Table of Contents
Introduction 1
Table of Contents 3
Changes for 2023 5
FEDVIP Program Highlights 6
Class B Intermediate 24
Class C Major 29
Class D Orthodontic 38
General Services 40
Section 6 International Services and Supplies 42
Section 7 General Exclusions – Things We Do Not Cover 43
Section 8 Claims Filing and Disputed Claims Processes 45
Section 9 Definitions of Terms We Use in This Brochure 47
Discounts and Features 49
Summary of Benefits 51
Stop Health Care Fraud! 54
Rate Information 55
Rates 56
Table of Contents 3
Changes for 2023 5
FEDVIP Program Highlights 6
A Choice of Plans and Options 6
Enroll Through BENEFEDS 6
Dual Enrollment 6
Coverage Effective Date 6
Pre-Tax Salary Deduction for Employees 6
Annual Enrollment Opportunity 6
Continued Group Coverage After Retirement 6
Waiting Period 6
Section 1 Eligibility 7Enroll Through BENEFEDS 6
Dual Enrollment 6
Coverage Effective Date 6
Pre-Tax Salary Deduction for Employees 6
Annual Enrollment Opportunity 6
Continued Group Coverage After Retirement 6
Waiting Period 6
Federal Employees 7
Federal Annuitants 7
Survivor Annuitants 7
Compensationers 7
TRICARE-eligible individual 7
Family Members 7
Not Eligible 8
Section 2 Enrollment 9Federal Annuitants 7
Survivor Annuitants 7
Compensationers 7
TRICARE-eligible individual 7
Family Members 7
Not Eligible 8
Enroll Through BENEFEDS 9
Enrollment Types 9
Dual Enrollment 9
Opportunities to Enroll or Change Enrollment 9
When Coverage Stops 11
Continuation of Coverage 12
FSAFEDS/High Deductible Health Plans and FEDVIP 12
Section 3 How You Obtain Care 13Enrollment Types 9
Dual Enrollment 9
Opportunities to Enroll or Change Enrollment 9
When Coverage Stops 11
Continuation of Coverage 12
FSAFEDS/High Deductible Health Plans and FEDVIP 12
Identification Cards/Enrollment Confirmation 13
Where You Get Covered Care 13
Plan Providers 13
In-Network 13
Out-of-Network 14
Emergency Services 14
Maximum Amount Allowed 14
Precertification 14
Alternate Benefit 14
Dental Review 15
FEHB First Payor 15
Coordination of Benefits 16
Rating Areas 17
Limited Access Area 17
Section 4 Your Cost For Covered Services 18Where You Get Covered Care 13
Plan Providers 13
In-Network 13
Out-of-Network 14
Emergency Services 14
Maximum Amount Allowed 14
Precertification 14
Alternate Benefit 14
Dental Review 15
FEHB First Payor 15
Coordination of Benefits 16
Rating Areas 17
Limited Access Area 17
Deductible 18
Coinsurance 18
Annual Benefit Maximum 19
Lifetime Benefit Maximum 19
In-Network Services 19
Out-of-Network Services 19
Calendar Year 19
Emergency Services 19
Section 5 Dental Services and Supplies Class A Basic 21Coinsurance 18
Annual Benefit Maximum 19
Lifetime Benefit Maximum 19
In-Network Services 19
Out-of-Network Services 19
Calendar Year 19
Emergency Services 19
Class B Intermediate 24
Class C Major 29
Class D Orthodontic 38
General Services 40
Section 6 International Services and Supplies 42
Section 7 General Exclusions – Things We Do Not Cover 43
Section 8 Claims Filing and Disputed Claims Processes 45
Section 9 Definitions of Terms We Use in This Brochure 47
Discounts and Features 49
Summary of Benefits 51
Stop Health Care Fraud! 54
Rate Information 55
Rates 56