per tooth, in addition to restoration
D2989 Excavation of a tooth resulting in the determination of non-restorability -Limit 1 per tooth per lifetime
D7288 Brush Biopsy - Limit 1 every 12 months
Class B Minor Restorative Services Notes:
• Restorations are covered benefits only when necessary to replace tooth structure due to fracture or decay
21 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Endodontic Services
D3110 Pulp cap - direct (excluding final restoration)
D3120 Pulp cap - indirect (excluding final restoration)
D3220 Therapeutic pulpotomy (excluding final restoration) - Primary teeth only, 1 per lifetime
D3221 Pulpal debridement, primary and permanent teeth
D3222 Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development - 1 per lifetime
D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) - 1 per lifetime
D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) - 1 per lifetime
D3355 Pulpal regeneration - initial visit
D3356 Pulpal regeneration - interim medication replacement
D3357 Pulpal regeneration completion of treatment
Periodontal Services
D4341 Periodontal scaling and root planing - four or more teeth per quadrant - Limit 1 every 24 months, 2 quadrants per
date of service
D4342 Periodontal scaling and root planing - one to three teeth per quadrant - Limit 1 every 24 months, 2 quadrants per
date of service
D4346 Scaling in presence of generalized moderate or severe gingival inflammation - Full mouth, after oral exam -
Limited 3 in combination with D1110 and/or D1120 during calendar year
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth
D4910 Periodontal maintenance - Limit 4 every12 months combined with adult prophylaxis, and scaling in presence of
generalized moderate or severe gingival inflammation, after the completion of active periodontal therapy
Class B Periodontal Services Notes:
Supporting documentation and criteria;
• Full mouth diagnostic quality radiographic images and/or a panoramic radiographic image including bitewings
radiographs; labeled and dated (within 12 months of submitted procedure).
• Periodontal Charting: 6-point periodontal pocket depth charting as described by the ADA and American Academy of
Periodontology (AAP) labeled and dated (within 12 months of submitted procedure).
• Teeth to be treated must demonstrate at least 4 millimeter (mm) pocket depths, bleeding on probing, with demonstrable
radiographic evidence of bone loss (either vertical or horizontal) of the alveolar crest.
• Bone loss is considered to be a bone level that is greater 1.5 mm apical to the cementoenamel junction (CEJ).
Non-surgical periodontal and periodontal maintenance procedures will be disallowed with no patient responsibility when
submitted on the same date of service as preventive prophylaxis procedures.
Prosthodontic Services
D5410 Adjust complete denture – maxillary - Limit 1 per year beginning 6 months after the initial installation
D5411 Adjust complete denture – mandibular - Limit 1 per year beginning 6 months after the initial installation
D5421 Adjust partial denture – maxillary - Limit 1 per year beginning 6 months after the initial installation
D5422 Adjust partial denture – mandibular - Limit 1 per year beginning 6 months after the initial installation
D5511 Repair broken complete denture base mandibular - Limit 1 per year beginning 6 months after the initial installation
D5512 Repair broken complete denture base, maxillary - Limit 1 per year beginning 6 months after the initial installation
D5520 Replace missing or broken teeth – complete denture (each tooth) - Limit 1 per year beginning 6 months after the
initial installation
D5611 Repair resin denture base mandibular - Limit 1 per year beginning 6 months after the initial installation
D5612 Repair resin partial denture base, maxillary - Limit 1 per year beginning 6 months after the initial installation
D5621 Repair cast framework, mandibular - Limit 1 per year beginning 6 months after the initial installation
Prosthodontic Services - continued on next page
22 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Prosthodontic Services (cont.)
D5622 Repair cast partial framework, maxillary - Limit 1 per year beginning 6 months after the initial installation
D5630 Repair or replace broken retentive/clasping materials per tooth - Limit 1 per year beginning 6 months after the
initial installation
D5640 Replace broken teeth – per tooth - Limit 1 per year beginning 6 months after the initial installation
D5650 Add tooth to existing partial denture - Limit 1 per year beginning 6 months after the initial installation
D5660 Add clasp to existing partial denture - Limit 1 per year beginning 6 months after the initial installation
D5670 Replace all teeth and acrylic on cast metal framework, maxillary – Limit 2 every 24 months beginning 6 months
after the initial installation
D5671 Replace all teeth and acrylic on cast metal framework, mandibular – Limit 2 every 24 months beginning 6 months
after the initial installation
D5710 Rebase complete maxillary denture – Limit 1 every 36 months beginning 6 months after the initial installation
D5711 Rebase complete mandibular denture – Limit 1 every 36 months beginning 6 months after the initial installation
D5720 Rebase maxillary partial denture – Limit 1 every 36 months beginning 6 months after the initial installation
D5721 Rebase mandibular partial denture - Limit 1 every 36 months beginning 6 months after the initial installation
D5725 Rebase hybrid prosthesis – Limit 1 every 36 months beginning 6 months after the initial installation
D5730 Reline complete maxillary denture (direct) – Limit 1 every 36 months beginning 6 months after the initial
installation
D5731 Reline complete mandibular denture (direct) - Limit 1 every 36 months beginning 6 months after the initial
installation
D5740 Reline maxillary partial denture (direct) – Limit 1 every 36 months beginning 6 months after the initial installation
D5741 Reline mandibular partial denture (direct) – Limit 1 every 36 months beginning 6 months after the initial
installation
D5750 Reline complete maxillary denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial
installation
D5751 Reline complete mandibular denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial
installation
D5760 Reline maxillary partial denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial
installation
D5761 Reline mandibular partial denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial
installation
D5765 Soft liner for complete or partial removable denture – indirect – Limit 1 every 36 months beginning 6 months after
the initial installation.
D5850 Tissue conditioning (maxillary)
D5851 Tissue conditioning (mandibular)
D6096 Remove broken implant retaining screw – Limit 1 every 60 months
D6930 Re-cement or re-bond fixed partial denture - Limit 1 per bridge beginning 6 months after the initial installation
D6980 Fixed partial denture repair, by report
D9120 Fixed partial denture sectioning - 1 per 60 Months
Class B Prosthodontic Services Notes:
• For reporting and benefit purposes, the completion date for crowns and fixed partial dentures is the cementation date.
The completion date is the insertion date for removable prosthodontic appliances. For immediate dentures, the dentist
who fabricated the denture may be reimbursed for the service after insertion by another dentist (e.g., oral surgeon).
• Tissue conditioning is considered inclusive when performed on the same day as the delivery of a denture or a reline/
rebase.
23 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Oral Surgery
D7111 Extraction coronal remnants, primary tooth
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 Surgical 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
D7272 Tooth transplantation - includes splinting or stabilization
D7280 Exposure of an unerupted tooth
D7310 Alveoloplasty in conjunction with extractions – per quadrant
D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant
D7320 Alveoloplasty not in conjunction with extractions – 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)
D7485 Surgical reduction of tuberosity
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 - Limit 1 in 36 months
D7953 Bone replacement graft for ridge preservation - per site - No review on anterior teeth. Posterior teeth reviewed to
determine if covered or not. 3rd Molar extraction sites denied unless D7251 performed. Anterior teeth and approved
posterior teeth, Limit 1 every 60 months
D7971 Excision of pericoronal gingiva
D7972 Surgical reduction of fibrous tuberosity – Limit 1 every 6 months
D7999 Unspecified oral surgery procedure, by report
Class B Oral Surgery Notes:
• Bone replacement grafts for ridge preservation are limited to extraction sites when implants are approved for placement
or when implant removal may be necessary.
Services Not Covered
Refer to Section 7 for a list of general exclusions
24 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Class C Major
Important things you should keep in mind about these benefits:
•Please remember that 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 broadly accepted national standards of practice.
•The calendar year deductible is $0 if you use an in-network dentist.
•If you elect to use an out-of-network dentist, Standard Option has a $75 deductible per person; High Option
has a $50 deductible per person. Neither option contains a family deductible; each enrolled covered person
must satisfy their own deductible.
