Class C Major

Blue Cross Blue Shield FEP Dental
Class C Major

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 generally accepted dental protocols.
The calendar year deductible is $0 if you use an in-network provider.
If you elect to use an out-of-network provider, Standard Option has a $75 deductible per person; High Option has a $50 deductible. 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 covered person’s dental condition, BCBS FEP Dental may decide to authorize alternate treatment for a less costly covered service or procedure if the service selected is an appropriate method of treatment. This may apply but not limited to include: a filing may be the alternate benefit of a crown or only, a removable partial denture may be an alternate benefit for implants. Should the member and the dentist choose the more expensive treatment, the member is responsible for the additional charges beyond the allowance for the alternate service, even if an in-network provider.
A number of services listed in this section may be subject to dental review or an alternate benefit may be paid. We recommend that your dentist submit a pre-treatment estimate of benefits. To avoid expenses for services the plan will not cover, pre-treatment estimate of benefits accompanied by diagnostic quality pre-operative periapical radiographic and/or panoramic images is encouraged. 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 Maximum Allowable Amount is based on your current eligibility and contract benefits in effect at the time of the completed service. Submission of other claims or changes in eligibility or the contract may alter final payment. A pretreatment estimate is not a guarantee of benefits.
For inlay services (D2510, D2520, D2530, D2650, D2651, D2652), 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.
The following list is an all-inclusive list of covered services. BCBS FEP Dental will provide benefits for these services, subject to the exclusions and limitations shown in this section and Section 7.
In-progress treatment for dependents of retiring TDP enrollees will be covered for the 2023 plan year. This is regardless of any current plan exclusions for care initiated prior to the enrollee’s effective date.

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.
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.