Delta Dental's
Federal Employees Dental Program
deltadentalins.com/fedvip
2022
A Nationwide Dental PPO Plan
IMPORTANT
• Rates: Back Cover
• Changes for 2022: Page 4
• Summary of Benefits: Page 55
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 Delta Dental's Federal Employees Dental Program under Delta Dental of California
contract OPM02-FEDVIP-02AP-05 with OPM, as authorized by the FEDVIP law. The address for our administrative office
is:
Delta Dental of California
Federal Employees Dental Program
PO Box 537007
Sacramento, CA 95853-7007
855-410-3255
deltadentalins.com/fedvip
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, 2021, unless those benefits are also
shown in this brochure.
OPM negotiates benefits and rates with each carrier annually. Rates are shown at the end of this brochure.
Delta Dental maintains the network of providers available to enrollees in the Federal Employees Dental Program. You may
view the most current network provider directory on our website at deltadentalins.com/fedvip, or you may contact us at
855-410-3255 (TDD 866-847-1264) to request a list of participating providers in your area. Continued participation of any
specific provider cannot be guaranteed. Thus, you should choose your plan based on the benefits provided and not for a
specific provider’s participation. When you phone for an appointment, please remember to verify that the provider is
currently in Delta Dental's network for the Federal Employees Dental Program. You cannot change plans because of changes
to the provider network. If your provider is not currently participating in the provider network, you may nominate him or her
to join at http://www.deltadentalca.org/enrollee/forms/Nominatedentist.asp?DPO. Nomination forms are available on our
website, or call us and we will have a form sent to you. Please note that Delta Dental offers various dental plans in the U.S.
and not all Delta Dental network dentists are considered "in-network" for the Federal Employees Dental Program.
Provider networks 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, please contact us for assistance.
Delta Dental's Federal Employees Dental Program 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, please visit our website
at deltadentalins.com/fedvip. If you do not have access to the Internet or would like further information, please contact us by
calling 855-410-3255.
Discrimination is Against the Law
Delta Dental's Federal Employees Dental Program 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, Delta
Dental's Federal Employees Dental Program does not discriminate, exclude people, or treat them differently on the basis
of race, color, national origin, age, disability, or sex.
1 2022 Delta Dental's
Federal Employees Dental Program
Enroll at www.BENEFEDS.com
Table of Contents
Introduction ...................................................................................................................................................................................1
Table of Contents ..........................................................................................................................................................................2
How We Have Changed for 2022 .................................................................................................................................................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
Waiting Period .....................................................................................................................................................................5
Section 1 Eligibility ......................................................................................................................................................................6
Federal Employees ..............................................................................................................................................................6
Federal Annuitants ..............................................................................................................................................................6
Survivor Annuitants ............................................................................................................................................................6
Compensationers .................................................................................................................................................................6
Family Members .................................................................................................................................................................6
Not Eligible .........................................................................................................................................................................7
Section 2 Enrollment .....................................................................................................................................................................8
Enroll Through BENEFEDS ...............................................................................................................................................8
Enrollment Types ................................................................................................................................................................8
Dual Enrollment ..................................................................................................................................................................8
Opportunities to Enroll or Change Enrollment ...................................................................................................................8
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 Providers ...................................................................................................................................................................12
In-Network ........................................................................................................................................................................12
Out-of-Network .................................................................................................................................................................12
Emergency Services ..........................................................................................................................................................12
Plan Allowance .................................................................................................................................................................13
Precertification/Predetermination Notice ..........................................................................................................................13
Alternate Benefit ...............................................................................................................................................................13
Dental Review ...................................................................................................................................................................13
FEHB First Payor ..............................................................................................................................................................13
Coordination of Benefits ...................................................................................................................................................13
Right of Recovery .............................................................................................................................................................14
Rating Areas ......................................................................................................................................................................14
Limited Access Area .........................................................................................................................................................14
Section 4 Your Cost For Covered Services .................................................................................................................................15