•There is no High Option Annual Benefit Maximum for non-orthodontic in-network services, and $3,000 for
out-of-network services.
•The Standard Option Annual Benefit Maximum for non-orthodontic services is $1,500 for in-network
services and $750 for out-of-network services. In no instance will BCBS FEP Dental allow more than $1,500
in combined benefits under Standard Option in any plan year.
•If more than one service or procedure can be used to treat the dental condition, we reserve the right authorize
an alternate, less costly covered service as deemed by a dental professional to be appropriate and to meet
broadly accepted national standards of dental practice. If you and your dentist choose the more expensive
treatment instead of the alternate benefit, you are responsible for the additional charges beyond the plan
allowance for the alternate service.
•Pre-treatment estimates are not mandatory. However, we do recommend that your dentist submits a pre-
treatment estimate if you are considering major or extensive dental care. Pre-treatment estimates should
include a comprehensive treatment plan and necessary supporting documentation such as, chart notes,
radiographic images, and photos. Benefits may be alternated to a least costly procedure that meets broadly
accepted national standards of dental practice. We will provide a non-binding, explanation of benefits to both
you and your dentist that will indicate if procedures are covered and an estimate of what we will pay for
those specific services. The estimated plan allowance is based on your current eligibility and benefits in
effect at the time of the pre-treatment estimate. Submission of other claims or changes in eligibility or
benefit may alter final payment. A pretreatment estimate is not a guarantee of benefits.
•For inlay services, if you decide to have the alternate benefit of a filling done, the time limitation would be 1
every 24 months.
•All services requiring more than one visit are payable once all visits are completed.
•In-progress treatment for dependents of retiring TDP enrollees will be covered for the 2024 plan year. This is
regardless of any current plan exclusions for care initiated prior to the enrollee’s effective date.
•The following is an all-inclusive list of covered services.
You Pay:
High Option
•In-Network: No deductible; you pay 50% of the plan allowance for covered services as defined by the plan,
subject to plan maximums. For children age 13 and under you pay $0 for covered services as defined by the
plan, subject to plan maximums.
•Out-of-Network: $50 deductible; you pay 60% of the plan allowance for covered services as defined by the
plan, subject to plan maximums and any difference between our allowance and the billed amount.
Standard Option
•In-Network: No deductible; you pay 65% of the plan allowance for covered services as defined by the plan,
subject to plan maximums. For children age 13 and under, you pay $0 for covered services as defined by the
plan, subject to plan maximums.
25 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
•Out-of-Network: $75 deductible; you pay 80% of the plan allowance for covered services as defined by the
plan, subject to plan maximums and any difference between our allowance and the billed amount.
Major Restorative Services
D2410 Gold Foil – one surface – Limit 1 every 24 months - An alternate benefit will be provided
D2420 Gold Foil – two surfaces – Limit 1 every 24 months - An alternate benefit will be provided
D2430 Gold Foil – three surfaces – Limit 1 every 24 months - An alternate benefit will be provided
D2510 Inlay - metallic - one surface - Limit 1 per tooth every 60 months - An alternate benefit will be provided
D2520 Inlay - metallic - two surfaces -Limit 1 per tooth every 60 months - An alternate benefit will be provided
D2530 Inlay - metallic - three surfaces - Limit 1 per tooth every 60 months - An alternate benefit will be provided
D2542 Onlay - metallic - two surfaces - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2543 Onlay - metallic - three surfaces - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2544 Onlay - metallic - four or more surfaces - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2642 Onlay-porcelain/ceramic - two surfaces - Limit 1 per tooth every 60 months
D2643 Onlay-porcelain/ceramic - three surfaces - Limit 1 per tooth every 60 months
D2644 Onlay porcelain/ceramic - four or more surfaces - Limit 1 per tooth every 60 months
D2650 Inlay - resin-based composite - one surface, lab proc - Limit 1 every 60 months - An alternate benefit will be provided
D2651 Inlay - resin-based composite - two surfaces, lab proc - Limit 1 every 60 months - An alternate benefit will be provided
D2652 Inlay - resin-based composite - three surfaces, lab proc - Limit 1 every 60 months - An alternate benefit will be provided
D2662 Onlay - resin-based composite - two surfaces, lab proc - Limit 1 every 60 months
D2663 Onlay - resin-based composite - three surfaces, lab proc - Limit 1 per tooth every 60 months
D2664 Onlay - resin-based composite - four or more surfaces, lab proc - Limit 1 per tooth every 60 months
D2710 Crown - resin-based composite, lab proc - Limit 1 every 60 months
D2712 Crown - 3/4 resin-based composite, lab proc - Limit 1 per tooth every 60 months
D2720 Crown - resin with high noble metal - Limit 1 per tooth every 60 months
D2721 Crown - resin with predominantly base metal - Limit 1 per tooth every 60 months
D2722 Crown - resin with noble metal - Limit 1 per tooth every 60 months
D2740 Crown - porcelain/ceramic - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2750 Crown - porcelain fused to high noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2751 Crown - porcelain fused to predominately base metal - Limit 1 per tooth every 60 months, including crowns, bridges,
prosthetics
D2752 Crown - porcelain fused to noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2753 Crown - porcelain fused to titanium and titanium alloys- Limit 1 per tooth every 60 months, including crowns, bridges,
prosthetics
D2780 Crown - 3/4 cast high noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2781 Crown - 3/4 cast predominately base metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2782 Crown - 3/4 cast noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2783 Crown - 3/4 porcelain/ceramic - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics. Denied if done
on an anterior tooth.
D2790 Crown - full cast high noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2791 Crown - full cast predominately base metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2792 Crown - full cast noble metal - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2794 Crown - titanium and titanium alloys - Limit 1 per tooth every 60 months, including crowns, bridges, prosthetics
D2932 Crown prefabricated resin – Limit 1 per tooth every 60 months for patients up to age 15, including crowns, bridges,
prosthetics
D2933 Crown prefabricated stainless steel crown/resin window - Limit 1 per tooth every 60 months for patients up to age of 15 -
alternate benefit will be provided
Major Restorative Services - continued on next page
26 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Major Restorative Services (cont.)
D2934 Prefabricated esthetic coated stainless steel crown, primary tooth – Limit 1 per tooth every 60 months for patients, including
crowns, bridges, prosthetics
D2950 Core buildup, including any pins - Limit 1 buildup procedure, per tooth every 60 months
D2952 Post and core in addition to crown, indirectly fabricated - Limit 1 buildup procedure, per tooth, every 60 months
D2954 Prefabricated post and core, in addition to crown - Limit 1 buildup procedure, per tooth every 60 months
D2955 Post removal
D2971 Additional procedures to customize a crown to fit under existing partial denture framework - Limit 1 every 60 months
D2980 Crown repair necessitated by restorative material failure – Limit 1 every 12 months
D2981 Inlay Repair necessitated by restorative material failure - Limit 1 every 12 months
D2982 Onlay Repair necessitated by restorative material failure – Limit 1 every 12 months
D2983 Veneer Repair necessitated by restorative material failure – Limit 1 every 12 months
D2990 Resin infiltration of incipient smooth surface lesions
Class C Major Restorative Services Notes:
• For reporting and benefit purposes, the completion date for crowns is the cementation date.
• An implant is a covered procedure of the plan only if determined to be dentally necessary and the least expensive appropriate
treatment.
• All major restorative and prosthodontic services (i.e., crown, bridges, implants and dentures) are combined under one
replacement limitation under the plan. Benefits for major restorative and prosthodontic services are combined and limited to one
every 60 months per tooth or arch depending on the service. For example, if benefits for a removable partial denture are paid,
this includes benefits to replace all missing teeth in the arch. No additional benefits for the arch would be considered until the 60
month replacement limit was met.
• When dental services that are subject to a frequency limitation were performed prior to your effective date of coverage, the date
of the prior service may be counted toward the time, frequency limitations and/or replacement limitations under this dental
insurance. (For example, even if a crown, partial bridge, etc. was not placed while covered under BCBS FEP Dental, or paid by
BCBS FEP Dental, the frequency limitations may apply.)
