Section 5 Dental Services and Supplies Class A Basic

Blue Cross Blue Shield FEP Dental
Section 5 Dental Services and Supplies Class A Basic

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 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, the 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.
All services requiring more than one visit are payable once all visits are completed.
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 both policies)
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.

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.