Deductible .........................................................................................................................................................................15
Coinsurance .......................................................................................................................................................................15
2 2022 Delta Dental's
Federal Employees Dental Program
Enroll at www.BENEFEDS.com
Annual Benefit Maximum ................................................................................................................................................16
Lifetime Benefit Maximum ..............................................................................................................................................16
In-Network Services .........................................................................................................................................................16
Out-of-Network Services ..................................................................................................................................................16
Plan Allowance .................................................................................................................................................................16
Calendar Year ....................................................................................................................................................................16
Tooth Missing but Not Replaced Rule ..............................................................................................................................16
Section 5 Dental Services and Supplies Class A Basic ...............................................................................................................18
Class B Intermediate ...................................................................................................................................................................21
Class C Major ..............................................................................................................................................................................26
Class D Orthodontic ....................................................................................................................................................................35
General Services .........................................................................................................................................................................37
Section 6 International Services and Supplies ............................................................................................................................41
Section 7 General Exclusions – Things We Do Not Cover .........................................................................................................42
Section 8 Claims Filing and Disputed Claims Processes ............................................................................................................46
How to File a Claim for Covered Services .......................................................................................................................46
International Claims ..........................................................................................................................................................46
Deadline for Filing Your Claim .........................................................................................................................................46
Disputed Claims Process ...................................................................................................................................................46
Section 9 Definitions of Terms We Use in This Brochure ..........................................................................................................52
Stop Health Care Fraud! .............................................................................................................................................................54
Summary of Benefits ..................................................................................................................................................................55
Notes ...........................................................................................................................................................................................56
Rate Information .........................................................................................................................................................................58
3 2022 Delta Dental's
Federal Employees Dental Program
Enroll at www.BENEFEDS.com
How We Have Changed for 2022
Delta Dental’s benefit enhancements for 2022 include:
•Removal of Orthodontic Waiting Period for both the Standard and the High Plan
•Increase High Plan In-Network Annual Maximum from $30,000 to Unlimited
•Increase Standard Plan Out-Of-Network Annual Maximum from $600 to $1,000
Delta Dental will provide access to multiple discounts and perks that are non-insurance offers to all our members outside of
and in addition to their benefits.
We added the following procedure codes:
D3921 Decoronation or submergence of an erupted tooth
D5227 Immediate maxillary partial denture - flexible base (including any clasps, rests and teeth)
D5228 Immediate mandibular partial denture - flexible base (including any clasps, rests and teeth)
D5725 Rebase hybrid prosthesis
D5765 Soft liner for complete or partial removable denture – indirect
We deleted the following codes:
D8050 Interceptive orthodontic treatment of the primary dentition
D8060 Interceptive orthodontic treatment of the transitional dentition
D8690 Orthodontic treatment (alternative billing to a contract fee)
4 2022 Delta Dental's
Federal Employees Dental Program
Enroll at www.BENEFEDS.com
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 2021 Open Season, your coverage
will begin on January 1, 2022. Premium deductions will start with the first full pay period
beginning on/after January 1, 2022. 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 08,
2021 through midnight EST December 13, 2021. 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
There are no waiting periods in our plans. Waiting Period
5 2022 Delta Dental's
Federal Employees Dental Program
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
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
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.
Family Members
6 2022 Delta Dental's
Federal Employees Dental Program
Enroll at www.BENEFEDS.com
With respect to TRICARE-eligible individuals, family members include your spouse,
unremarried widow, unremarried widower, unmarried child, an unremarried former spouse
who meets the U.S Department of Defense's 20-20-20 or 20-20-15 eligibility
requirements, 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.
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 vision 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).
Not Eligible
7 2022 Delta Dental's
Federal Employees Dental Program
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 (1-877-888-3337), 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 plan's premiums may change for 2022.
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 08, 2021 through midnight EST December
13, 2021, Open Season. Coverage is effective January 1, 2022.
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; or
- an employee returning to service following a break in service of at least 31 days.
- a TRICARE-eligible individual
Your enrollment will be effective the first day of the pay period following the one in which
BENEFEDS receives and confirms your enrollment.
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.
Opportunities to Enroll
or Change Enrollment
8 2022 Delta Dental's
Federal Employees Dental Program
Enroll at www.BENEFEDS.com
The following chart 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
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)
9 2022 Delta Dental's
Federal Employees Dental Program
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.
Generally, 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 and confirms 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.