Endodontic Services
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 (apical closure/calcific repair of perforations, root resorption,
etc.)
D3353 Apexification/recalcification – final visit (includes completed root canal therapy, apical closure/calcific repair of
perforations, root resorption, etc.)
D3410 Apicoectomy/periradicular surgery – anterior
D3421 Apicoectomy/periradicular surgery – premolar (first root)
D3425 Apicoectomy/periradicular surgery – molar (first root)
D3426 Apicoectomy/periradicular surgery (each additional root)
D3430 Retrograde filling – per 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
Endodontic Services - continued on next page
27 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Endodontic Services (cont.)
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
Periodontal Services
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant - Limit 1 every 36
months
D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant – Limit 1 every 36
months
D4212 Gingivectomy or gingivoplasty - to allow access for restorative procedure, per tooth – Limit 1 every 36 months
D4240 Gingival flap procedure, including root planing- four or more contiguous teeth or tooth bounded spaces per quadrant – Limit
1 every 36 months
D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant – Limit
1 every 36 months
D4245 Apically positioned flap – Limit 1 every 36 months, permanent teeth only
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 – Limit 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 – Limit 1 every 36 months
D4263 Bone replacement graft – retained natural tooth - first site in quadrant - Limit 1 every 36 months, permanent teeth only
D4264 Bone replacement graft – retained natural tooth - each additional site in quadrant - Limit 1 every 36 months, permanent teeth
only
D4268 Surgical revision procedure, per tooth
D4270 Pedicle soft tissue graft procedure – Limit 1 every 36 months
D4273 Autogenous connective tissue graft procedures first tooth (including donor and recipient surgical site) first tooth, implant, or
edentulous tooth position in graft – Limit 1 every 36 months
D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same
anatomical area) – Limit 1 every 36 months, permanent teeth only
D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth
position in graft - Limit 1 every 36 months
D4276 Combined connective tissue and pedicle graft, per tooth – Limit 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 – Limit 1 every 36 months
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 – Limit 1 every 36 months
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 – Limit 1 every 36 months
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 – Limit 1 every 36 months
D4355 Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis on a subsequent visit - Limit 1 per
lifetime
D4999 Unspecified periodontal procedure, by report
Periodontal Services - continued on next page
28 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Periodontal Services (cont.)
Class C Periodontal Services Notes:
Supporting documentation and criteria:
• Full mouth diagnostic quality radiographic images and/or a panoramic radiographic image including bitewings radiographs,
labeled and dated (within 12 months of submitted procedure)
• Periodontal charting: 6-point periodontal pocket depth charting as described by the ADA and AAP labeled and dated (within 12
months of submitted procedure)
• Teeth to be treated must demonstrate at least 5 mm pocket depths
• Gingival flap procedure must be a surface adjacent to an edentulous/terminal tooth area
Gingivectomy or gingivoplasty performed in conjunction with restorative services are considered to be inclusive of the restoration
and will not be reimbursed.
Clinical crown lengthening: Prior to final restoration of a tooth, a minimum of six weeks must be allowed for healing of bone and
soft tissue following clinical crown lengthening.
Prosthodontic Services
D5110 Complete denture – maxillary – Limit 1 every 60 months – Denied if using as an interim denture
D5120 Complete denture - mandibular – Limit 1 every 60 months – Denied if using as an Interim denture
D5130 Immediate denture – maxillary – Limit 1 every 60 months – Denied if using as an interim denture
D5140 Immediate denture - mandibular – Limit 1 every 60 months – Denied if using as an interim denture
D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth) – Limit 1 every 60 months.
Denied if using as an interim denture
D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth) – Limit 1 every 60 months.
Denied if using as an interim denture.
D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and
teeth) – Limit 1 every 60 months
D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and
teeth) – Limit 1 every 60 months
D5221 Immediate maxillary partial denture, resin base – (including retentive/clasping materials, rests and teeth) - Limit 1 every 60
months – Denied if using as an interim denture
D5222 Immediate mandibular partial denture, resin base – (including retentive/clasping materials, rests and teeth) - Limit 1 every
60 months – Denied if using as an interim denture
D5223 Immediate maxillary partial denture, cast metal framework with resin denture bases (including retentive/clasping materials,
rests and teeth) - Limit 1 every 60 months
D5224 Immediate mandibular partial denture, cast metal framework with resin denture bases (including retentive/clasping
materials, rests and teeth)- Limit 1 every 60 months
D5225 Maxillary partial denture – flexible base (including retentive/clasping materials, rests and teeth)– Limit 1 every 60 months -
Denied if using as an interim denture
D5226 Mandibular partial denture – flexible base (including retentive/clasping materials, rests and teeth) – Limit 1 every 60 months
- Denied if using as an inteirm denture
D5227 Immediate maxillary partial denture – flexible base (including any clasps, rest and teeth) – Limit 1 every 60 months –
Denied if using as an interim denture
D5228 Immediate mandibular partial denture – flexible base (including any clasps, rest and teeth) – Limit 1 every 60 months –
Denied if using as an interim denture
D5282 Removable unilateral partial denture - one piece cast metal (including retentive/clasping materials, rests and teeth),
maxillary - Limit 1 every 60 months
D5283 Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests and teeth),
mandibular - Limit 1 every 60 months
D5863 Overdenture – complete maxillary - Limit 1 every 60 months - an alternate benefit will be provided
Prosthodontic Services - continued on next page
29 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Prosthodontic Services (cont.)
D5864 Overdenture – partial maxillary - Limit 1 every 60 months - an alternate benefit will be provided
D5865 Overdenture – complete mandibular - Limit 1 every 60 months - an alternate benefit will be provided
D5866 Overdenture – partial mandibular - Limit 1 every 60 months - an alternate benefit will be provided
D5876 Add metal substructure to acrylic full denture (per arch) – Limit 1 every 60 months
D6010 Surgical placement of implant body: endosteal implant – Limit 1 per site every 60 months
D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant – Limit 1 per site every 60 months
D6013 Surgical placement of mini implant – Limit 1 per site every 60 months
D6040 Surgical placement: eposteal implant – Limit 1 per site every 60 months
D6050 Surgical placement: transosteal implant – Limit 1 per site every 60 months
D6055 Connecting bar – implant supported or abutment supported – Limit 1 every 60 months
D6056 Prefabricated abutment - includes modification and placement – Limit 1 every 60 months
D6057 Custom fabricated abutment - includes placement – Limit 1 every 60 months
D6058 Abutment supported porcelain/ceramic crown – Limit 1 every 60 months
D6059 Abutment supported porcelain fused to metal crown (high noble metal) - Limit 1 every 60 months
D6060 Abutment supported porcelain fused to metal crown (predominately base metal) - Limit 1 every 60 months
D6061 Abutment supported porcelain fused to metal crown (noble metal) - Limit 1 every 60 months
D6062 Abutment supported cast metal crown (high noble metal) - Limit 1 every 60 months
D6063 Abutment supported cast metal crown (predominately base metal) – Limit 1 every 60 months
D6064 Abutment supported cast metal crown (noble metal) – Limit 1 every 60 months
D6065 Implant supported porcelain/ceramic crown – Limit 1 every 60 months
D6066 Implant supported crown - porcelain fused to high noble alloys – Limit 1 every 60 months
D6067 Implant supported crown - high noble alloys – Limit 1 every 60 months
D6068 Abutment supported retainer for porcelain/ceramic FPD – Limit 1 every 60 months
D6069 Abutment supported retainer for porcelain fused to metal FPD - high noble metal – Limit 1 every 60 months
D6070 Abutment supported retainer for porcelain fused to metal FPD - predominately base metal – Limit 1 every 60 months
D6071 Abutment supported retainer for porcelain fused to metal FPD - noble metal – Limit 1 every 60 months
D6072 Abutment supported retainer for cast metal FPD - high noble metal – Limit 1 every 60 months
D6073 Abutment supported retainer for cast metal FPD - predominately base metal - Limit 1 every 60 months
D6074 Abutment supported retainer for cast metal FPD - noble metal - Limit 1 every 60 months
D6075 Implant supported retainer for ceramic FPD – Limit 1 every 60 months
D6076 Implant supported retainer for FPD porcelain fused to high noble alloys - Limit 1 every 60 months
D6077 Implant supported retainer for metal FPD - high noble alloys – Limit 1 every 60 months
D6080 Implant Maintenance Procedures – Limit 1 every 60 months
D6082 Implant supported crown – porcelain fused to predominantly base alloys - Limit 1 every 60 months
D6083 Implant supported crown – porcelain fused to noble alloys - Limit 1 every 60 months
D6084 Implant supported crown – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6086 Implant supported crown – predominantly base alloys - Limit 1 every 60 months
D6087 Implant supported crown – noble alloys - Limit 1 every 60 months
D6088 Implant supported crown – titanium and titanium alloys - Limit 1 every 60 months
D6089 Accessing and retorquing loose implant screw - per screw - Limit 1 per 12 months
D6090 Repair Implant Prosthesis – Limit 1 every 60 months
D6091 Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis, per
attachment – Limit 1 every 60 months
D6092 Recement or re-bond implant/abutment supported crown - Limit 1 every 60 months
D6093 Recement or re-bond implant/abutment supported fixed partial denture – Limit 1 every 60 months
D6094 Abutment supported crown - titanium and titanium alloys - Limit 1 every 60 months
Prosthodontic Services - continued on next page
30 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Prosthodontic Services (cont.)
