Blue Cross Blue Shield FEP Dental
Summary of Benefits

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.
You Pay
In-Network: 0%
Out-of-Network: 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.
You Pay
In-Network: 30%
Out-of-Network: 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.
You Pay
In-Network: 50%
Out-of-Network: 60%

Class D Services – orthodontic
up to $3,500 Lifetime Maximum
You Pay
In-Network: 50%
Out-of-Network: 50%