Canceling an enrollment
You may cancel your enrollment only during the annual Open Season. An eligible family
member’s coverage also ends upon the effective date of the cancellation.
Your cancellation is effective at the end of the day before the date OPM sets as the Open Season
effective date.
Coverage ends for active and retired Federal, 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;
• as sponsor or primary enrollee leaves active duty
• 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;
• are making direct premium payments to BENEFEDS and you stop making the payments;
• 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.
When Coverage Stops
10 2022 Delta Dental's
Federal Employees Dental Program
Enroll at www.BENEFEDS.com
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
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.
If you have an HCFSA or LEX HCFSA FSAFEDS account and you haven’t exhausted your
funds by December 31st of the plan year, FSAFEDS can automatically carry over up to $550 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 31. You must also actively reenroll
in a health care or limited expense account during the NEXT Open Season to be carryover
eligible. Your reenrollment must be for at least the minimum of $100. If you do not reenroll, 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 period permitted. This is
known as the “Use-it-or-Lose-it” rule. Carefully consider the amount you will elect.
For a health care or limited expense account, each participant must contribute a minimum of
$100 to a maximum of $2,750.
Current FSAFEDS participants must re-enroll to participate next year. See 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 are enrolled in an FSAFEDS HCFSA, you can take advantage of the Paperless
Reimbursement option, which allows you to be reimbursed from your HCFSA without
submitting an FSAFEDS claim. When Delta Dental receives a Federal Employees Dental
Program claim for payment, we forward information about your out-of-pocket expenses (such as
copayment and deductible amounts) to FSAFEDS for processing. FSAFEDS then reimburses
you for your eligible out-of-pocket costs without the need for a claim form or receipt.
Reimbursement is made directly to your bank from your HCFSA account via electronic funds
transfer. You may need to file a paper claim to FSAFEDS in certain situations. Visit www.
FSAFEDS.com for more information.
If you enroll or are enrolled in a high deductible health plan with a health savings account (HSA)
or health reimbursement arrangement (HRA), you can use your HSA or HRA to pay for qualified
dental/vision costs not covered by your FEHB and FEDVIP plans. You will be required to submit
your claim on behalf of Delta Dental's Federal Employees Dental Program to the FSAFEDS
Health Care Spending Account (HCFSA) or Limited Expense Health Care Flexible Spending
Account (LEX HCFSA).
FSAFEDS/High Deductible
Health Plans and FEDVIP
11 2022 Delta Dental's
Federal Employees Dental Program
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 card ("ID Card"). ID Cards are issued in the primary member's name only. It
is important to bring your FEDVIP and FEHB ID cards to every dental appointment.
Because 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.
If you require a replacement ID card, you will be able to print your ID card through the
Member Portal at deltadentalins.com/fedvip. An ID card is neither a guarantee of benefits
nor is it required in order for you to obtain dental services. Your provider may call
855-410-3255 or visit deltadentalins.com/fedvip/dentists/ to confirm your enrollment in
the plan and the benefits available to you.
If you were enrolled in Delta Dental's Federal Employees Dental Program in 2021 and
continue coverage for 2022, please visit deltadentalins.com/fedvip where you can view
and print the Plan Brochure, find network dentists and much more.
Identification Cards/
Enrollment
Confirmation
Plan benefits are available, subject to plan provisions, from any licensed dentist in the 50
United States, the District of Columbia and Puerto Rico as well as overseas.
Where You Get Covered
Care
The provider network for Delta Dental's Federal Employees Dental Program consists of
independently credentialed and contracted providers. IMPORTANT: Note there are
different dentist networks for other Delta Dental plans—so be sure to use the Dentist
Search function at deltadentalins.com/fedvip to find a dentist who participates in the
network for Delta Dental's Federal Employees Dental Program. Contact your dentist to
verify he/she is participating in Delta Dental's Federal Employees Dental Program. You
may also contact Customer Service at 855-410-3255 for a list of Federal Employees
Dental Program network providers near you.