D6095 Repair implant abutment, by report – Limit 1 every 60 months
D6097 Abutment supported crown – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6098 Implant supported retainer – porcelain fused to predominantly base alloys - Limit 1 every 60 months
D6099 Implant supported retainer for FPD – porcelain fused to noble alloys - Limit 1 every 60 months
D6100 Surgical removal of implant body – Limit once per implant location
D6101 Debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of exposed implant
surfaces, including flap entry and closure – Limit 1 per lifetime
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 – Limit 1 per lifetime
D6103 Bone graft for repair of peri-implant defect – does not include flap entry and closure - Limit 1 every 36 months
D6104 Bone graft at time of implant placement - Limit 1 every 36 months
D6105 Removal of implant body not requiring bone removal or flap elevation - Limit once per implant location
D6106 Guided tissue regeneration – resorbable barrier, per implant - Limit 1 every 36 months
D6107 Guided tissue regeneration – non-resorbable barrier, per implant - Limit 1 every 36 months
D6110 Implant/abutment supported removable denture for edentulous arch - maxillary - Limit 1 every 60 months
D6111 Implant/abutment supported removable denture for edentulous arch - mandibular - Limit 1 every 60 months
D6112 Implant/abutment supported removable denture for partially edentulous arch - maxillary - Limit 1 every 60 months
D6113 Implant/abutment supported removable denture for partially edentulous arch - mandibular - Limit 1 every 60 months
D6114 Implant/abutment supported fixed denture for edentulous arch - maxillary - Limit 1 every 60 months
D6115 Implant/abutment supported fixed denture for edentulous arch - mandibular - Limit 1 every 60 months
D6116 Implant/abutment supported fixed denture for partially edentulous arch - maxillary - Limit 1 every 60 months
D6117 Implant/abutment supported fixed denture for partially edentulous arch - mandibular - Limit 1 every 60 months
D6120 Implant supported retainer – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6121 Implant supported retainer for metal FPD – predominantly base alloys - Limit 1 every 60 months
D6122 Implant supported retainer for metal FPD – noble alloys - Limit 1 every 60 months
D6123 Implant supported retainer for metal FPD – titanium and titanium alloys - Limit 1 every 60 months
D6190 Radiographic/surgical implant index, by report – Limit 1 every 60 months
D6191 Semi-precision abutment – placement – Limit 1 every 60 months
D6192 Semi-precision attachment – placement – Limit 1 every 60 months
D6194 Abutment supported retainer crown for FPD - titanium and titanium alloys - Limit 1 every 60 months
D6195 Abutment supported retainer – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6205 Pontic – indirect resin based composite – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6210 Pontic - cast high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6211 Pontic - cast predominately base metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6212 Pontic - cast noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6214 Pontic - titanium and titanium alloys - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6240 Pontic - porcelain fused to high noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6241 Pontic - porcelain fused to predominately base metal - Limit 1 every 60 months, including all other crowns, bridges,
prosthetics
D6242 Pontic - porcelain fused to noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6243 Pontic – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months, including all other crowns, bridges,
prosthetics
D6245 Pontic - porcelain/ceramic - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6250 Pontic – resin with high noble metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6251 Pontic - resin with predominantly base metal – Limit 1 every 60 months, including all other crowns, bridges, prosthetics
D6252 Pontic - resin with noble metal - Limit 1 every 60 months, including all other crowns, bridges, prosthetics
Prosthodontic Services - continued on next page
31 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Prosthodontic Services (cont.)
D6545 Retainer - cast metal for resin bonded fixed prosthesis - Limit 1 every 60 months, including all other crowns, bridges,
prosthetics
D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis - Limit 1 every 60 months, including all other crowns,
bridges, prosthetics - An alternate benefit will be provided
D6549 Resin retainer - for resin bonded fixed prosthesis - Limit 1 every 60 months
D6600 Retainer inlay - porcelain/ceramic, two surfaces - Limit 1 every 60 months - An alternate benefit will be provided
D6601 Retainer inlay - porcelain/ceramic, three or more surfaces - Limit 1 every 60 months - An alternate benefit will be
provided
D6602 Retainer inlay - cast high noble metal, two surfaces – Limit 1 every 60 months
D6603 Retainer inlay - cast high noble metal, three or more surfaces – Limit 1 every 60 months
D6604 Retainer inlay - cast predominantly base metal, two surfaces - Limit 1 every 60 months
D6605 Retainer inlay - cast predominantly base metal, three or more surfaces - Limit 1 every 60 months
D6606 Retainer inlay - cast noble metal, two surfaces – Limit 1 every 60 months
D6607 Retainer inlay - cast noble metal, three or more surfaces – Limit 1 every 60 months
D6608 Retainer onlay - porcelain/ceramic, two or more surfaces - Limit 1 every 60 months - An alternate benefit will be provided
D6609 Retainer onlay - porcelain/ceramic, three or more surfaces - Limit 1 every 60 months - An alternate benefit will be
provided
D6610 Retainer onlay - cast high noble metal, two surfaces – Limit 1 every 60 months
D6611 Retainer onlay - cast high noble metal, three or more surfaces – Limit 1 every 60 months
D6612 Retainer onlay - cast predominantly base metal, two surfaces – Limit 1 every 60 months
D6613 Retainer onlay - cast predominantly base metal, three or more surfaces – Limit 1 every 60 months
D6614 Retainer onlay - cast noble metal, two surfaces – Limit 1 every 60 months
D6615 Retainer onlay - cast noble metal, three or more surfaces – Limit 1 every 60 months
D6624 Retainer inlay – titanium – Limit 1 every 60 months
D6634 Retainer onlay - titanium – Limit 1 every 60 months
D6710 Retainer crown - indirect resin based composite - Limit 1 every 60 months
D6720 Retainer crown - resin with high noble metal - Limit 1 every 60 months
D6721 Retainer crown - resin with predominantly base metal - Limit 1 every 60 months
D6722 Retainer crown - resin with noble metal – Limit 1 every 60 months
D6740 Retainer crown - porcelain/ceramic – Limit 1 every 60 months
D6750 Retainer crown - porcelain fused to high noble metal - Limit 1 every 60 months
D6751 Retainer crown - porcelain fused to predominately base metal – Limit 1 every 60 months
D6752 Retainer crown - porcelain fused to noble metal - Limit 1 every 60 months
D6753 Retainer crown – porcelain fused to titanium and titanium alloys - Limit 1 every 60 months
D6780 Retainer crown - 3/4 cast high noble metal - Limit 1 every 60 months
D6781 Retainer crown - 3/4 cast predominately base metal - Limit 1 every 60 months
D6782 Retainer crown - 3/4 cast noble metal – Limit 1 every 60 months
D6783 Retainer crown - 3/4 porcelain/ceramic – Limit 1 every 60 months
D6784 Retainer crown ¾ – titanium and titanium alloys - Limit 1 every 60 months
D6790 Retainer crown - full cast high noble metal - Limit 1 every 60 months
D6791 Retainer crown - full cast predominately base metal - Limit 1 every 60 months
D6792 Retainer crown - full cast noble metal - Limit 1 every 60 months
D6794 Retainer crown - titanium and titanium alloys - Limit 1 every 60 months
D7994 Surgical placement zygomatic implant – Limit 1 per tooth every 60 months
D9932 Cleaning and inspection of removable complete denture, maxillary – Limit 3 times per calendar year
D9933 Cleaning and inspection of removable complete denture, mandibular – Limit 3 times per calendar year
Prosthodontic Services - continued on next page
32 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Prosthodontic Services (cont.)