Plan Providers
Delta Dental's Federal Employees Dental Program network dentists are available in the 50
U.S. states, the District of Columbia and Puerto Rico. Our list of participating network
dentists is updated daily. When you make your appointment, please advise the dental
office that you are enrolled in the Federal Employees Dental and Vision
Insurance Program (FEDVIP) and wish to use your in-network benefits; be sure to
confirm that the dentist is a participating network provider for Delta Dental's Federal
Employees Dental Program.
Delta Dental's Federal Employees Dental Program network does not require an enrollee to
select a primary care provider. When you use a Delta Dental Federal Employees Dental
Program network provider, you are responsible only for billable charges up to our
negotiated plan allowance per procedure. You are not responsible for treatment service
charges in excess of the in-network negotiated per-procedure maximum unless you
consent in writing to additional treatment charges.
In-Network
You may obtain care from any licensed dentist. If the dentist is not part of our network,
benefits will be considered out-of-network. When you see a dentist who is outside of
Delta Dental's participating network for the Federal Employees Dental Program, you will
have a lower annual maximum benefit and we pay for services based on an out-of-
network plan allowance. You are responsible for any difference between the plan payment
and the amount submitted/approved.
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
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All expenses for emergency services are payable as any other expense and are subject to
plan limitations such as deductibles, frequencies and maximums. If you use an out-of-
network provider for emergency services, benefits will be paid under the out-of-network
plan provisions. You are responsible for the difference between the plan payment and the
amount submitted/approved.
The plan allowance is the amount we allow for a specific procedure. When you use an in-
network Delta Dental Federal Employees Dental Program provider, your out-of-pocket
cost is limited to the difference between the plan allowance and our payment. When you
use an out-of-network dentist, you are responsible for the difference between the plan
allowance and our payment plus the difference up to the submitted/approved charges.
Plan Allowance
You and your provider may request us to predetermine benefits for dental procedures that
your dentist has planned. This is especially recommended for more complex and/or major
procedures. We will provide both you and your dentist with a non-binding, written Pre-
treatment Estimate indicating if the procedures are covered and, if so, an estimate of what
we will pay for those specific procedures.
When the treatment is complete, the provider will fill in the date(s) of service on the Pre-
treatment Estimate, sign and date the notice, and return it to Delta Dental at the address
provided for claims submission (see Section 9 Claims Filing and Disputed Clams
Processes). Pre-treatment Estimates submitted for payment will be processed in
accordance with Delta Dental's claims processing policies. The final determination of
eligibility, maximums, program benefits, limitations and allowable fees will be made by
Delta Dental when the Pre-treatment Estimate is processed for payment.
Precertification/
Predetermination Notice
If more than one service or procedure can be used to treat the dental condition, Delta
Dental reserves 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.
Alternate Benefit
Some dental services submitted on a claim may be reviewed if deemed appropriate. Your
provider should submit radiographic images with crowns and periodontal charting with
periodontal surgeries. There may be situations resulting from the dental review in which
an alternate benefit is recommended. For more extensive and costly services, we
recommend that a Pre-Treatment Estimate request be submitted so you have an estimate
of your coverage before the services are rendered.
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 Delta Dental's Federal Employees Dental
Program. Therefore, it is important to provide your dental office with both your FEHB ID
card and your Delta Dental Federal Employees Dental Program enrollment card at each
appointment. Your dental office should submit your 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. The FEDVIP plan allowance will be the
prevailing charge in these cases. You are responsible for the difference between the FEHB
and FEDVIP benefit payments and the FEDVIP plan allowance. We are responsible for
facilitating the process with the primary FEHB payor, which is supported when your
dental office submits to your FEHB carrier first.
FEHB First Payor
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/vision
costs under no-fault insurance that pays benefits without regard to fault.
If you are covered under a non-FEHB plan, Delta Dental's Federal Employees Dental
Program dental benefits will be coordinated using traditional COB provisions for
determining payment.
Coordination of Benefits
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If your other dental coverage is part of your FEHB plan, it is important to note that by law,
your FEHB plan must pay first. Your dentist must submit your claim to your FEHB carrier
first and then to Delta Dental. It is your responsibility to let the dentist know if you have
both FEHB and FEDVIP coverage so the claim is submitted and processed correctly. Your
dental provider should submit to the primary carrier first, then any subsequent insurance
carrier thereafter.
If the amount we pay is more than we should have paid under the First Payor provision or
when benefits are coordinated, we may recover the excess from one or more of:
• the person we have paid;
• insurance companies; or
• other organizations.
However, the member will never be held responsible for a greater out-of-pocket amount
than he/she would have been responsible for had there been no overpayment.
Right of Recovery
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 877-888-3337. Your rates might change because of the move.
Rating Areas
If you live in an area with insufficient access (based on contractual standards) to a Delta
Dental Federal Employees Dental Program network provider and you receive covered
services from an out-of-network dentist, we will pay the same benefit level as if you used
the services of an in-network dentist. Your responsibility is limited to any difference
between the amount billed and our payment.
Limited Access Area
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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: $0
Out-of-Network Standard Option: $0
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%
Coinsurance
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Orthodontics
In-Network High Option: 50%
In-Network Standard Option: 50%
Out-of-Network High Option: 50%
Out-of-Network Standard Option: 50%
Once you reach this amount, you are responsible for all additional charges. The Annual
Benefit Maximums within each option are combined between in and out of network
services. The total Annual Benefit Maximum will never be greater than the In-Network
Maximum Annual Benefit.
Maximum Annual Benefits:
In-Network High Option: Unlimited
In-Network Standard Option: $1,500
Out-of-Network High Option: $3,000
Out-of-Network Standard Option: $1000
Annual Benefit
Maximum
The Lifetime Maximum is applicable to Orthodontia benefits only. There are no other
lifetime maximums under this Plan.
Lifetime Orthodontic Maximum
In-Network High Option: $3,500 for dependents up to 21 for TRICARE-eligible
individuals (or 23 if they’re full-time college students) or 22 for civilian dependents;
$2,000 for members and spouses
In-Network Standard Option: $2,000 for dependent children up to age 19
Out-of-Network High Option: $3,500 for dependents up to 21 for TRICARE-eligible
individuals (or 23 if they’re full-time college students) or 22 for civilian dependents;
$2,000 for members and spouses
Out-of-Network Standard Option: $1,000 for dependent children up to age 19
Lifetime Benefit
Maximum
You pay the coinsurance percentage of our network allowance for covered services. You
are not responsible for charges above that allowance.
In-Network Services
If the dentist you use is not part of our network, benefits will be considered out-of-
network. Because these providers are not part of our network, we pay for
services rendered by an out-of-network provider 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
The plan allowance is the amount we allow for a specific procedure. When you use a
participating provider, your out-of-pocket cost is limited to the difference between the
plan allowance and our payment. When you use an out-of-network provider, you are
responsible for the difference between our payment and the submitted/approved amount.
Plan Allowance
The calendar year refers to the plan year, which is defined as January 1, 2022 to December
31, 2022.
Calendar Year
The installation of complete or partial removable dentures, fixed partial dentures
(bridges), implants and other prosthodontic services will be covered when replacing or
repairing a pre-existing, failed prosthodontic appliance/device that was in existence prior
to your coverage effective date under the Delta Dental Federal Employees Dental
Program. Initial prosthodontic services to replace natural teeth that were missing prior to
your Delta Dental Federal Employees Dental Program date of coverage are not covered.
Tooth Missing but Not
Replaced Rule
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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 2022 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 2022 plan year
such as crowns and implants. FEDVIP carriers will not cover in-progress treatment if you
enroll in a FEDVIP plan that has a waiting period, or does not cover the service. Several
FEDVIP dental plans have options that offer orthodontia coverage without a 12-month
waiting period, and without age limits. Note - There are no waiting periods for
any covered benefits in this plan.
In-Progress Treatment
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Section 5 Dental Services and Supplies Class A Basic
Important things you should keep in mind about these benefits:
•All benefits are subject to the definitions, limitations, and exclusions in this plan 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 under both the High and Standard options when services are
rendered by an in-network provider.
•The annual benefit maximum in the High Option is Unlimited for non-orthodontic services when the
services are rendered by an in-network provider and $3,000 when services are rendered by an out-
of-network provider. The annual benefit maximum in the Standard Option is $1,500 when services
are rendered by an in-network provider and $1,000 when services are rendered by an out-of-network
provider.