D9934 Cleaning and inspection of removable partial denture, maxillary – Limit 3 times per calendar year
D9935 Cleaning and inspection of removable partial denture, mandibular – Limit 3 times per calendar year
Class C Major Services Notes:
• For reporting and benefit purposes, the completion date for fixed partial dentures is the cementation date. The completion date is
the insertion date for removable prosthodontic appliances. For immediate dentures, the dentist who fabricated the denture may be
reimbursed for the service after insertion by another dentist (e.g., oral surgeon).
• All major restorative and prosthodontic services (i.e., crown, bridges, implants and dentures) are combined under one
replacement limitation under the plan. Benefits for major restorative and prosthodontic services are combined and limited to one
every 60 months per tooth or arch depending on the service. For example, if benefits for a removable partial denture are paid,
this includes benefits to replace all missing teeth in the arch. No additional benefits for the arch would be considered until the 60
month replacement limit was met.
• When dental services that are subject to a frequency limitation were performed prior to your effective date of coverage, the date
of the prior service may be counted toward the time, frequency limitations and/or replacement limitations under this dental
insurance. (For example, even if a crown, partial bridge, etc. was not placed while covered under BCBS FEP Dental, or paid by
BCBS FEP Dental, the frequency limitations may apply.)
Oral Surgery
D7340 Vestibuloplasty - Ridge extension (secondary epithelialization)
D7350 Vestibuloplasty - Ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and
management of hypertrophied and hyperplastic tissue)
Services Not Covered
Refer to Section 7 for a list of general exclusions
33 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Class D Orthodontic
Important things you should keep in mind about these benefits:
•Please remember that 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 broadly accepted national standards of practice.
•There is no calendar year deductible.
•We pay 50% of the plan allowance up to the lifetime maximum. The lifetime maximum for orthodontic
services (clear aligners or traditional braces) depends on the option in which you enroll and if you choose to
receive services from a network dentist. If you are covered by High Option, the lifetime maximum is up to
$3,500. However, the plan allowance (see page 16) depends on the participation status of the dentist. If you
are enrolled in Standard Option, the lifetime maximum for services rendered by an in-network dentist is up to
$2,500 and for services rendered by an out-of-network dentist the lifetime maximum is up to $1,250. Your
out-of-pocket expenses will be higher when using an out-of-network dentist.
•In no instance will BCBS FEP Dental allow more than $2,500 in orthodontic benefits under Standard Option.
•The benefit for the initial placement will not exceed 25% of the lifetime maximum benefit amount for the
appliance. All subsequent payments will be made in equal installments pro-rated over the balance of a
maximum period of 29 months. If your coverage terminates, all orthodontia benefit payments will end.
•Covered services are limited to the maximum allowable charge as determined by the plan and are subject to
alternate benefit, coinsurance, maximum benefit limits, and the other limitations described in this plan
document.
•We cover traditional orthodontic treatment (braces) as well as clear aligners.
To determine what is most cost
effective, we recommend a pretreatment estimate.
•The allowed amount is based on the orthodontic treatment and does not guarantee that the full lifetime
maximum will be paid out on a single treatment. If the orthodontic treatment is already in progress at the
time of eligibility, the orthodontic benefit will be prorated based on the number of months remaining in the
treatment plan up to the lifetime maximum.
•Coverage for pre-treatment orthodontic exam and radiographic images may be allowed if completed more
than 3 months from initial appliance placement.
•Applying the limited access provision will not result in additional payment under the High Option
orthodontic plan.
•The following is an all-inclusive list of covered services.
You Pay:
High Option
•In-Network: 50% of the plan allowance up to the lifetime maximum. You are responsible for all charges that
exceed the lifetime maximum.
•Out-of-Network: 50% of the plan allowance up to the lifetime maximum and any difference between our
allowance and the billed amount.
Standard Option
•In-Network: 50% of the plan allowance up to the lifetime maximum. You are responsible for all charges that
exceed the lifetime maximum.
•Out-of-Network: 50% of the plan allowance up to the lifetime maximum and any difference between our
allowance and the billed amount.
34 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Orthodontic Services
D0340 2D cephalometric radiographic image – acquisition, measurement and analysis - may be allowed if completed more than 3
months prior to the start of orthodontic treatment
D0350 2D oral/facial photographic image obtained intra-orally or extra-orally – may be allowed if completed more than 3 months
prior to the start of orthodontic treatment
D0470 Diagnostic casts – may be allowed if completed more than 3 months prior to the start of orthodontic treatment
D0801 3D dental surface scan – direct - may be allowed if completed more than 3 months prior to the start of orthodontic treatment
D0802 3D dental surface scan – indirect - may be allowed if completed more than 3 months prior to the start of orthodontic
treatment
D7283 Placement of device to facilitate eruption of impacted tooth, covered 1 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
D8040 Limited orthodontic treatment of the adult dentition
D8070 Comprehensive orthodontic treatment of the transitional dentition
D8080 Comprehensive orthodontic treatment of the adolescent dentition
D8090 Comprehensive orthodontic treatment of the adult dentition
D8210 Removable appliance therapy
D8220 Fixed appliance therapy
D8660 Pre-orthodontic treatment examination to monitor growth and development
D8670 Periodic orthodontic treatment visit (as part of contract) – monthly payments automatically made if orthodontic treatment
plan is in place
D8681 Removable orthodontic retainer adjustment
Services Not Covered
Refer to Section 7 for a list of general exclusions:
• Repair of damaged orthodontic appliances
• Replacement of lost or missing appliances
• 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.
• Over-the-counter or mail order orthodontic treatments
35 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
General Services
Important things you should keep in mind about these benefits:
•Please remember that 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 broadly accepted national standards of practice.
•The calendar year deductible is $0, if you use an in-network dentist.
•If you elect to use an out-of-network dentist, Standard Option has a $75 deductible per person; High Option
has a $50 deductible per person. Neither option contains a family deductible; each enrolled covered person
must satisfy their own deductible.
•There is no High Option Annual Benefit Maximum for non-orthodontic in-network services, and $3,000 for
out-of-network services.
•The Standard Option Annual Benefit Maximum for non-orthodontic services is $1,500 for in-network
services and $750 for out-of-network services. In no instance will BCBS FEP Dental allow more than
$1,500 in combined benefits under Standard Option in any plan year.
•All services requiring more than one visit are payable once all visits are completed.
•The following is an all-inclusive list of covered services.
You Pay:
High Option
•In-Network: No deductible; you pay 30% of the plan allowance for covered services as defined by the plan,
subject to plan maximums.
•Out-of-Network: $50 deductible; you pay 40% of the plan allowance for covered services as defined by the
plan, subject to plan maximums and any difference between our allowance and the billed amount.
Standard Option
•In-Network: No deductible; you pay 45% of the plan allowance for covered services as defined by the plan,
subject to plan maximums.
•Out-of-Network: $75 deductible; you pay 60% of the plan allowance for covered services as defined by the
plan, subject to plan maximums and any difference between our allowance and the billed amount.