•Under no circumstances will Delta Dental's Federal Employees Dental Program allow more
than $3,000 in out of network benefits under the High Option in any plan year or more than $1,500
in combined benefits under the Standard Option in any plan year.
•Any dental service or treatment not listed as a covered service is not eligible for benefits. Also see
Section 7, General Exclusions – Things We Do Not Cover, for a list of exclusions and limitations.
You Pay:
•
High Option
- In-Network: $0 for covered services as defined by the plan and subject to plan limitations and
maximums.
- Out-of-Network: 10% of the plan's out-of-network allowance and any difference between that
allowance and the billed/approved amount.
•
Standard Option
- In-Network: $0 for covered services as defined by the plan and subject to plan limitations and
maximums.
- Out-of-Network: 40% of the plan's out-of-network allowance and any difference between that
allowance and the billed/approved amount.
Diagnostic Services
D0120 Periodic oral evaluation – established patient - Limited to two in a calendar year
D0140 Limited oral evaluation - problem-focused – Limited to one emergency visit per office in a 12-month period
D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver
D0150 Comprehensive oral evaluation – new or established patient - Limited to one in a calendar year
D0160 Detailed and extensive oral evaluation – problem-focused, by report
D0180 Comprehensive periodontal evaluation – new or established patient - Limited to one in a calendar year
D0210 Intraoral - complete set of radiographic images – Limited to one every 48 months
D0220 Intraoral - periapical first radiographic image
D0230 Intraoral - periapical each additional radiographic image
D0240 Intraoral - occlusal radiographic image
D0250 Extraoral - 2D projection radiographic images created using a stationary radiation source, and detector
D0251 Extraoral - posterior dental radiographic image
D0270 Bitewing - single radiographic image – Limited to one in a calendar year
D0272 Bitewings - two radiographic images – Limited to one in a calendar year
D0273 Bitewings - three radiographic images – Limited to one in a calendar year
Diagnostic Services - continued on next page
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Federal Employees Dental Program
Diagnostic Services (cont.)
D0274 Bitewings - four radiographic images – Limited to one in a calendar year
D0277 Vertical bitewings - 7 to 8 radiographic images – Limited to one in a calendar year
D0330 Panoramic radiographic images – Limited to one every 48 months
D0425 Caries susceptibility tests
D0701 Panoramic radiographic image – image capture only
D0705 Extra-oral posterior dental radiographic image – image capture only
D0706 Intraoral – occlusal radiographic image – image capture only
D0707 Intraoral – periapical radiographic image – image capture only
D0708 Intraoral – bitewing radiographic image – image capture only
D0709 Intraoral – complete series of radiographic images – image capture only
Benefit Limitations for Class A Diagnostic Services
1. Pulp vitality tests are considered integral to all services.
2. Examinations/evaluations by specialists are payable as comprehensive or periodic examinations/evaluations and are
counted towards the two-in-a-calendar-year limitation on examinations/evaluations.
3. A full-mouth series (complete series) of radiographs includes bitewings. Any additional radiographic image taken with a
complete radiographic series is considered integral to the complete series.
4. If the total fee for individually listed radiographs equals or exceeds the fee for a complete series, these radiographs are
paid as a complete series and are subject to the same benefit limitations.
5. Payment for more than one of any category of full-mouth radiographs within a 48-month period is the patient's
responsibility.
6. A panoramic radiograph taken with any other radiographic image is considered a full-mouth series and is paid as such,
and is subject to the same benefit limitation. A panoramic radiograph is not a benefit for patients under six years of age.
7. Payment for periapical radiographic images (other than as part of a complete series) is limited to four within a calendar
year except when done in conjunction with emergency services and submitted by report.
8. Payment for a bitewing survey, whether single, two, three, four or vertical radiographic image(s), including those taken
as part of a complete series, is limited to one within a calendar year.