Anesthesia Services
D9219 Evaluation for moderate sedation, deep sedation or general anesthesia
D9222 Deep sedation/general anesthesia – first 15 minutes. Up to 8 total units of anesthesia (D9222 & D9223)
D9223 Deep sedation/general anesthesia - each subsequent 15 minute increment. Up to 8 total units of anesthesia (D9222 & D9223)
D9230 Inhalation of nitrous oxide/analgesia, anxiolysis - for children 5 and under and other individuals with a medical condition
that may require it
D9239 Intravenous moderate (conscious) sedation/analgesia – first 15 minutes. Up to 8 total units of anesthesia (D9239 & D9243)
D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment. Up to 8 total units of
anesthesia (D9239 & D9243)
Medications
D9610 Therapeutic parenteral drug, single administration, by report.
D9612 Therapeutic parenteral drugs, two or more administrations, different medications
D9613 Infiltration of sustained release therapeutic drug, per quadrant
36 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Post-Surgical Services
D9930 Treatment of complications (post-surgical) unusual circumstances, by report
Miscellaneous Services
D9941 Fabrication of athletic mouthguard –Limit 1 every 12 months
D9943 Occlusal guard adjustment - Limit 1 every 6 months for patients 13 and older
D9944 Occlusal guard – hard appliance, full arch – Limit 1 every 12 months for patients 13 and older
D9945 Occlusal guard – soft appliance, full arch – Limit 1 every 12 months for patients 13 and older
D9946 Occlusal guard – hard appliance, partial arch – Limit 1 every 12 months for patients 13 and older
D9974 Internal bleaching - per tooth
D9999 Unspecified Adjunctive procedure, by report
General Services Notes:
• Deep sedation/general anesthesia and intravenous sedation are covered when provided in conjunction with covered surgical
procedures. The services must be rendered by a dentist licensed and approved to provide anesthesia in the state where rendered.
• Deep sedation/general anesthesia and intravenous sedation are covered when determined to be medically or dentally necessary
for documented handicapped or uncontrollable patients or justifiable conditions.
• In order for deep sedation/general anesthesia and intravenous conscious sedation to be covered, submission must include the
procedure for which it was necessary.
Services Not Covered
Refer to Section 7 for a list of general exclusions.
37 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Section 6 International Services and Supplies
We will pay benefits, subject to plan provisions, in an amount equal to the covered
percentage for the charges incurred by you. You are responsible for paying the dentist and
for submitting your claims to BCBS FEP Dental. We will reimburse you in US dollars
based on the OANDA currency conversion rate.
International Claims
Payment
You may visit any dentist and you will receive in-network benefits for any covered
benefits received internationally. Our international dental program includes English-
speaking dentists in approximately 100 countries worldwide. Customer service is
available 24/7 to assist in making an appointment.
For help locating an English-speaking dentist, you may call 24 hours a day (outbound
calling code for the country you are calling from) plus 353-94-9372257. If calling from
Ireland, press 0-94-9372257.
Customer service (in the U.S.) 1-855-504-BLUE (2583)
Customer service (international) call collect 651-994-2583
Finding
an International Dentist
You are responsible for paying the dentist and submitting the claims to BCBS FEP Dental
for reimbursement. The claim form can be accessed online at www.bcbsfepdental.com/
claimform. Mail the completed claim form and receipt to:
BCBS FEP Dental Claims
P.O. Box 75
Minneapolis, MN 55440-0075
Filing International
Claims
There is one rating area for all international locations. Use rating area 1 in the rate table to
find international premium amounts.
International Rates
38 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Section 7 General Exclusions – Things We Do Not Cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not
cover it unless we determine it is necessary for the prevention, diagnosis, care, or treatment of a covered condition.
We do not cover the following:
• Services and treatment not prescribed by or under the direct supervision of a dentist, except in those states where dental
hygienists are permitted to practice without supervision by a dentist. In these states, we will pay for eligible covered services
provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law;
• Services and treatment that are experimental or investigational;
• Services and treatment that are for any illness or bodily injury that occurs in the course of employment if a benefit or
compensation is available, in whole or in part, under the provision of any law or regulation or any government unit. This
exclusion applies whether or not you claim the benefits or compensation;
• Services and treatment received from a dental or medical department maintained by or on behalf of an employer, mutual
benefit association, labor union, trust, VA hospital or similar person or group;
• Services and treatment performed prior to your effective date of coverage;
• Services and treatment incurred after the termination date of your coverage unless otherwise indicated;
• Services and treatment that are not dentally necessary or do not meet generally accepted standards of dental practice.
• Services and treatment resulting from your failure to comply with professionally prescribed treatment;
• Any charges for failure to keep a scheduled appointment;
• Any services that are considered strictly cosmetic in nature including, but not limited to, charges for personalization or
characterization of prosthetic appliances;
• Services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMD);
• Services or treatment provided as a result of intentionally self-inflicted injury or illness;
• Services or treatment provided as a result of injuries suffered while committing or attempting to commit a felony, engaging
in an illegal occupation, or participating in a riot, rebellion or insurrection;
• Office infection control charges;
• Charges for copies of your records, charts or radiographic images, or any costs associated with forwarding/mailing copies
of your records, charts or radiographic images;
• State or territorial taxes on dental services performed;
• Those services submitted by a dentist, which is for the same services performed on the same date for the same member by
another dentist;
• Those services provided free of charge by any governmental unit, except where this exclusion is prohibited by law;
• Those services for which the member would have no obligation to pay in the absence of this or any similar coverage;
• Those services that are for specialized procedures and techniques;
• Those services performed by a dentist who is compensated by a facility for similar covered services performed for
members;
• Duplicate, provisional and temporary devices, appliances, and services;
• Plaque control programs, oral hygiene instruction, and dietary instructions;
39 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
• 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;
• Gold foil restorations;
• Charges for sterilizing;
• Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is
paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insurance plan;
• Treatment of services for injuries resulting from war or act of war, whether declared or undeclared, or from police or
military service for any country or organization;
• Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or
outpatient);
• Charges by the dentist for completing dental forms;
• Adjustment of a denture or bridgework that is made within 6 months after installation by the same dentist who installed it;
• Use of material or home health aids to prevent decay, such as toothpaste, fluoride gels, dental floss and teeth whiteners;
• Cone Beam Imaging and Cone Beam MRI procedures;
• Sealants for teeth other than 1st and 2nd permanent molars;
• Precision attachments, personalization, precious metal bases and other specialized techniques;
• Replacement of dentures that have been lost, stolen or misplaced;
• Repair of damaged orthodontic appliances;
• Replacement of lost or missing appliances;
• External bleaching;
• Nitrous oxide is excluded for individuals over 5 years of age in the absence of a medical condition that may require it;
• Oral sedation;
• Topical medicament center;
• Bone grafts when done in connection with extractions, apicoetomies or non-covered/non-eligible implants;
• Interim therapeutic restoration - primary;
• Veneers;
• Blood glucose level test - in-office using a glucose meter;
• Duplicate/copy patient's records;
• When two or more services are submitted and the services are considered part of the same service, we will pay the most
comprehensive service (the service that includes the other service) as determined by BCBS FEP Dental;
• When two or more services are submitted on the same day and the services are considered mutually exclusive (when one
service contradicts the need for the other service), we will pay for the service that represents the final treatment as determined
by this plan;
• Incomplete Endodontic Therapy, inoperable, unrestorable or fractured tooth is not a covered service.
40 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Section 8 Claims Filing and Disputed Claims Processes
To avoid delay in the payment of your dental claims, please have your dentist submit your claims
directly to your FEHB plan (should you be enrolled), then to BCBS FEP Dental. Pre-treatment
estimates and diagnostic quality preoperative periapical radiographs and/or panoramic
images can be submitted directly to BCBS FEP Dental (Exception: If accidental injury occurs,
pre-treatment estimates should be submitted to your FEHB plan).
If you need to send in a claim you may download a claim form from BCBS FEP Dental’s
website, www.bcbsfepdental.com
Mail completed claim form to:
BCBS FEP Dental Claims
P.O. Box 75
Minneapolis, MN 55440-0075
How to File a Claim for
Covered Services
You must submit your claim and any requested documentation within 24 months from the date
the service was rendered.