Preventive Services
D1110 Prophylaxis - Adult – Limited to two in a calendar year (or three if enrollee is a Type 1 or Type 2 diabetic)
D1120 Prophylaxis - Child – Limited to two in a calendar year (or three if enrollee is a Type 1 or Type 2 diabetic)
D1206 Topical application of fluoride varnish - limited to two in a calendar year
D1208 Topical application of fluoride - excluding varnish – Limited to two in a calendar year
D1351 Sealant - per tooth - permanent molars free from caries to patients under 19 – Limited to one in 36 months
D1352 Preventive resin restoration in a moderate-to-high-caries-risk patient - permanent molars free from caries for
dependent children under 19- Limited to one in 36 months
D1353 Sealant repair – per tooth
D1354 Application of caries arresting medicament-per tooth.
D1510 Space maintainer - fixed - unilateral – per quadrant – For dependent children under age 19
D1516 Space maintainer - fixed - bilateral – maxillary - For dependent children under age 19
D1517 Space maintainer – fixed – bilateral – mandibular – For dependent children under age 19
D1520 Space maintainer - removable - unilateral – per quadrant – For dependent children under age 19
D1526 Space maintainer - removable - bilateral – maxillary For dependent children under age 19
D1527 Space maintainer – removable – bilateral – mandibular For dependent children under age 19
D1551 Re-cement or re-bond bilateral space maintainer – maxillary
D1552 Re-cement or re-bond bilateral space maintainer – mandibular
Preventive Services - continued on next page
19 2022 Delta Dental's
Federal Employees Dental Program
Preventive Services (cont.)
D1553 Re-cement or re-bond unilateral space maintainer – per quadrant
D1575 Distal shoe space maintainer – fixed – unilateral – per quadrant – For dependent children under age 19
Benefit Limitations for Class A Preventive Services
1. Three prophylaxes for adults and children diagnosed with Type 1 or Type 2 Diabetes are covered in a calendar year. A
statement from the patient’s physician documenting the patient’s medical condition must be provided.
2. Periodontal scaling in the presence of gingival inflammation is considered to be a routine prophylaxis and is paid as
such. Participating dentists may not bill the patient for any difference in fees.
3. There are no provisions for special consideration for a prophylaxis based on degree of difficulty. Scaling or polishing to
remove plaque, calculus and stains from teeth is considered to be part of the prophylaxis procedure.
4. Topical fluoride applications are covered only when performed as independent procedures. Use of a prophylaxis paste
containing fluoride is payable as a prophylaxis only.
5. Routine oral hygiene instructions are considered integral to a prophylaxis service.
6. The tooth number of the space to be maintained is required when requesting payment for space maintainers.
7. The fee for a stainless steel crown or band retainer is considered to be included in the total fee for the space maintainer.
8. Sealants provided on the same date of service and on the same tooth as a restoration of the occlusal surface are
considered integral procedures.
9. Procedure D4346 is included in the time limitation of an adult prophylaxis.
Additional Procedures Covered as Class A Basic Services
D9110 Palliative (emergency) treatment of dental pain - minor procedure
D9311 Consultation with a medical health care professional
20 2022 Delta Dental's
Federal Employees Dental Program
Class B Intermediate
Important things you should keep in mind about these benefits:
•All benefits are subject to the definitions, limitations and exclusions in this plan brochure and are
payable only when determined to be necessary for minor restorative care or treatment of a covered
condition and if they are determined to meet generally accepted dental protocols.
•The calendar year deductible is $0 under both the High and Standard options when services are
provided by an in-network provider.
•If an out-of-network provider renders the services, there is a $50.00 deductible per person per
calendar year for the High Option and a $75.00 deductible per person per year for the Standard
Option. Each enrolled covered person must satisfy his/her own deductible; there is no family
deductible in either option.
•The annual benefit maximum in the High Option is Unlimited for non-orthodontic services when the
services are rendered by an in-network provider and $3,000 when services are rendered by an out-
of-network provider. The annual benefit maximum in the Standard Option is $1,500 for non-
orthodontic services when services are rendered by an in-network provider and $1,000 when
services are rendered by an out-of-network provider.
•Under no circumstance will Delta Dental's Federal Employees Dental Program allow more than
$3,000 in out of network benefits under the High Option in any plan year or more than $1,500 in
combined benefits under the Standard Option in any plan year.
•Any dental service or treatment not listed as a covered service is not eligible for benefits. Also see
Section 7, General Exclusions – Things We Do Not Cover, for a list of exclusions and limitations.