Deadline for Filing Your
Claim
Step Description
1. Ask us in writing to reconsider our initial decision. You must include any pertinent
information omitted from the initial claim filing and send your additional proof to us within 60
days from the date of our determination. Non-covered services do not qualify for the disputed
claims process.
2. You may mail your request for reconsideration to:
BCBS FEP Dental Claims Appeals
P.O. Box 551
Minneapolis, MN 55440-0551
Or go to www.bcbsfepdental.com/contactus
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.
3. If you disagree with the decision regarding your request for reconsideration, you may request
a second review of the denial within 60 days from the date of our determination. 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.
4. If you do not agree with our final decision, under certain circumstances you may request an
independent third party, mutually agreed upon by BCBS FEP Dental and OPM, review the
decision. To qualify for this independent third-party review, 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. You must file the appeal in writing to BCBS FEP
Dental within 60 days from the date of our determination.
The decision of the independent third party is binding and is the final review of your claim.
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.
Members may appeal any claims decision by submitting a written notice via U.S. Mail or email.
Disputed Claims Process
41 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Section 9 Definitions of Terms We Use in This Brochure
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 Get
Care.
Alternate Benefit
The maximum annual benefit that a member can receive. Annual Benefit
Maximum
Federal retirees (who retired on an immediate annuity) and survivors (of those who retired on an
immediate annuity or died in service) receiving an annuity. This also includes those receiving
compensation from the Department of Labor’s Office of Workers’ Compensation Programs, who are
called compensationers. Annuitants are sometimes called retirees.
Annuitants
The enrollment and premium administration system for FEDVIP. BENEFEDS
Covered services or payment for covered services to which enrollees and covered family members are
entitled to the extent provided by this brochure.
Benefits
From January 1, 2024 through December 31, 2024. Also referred to as the plan year. Calendar Year
Basic services, which include oral examinations, prophylaxis, diagnostic evaluations, sealants, and
radiographic images.
Class A Services
Intermediate services, which include restorative procedures such as fillings, prefabricated stainless steel
crowns, periodontal scaling and root planing, extractions, and denture adjustments.
Class B Services
Major services, which include endodontic services such as root canals, periodontal services, such as
gingivectomy, major restorative services such as crowns, oral surgery, bridges, and prosthodontic
services such as complete dentures.
Class C Services
Orthodontic services. Class D Services
Coinsurance is the stated percentage of covered expenses you must pay. Coinsurance
A copayment is a fixed amount of money you pay the dentist when you receive the service. Copay/Copayment
A cosmetic procedure is any procedure or portion of a procedure performed primarily to improve
physical appearance or is performed for psychological purposes.
Cosmetic Procedure
Covered services shall include only those services specifically listed in Section 5 Dental Services and
Supplies. A covered service must be incurred and completed while the person receiving the service is a
covered person. Covered services are subject to plan provisions for exclusions and limitations and must
meet broadly accepted national standards of practice.
Covered Services
The calendar date on which you visit the dentist's office and services are rendered. Date of Service
The Federal employee, annuitant, or TRICARE-eligible individual enrolled in this plan. Enrollee
Federal Employees Dental and Vision Insurance Program. FEDVIP
Generally accepted dental protocol means that a dental service or treatment is performed in accordance
with broadly accepted national standards of practice, as determined from multiple sources, including
but not limited to, relevant clinical dental research from various research organizations, including dental
schools, current recognized dental school standard of care curriculums and organized dental groups,
including the American Dental Association, which is necessary to treat decay, disease or injury of teeth,
or essential for the care of teeth and supporting tissues of the teeth.
Generally Accepted
Dental Protocols
Dental services that initiated in 2023 that will be completed in 2024. In-Progress
Treatment
A covered service is deemed incurred on the date care, treatment or service is received. Incur/Incurred
42 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
The amount we use to determine our payment for services. If services are provided by an in-network
dentist, the allowance is based on the negotiated fee they accept as payment in full. If services are
provided by an out-of-network dentist, the plan allowance is based on the out-of-network plan
allowance.
Plan Allowance
Network allowance means the allowance per procedure that BCBS FEP Dental has negotiated with the
dentist, and they have agreed to accept as payment in full.
Network Allowance
BCBS FEP Dental Plan
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).
Sponsor
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.
TRICARE-eligible
individual (TEI)
certifying family
member
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.
TRICARE-eligible
individual (TEI)
family member
The amount of time that you must be enrolled in this plan before you can receive services. Note: There
are no waiting periods for BCBS FEP Dental.
Waiting Period
BCBS FEP Dental We/Us
Enrollee or eligible family member. You
43 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Discounts
Save with Blue365® Discounts
BCBS FEP Dental presents Blue365, a program that provides easy access to premier health and wellness products and services to
help members build a path to live a healthy life. With Blue365, members get access to over 90 handpicked discounts from leading
brands and there is no limit to how many deals a member can redeem. Many deals are available and new ones are constantly
being added, including:
•Fitness – Get the support you need to achieve your fitness goals with deals on wearable devices, apparel, home gym
equipment, virtual workout classes and in-person gym access.
•Healthy Eyes and Ears – Between replacing hearing aids and correcting your vision, caring for your eyes and ears can get
expensive quickly. Blue365 provides up to 60% off hearing aids, discounts on LASIK surgery and more.
•Home and Family – Your home and family can influence your mental, physical, emotional, and financial well-being. Blue365
offers discounts on premium vitamins and supplements, pet insurance, fertility services, products for new parents, financial
offers, family health and more.
•Nutrition – Blue365 offers a variety of deals that help you eat right. Choose from meal kit subscriptions, chef-prepared
entrees, weight management plans and more.
•Personal Care – A little self-care can go a long way toward improving your mental health. Blue365 offers exclusive discounts
on skin care products, oral care products, tooth-whitening kits, mindfulness subscriptions and much more.
•Travel – Sometimes a vacation is all you need to escape stress and reset. Blue365 makes family getaways more affordable with
discounted access to lodging, car rentals and vacation packages.
Each week, Blue365 members can receive great health and wellness deals via email. With Blue365, there is no paperwork to fill
out. Just visit http://www.bcbsfepdental.com/additional-discounts and select Visit Blue365 deals to learn more about the various
Blue365 vendors and discounts.
BCBS FEP Dental does not recommend, endorse, warrant, or guarantee any specific Blue365 vendor or item. Vendors and the
program are subject to change at any time.
44 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Tools and Resources
AskBlue BCBS FEP Dental Plan Finder
Description: Need help choosing between High Option and Standard Option? AskBlue makes it easy. In just 10 minutes, you can
answer some simple questions and get recommended a plan based on your needs. Try AskBlue by visiting askblue.bcbsfepdental.com.
Website
Description: On our website, bcbsfepdental.com, you can access tools and resources that help you get the most out of your coverage,
including:
•Compare benefit plans
•Read Oral health and wellness articles
•Learn how to enroll
•Opt-in for email communication
•Find a dentist
•Dental Pricing Tool
•Glossary of dental terms
•Dental anatomy
•And much more
Member Portal
Description: Visit our member portal at www.bcbsfepdental.com to check the status of your claims, request claim forms, request a
duplicate or replacement ID card, and track how you use your benefits. Additional features include:
•Opt-in for email communication
•Opt-in for paperless Explanation of Benefits (EOBs)
•View/share EOBs
•View/share/download ID cards
•Submit online claims
•Live chat with customer service
•And much more
BCBS FEP Dental Mobile Application
Description: BCBS FEP Dental’s mobile application is available for download for both iOS and Android mobile phones. The
application provides members with 24/7 access to helpful features, tools and information related to BCBS FEP Dental benefits.
Members can log in with their username and password to access personal dental information such as benefits, out-of-pocket costs, and
wellness information. They can also view claims and approval status, view/share EOB, view/share member ID cards, and locate in-
network dentists. Additional features include:
•Submit online claims
•Dental Pricing Tool
•Brush & floss timer
•Torp's Interactive timer for children
•Opt-in for email communication
Social Media
Description: Follow us @bcbsfepdental on Facebook and YouTube for the latest information happening at BCBS FEP Dental.
45 2024 Blue Cross Blue Shield FEP Dental®
Summary of Benefits
•Do not rely on this chart alone. This page summarizes your portion of the expenses we cover; please review the
individual sections of this brochure for more detail.
•If you want to enroll or change your enrollment in this plan, please visit www.BENEFEDS.com or call 1-877-888-FEDS
(3337), TTY number 1-877-889-5680.
•Out-of-network services under Class A, B and C are subject to a $50 deductible per person under High Option and a
deductible of $75 for Standard Option per person per calendar year.
•For children age 13 and under, you pay $0 for in-network Class B, and Class C covered services as defined by the plan,
subject to plan maximums.
High Option Benefits You Pay
In-Network Out-of-Network
Class A (Basic) Services – preventive and diagnostic
Class A, B, and C Services are subject to an unlimited
annual maximum benefit amount for in-network
services and $3,000 for out-of-network services.
0% 10%
Class B (Intermediate) Services – includes minor
restorative services
Class A, B, and C Services are subject to an unlimited
annual maximum benefit amount for in-network
services and $3,000 for out-of-network services.
30% 40%
Class C (Major) Services – includes major
restorative, endodontic, and prosthodontic services
Class A, B, and C Services are subject to an unlimited
annual maximum benefit amount for in-network
services and $3,000 for out-of-network services.
50% 60%
Class D Services – orthodontic
up to $3,500 Lifetime Maximum
50% 50%
Standard Option Benefits You Pay
In-Network Out-of-Network
Class A (Basic) Services – preventive and diagnostic
Class A, B, and C Services are subject to a $1,500
annual maximum benefit for the in-network benefits
and $750 for the out-of-network benefits
0% 40%
Class B (Intermediate) Services – includes minor
restorative services
Class A, B, and C Services are subject to a $1,500
annual maximum benefit for the in-network benefits
and $750 for the out-of-network benefits
45% 60%
Class C (Major) Services – includes major
restorative, endodontic, and prosthodontic services
Class A, B, and C Services are subject to a $1,500
annual maximum benefit for the in-network benefits
and $750 for the out-of-network benefits
65% 80%
- continued on next page
46 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Standard Option Benefits You Pay
(cont.) In-Network Out-of-Network
Class D Services – orthodontic
$2,500 Lifetime Maximum for in-network, or
$1,250 Lifetime Maximum for out-of-network
50% 50%
47 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Dental and Vision Insurance
Program premium.
Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:
•Do not give your plan identification (ID) number over the telephone or to people you do not know, except to your dentists,
BCBS FEP Dental, BENEFEDS, or OPM.
•Let only the appropriate dentists review your clinical record or recommend services.
•Avoid using dentists who say that an item or service is not usually covered, but they know how to bill us to get it paid.
•Carefully review your explanation of benefits (EOBs) statements.
•Do not ask your dentist to make false entries on certificates, bills or records in order to get us to pay for an item or service.
•If you suspect that a dentist has charged you for services you did not receive, billed you twice for the same service, or
misrepresented any information, do the following:
- Call the dentist and ask for an explanation. There may be an error.
- If the dentist does not resolve the matter, call us at 1-855-504-BLUE (2583) and explain the situation, you will be
required to state your complaint in writing to us.
•Federal Civilians - Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless they are disabled and incapable of self-support).
•TRICARE Eligibles - Do not maintain as a family member on your policy:
Your child over age 21 if they are not enrolled in school (unless they are disabled or incapable of self-support)
Your child over age 23 if they are enrolled in school (unless they are disabled or incapable of self-support)
If you have any questions about the eligibility of a dependent, please contact BENEFEDS.
Be sure to review Section 1, Eligibility, of this brochure prior to submitting your enrollment or obtaining benefits.
Fraud or intentional misrepresentation of material fact is prohibited under the plan. You can be prosecuted for fraud
and your agency may take action against you if you falsify a claim to obtain FEDVIP benefits or try to obtain services
for someone who is not an eligible family member or who is no longer enrolled in the plan, or enroll in the plan when
you are no longer eligible.
48 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Notes
49 2024 Blue Cross Blue Shield FEP Dental®
Rate Information
How to find your rate: In the first chart below, look up your state or Zip code to determine your rating area. In the second chart on
the following page match your rating area to the enrollment type and plan option.
Premium Rating Areas by State/Zip Code (first three digits)
State Zip Rating
Region
State Zip Rating
Region
State Zip Rating
Region
AK Entire State 5 LA Entire State 1 NY Rest of State 2
AL Entire State 1 MA 010-011, 013-027,
055
5 OH Entire State 1
AR Entire State 2 MA Rest of State 3 OK Entire State 1
AZ
855,859-860,863-865
2 MD 205-212, 214,
216-217
3 OR 970-973 4
AZ 850-853 3 MD Rest of State 2 OR Rest of State 2
AZ Rest of State 1 ME 039-042 5 PA 180-181, 183 4
CA 900-908, 910-928,
930-931, 933-935
4 ME Rest of State 2 PA 189-196 2
CA
939-952,954,956-959
5 MI 480-485 2 PA 172-174 3
CA Rest of State 2 MI Rest of State 1 PA Rest of State 1
CO Entire State 4 MN 550-551, 553-555,
563
4 PR Entire Area 1
CT 060-063 5 MN Rest of State 3 RI Entire State 5
CT Rest of State 4 MO 726 2 SC Entire State 2
DC Entire Area 3 MO Rest of State 1 SD Entire State 1
DE Entire State 2 MS Entire State 1 TN Entire State 1
FL 330-334, 349 2 MT Entire State 1 TX Entire State 1
FL Rest of State 1 NC 270-274, 278,
280-282, 284-289
2 UT Entire State 2
GA Entire State 1 NC 275-277, 283 3 VA 201, 205, 220-227 3
GU Entire Area 1 NC Rest of State 1 VA Rest of State 1
HI Entire State 3 ND Entire State 5 VI Entire Area 1
IA
500-514,516,520-528
3 NE Entire State 2 VT Entire State 5
IA Rest of State 2 NH 030-033, 038 5 WA 980-985 5
ID Entire State 4 NH Rest of State 3 WA Rest of State 4
IL 600-609, 613 2 NJ 070-079, 085-089 4 WI 540 4
IL 612 3 NJ Rest of State 2 WI Rest of State 3
IL Rest of State 1 NM Entire State 1 WV 254 3
IN 463-464 2 NV 897 5 WV Rest of State 1
IN Rest of State 1 NV Rest of State 2 WY 834 4
KS 664-665, 667-679 2 NY 120-123, 128 3 WY Rest of State 2
KS Rest of State 1 NY 063 5 INTL International 1
KY Entire State 1 NY 005, 100-119,
124-126
4
50 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
Rates
Rating Area
High - Bi-Weekly High - Monthly
Self Only Self Plus One Self and Family Self Only Self Plus One Self and Family
1 $18.39 $36.77 $55.16 $39.85 $79.67 $119.51
2 $20.60 $41.20 $61.80 $44.63 $89.27 $133.90
3 $22.43 $44.85 $67.28 $48.60 $97.18 $145.77
4 $24.29 $48.58 $72.87 $52.63 $105.26 $157.89
5 $27.19 $54.37 $81.56 $58.91 $117.80 $176.71
Rating Area
Standard - Bi-Weekly Standard - Monthly
Self Only Self Plus One Self and Family Self Only Self Plus One Self and Family
1 $9.87 $19.75 $29.62 $21.39 $42.79 $64.18
2 $10.82 $21.63 $32.45 $23.44 $46.87 $70.31
3 $12.30 $24.60 $36.90 $26.65 $53.30 $79.95
4 $13.28 $26.56 $39.85 $28.77 $57.55 $86.34
5 $14.67 $29.33 $44.00 $31.79 $63.55 $95.33
51 2024 Blue Cross Blue Shield FEP Dental® Enroll at www.BENEFEDS.com