•In-progress treatment for dependents of retiring TDP enrollees; active duty members who were
enrolled in the ADDP; and PHS Officers who were enrolled in the PHSADDP will be covered for
the 2022 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: 30% of the network allowance for covered services as defined by the plan and
subject to plan limitations and maximums.
- Out-of-Network: 40% of the plan's out-of-network allowance along with a $50 deductible and
any difference between that allowance and the billed/approved amount.
•
Standard Option
- In-Network: 45% of the network allowance for covered services as defined by the plan subject to
plan limitations and maximums.
- Out-of-Network: 60% of the plan's out-of-network allowance along with a $75 deductible and
any difference between that allowance and the billed/approved amount.
Minor Restorative Services
D2140 Amalgam – one surface, primary or permanent
D2150 Amalgam – two surfaces, primary or permanent
D2160 Amalgam – three surfaces, primary or permanent
D2161 Amalgam – four or more surfaces, primary or permanent
D2330 Resin-based composite – one surface, anterior
D2331 Resin-based composite – two surfaces, anterior
D2332 Resin-based composite – three surfaces, anterior
D2335 Resin-based composite – four or more surfaces or involving incisal angle (anterior)
Minor Restorative Services - continued on next page
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Minor Restorative Services (cont.)
D2390 Resin-based composite crown, anterior
D2391 Resin-based composite – one surface, posterior
D2392 Resin-based composite – two surfaces, posterior
D2393 Resin-based composite – three surfaces, posterior
D2394 Resin-based composite – four or more surfaces, posterior
D2610 Inlay-porcelain/ceramic-one surface
D2620 Inlay-porcelain/ceramic-two surfaces
D2630 Inlay-porcelain/ceramic-three or more surfaces
D2910 Recement or rebond inlay, onlay, veneer or partial coverage restorations
D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core
D2920 Recement or rebond crown
D2921 Reattachment of tooth fragment, incisal edge or cusp
D2930 Prefabricated stainless steel crown – primary tooth - One per patient, per tooth, per lifetime
D2931 Prefabricated stainless steel crown – permanent tooth - One per patient, per tooth, per lifetime
D2951 Pin retention – per tooth, in addition to restoration
Benefit Limitations for Class B Minor Restorative Services
1. Pin retention is covered only when reported in conjunction with an eligible restoration.
2. Preventive resin restorations or other restorations that do not extend into the dentin are considered sealants for purposes
of determining benefits.
3. Repair or replacement of restorations by the same dentist/dental office and involving the same tooth surfaces performed
within 24 months of the original restoration are considered integral procedures, and a separate fee is not chargeable to
the member by a participating dentist regardless of the number of combinations of restorations placed. However,
payment may be allowed if the repair or replacement is due to fracture of the tooth or the restoration involves the
occlusal surface of a posterior tooth or the lingual surface of an anterior tooth and is placed following root canal therapy.
4. The payment for restorations includes all related services including but not limited to etching, bases, liners, dentinal
adhesives, local anesthesia, polishing caries removal, preparation of gingival tissue, occlusal/contact adjustments and
detection agents.
5. Restorations are covered benefits only when necessary to replace tooth structure loss due to fracture or decay.
6. Prefabricated stainless steel crowns (D2930, D2931) are covered only on primary teeth, permanent teeth up to age 14, or
when placed as a result of accidental injury.
7. Payment for a resin restoration will be made when a laboratory-fabricated porcelain or resin veneer is used to restore an
anterior tooth due to tooth fracture or caries.
Endodontic Services
D3110 Pulp cap - direct (excluding final restoration)
D3120 Pulp cap - indirect (excluding final restoration) - Payable once per tooth
D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and
application of medicament - Payable once per tooth on primary teeth only
D3221 Pulpal debridement, primary and permanent teeth
D3222 Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development, per tooth, per lifetime
D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) - For dependent children to
age 6
D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) - For dependent children
to age 11 and limited to once per tooth per lifetime
D3355 Pulpal regeneration – initial visit
D3356 Pulpal regeneration – interim medication replacement
D3357 Pulpal regeneration – completion of treatment
Endodontic Services - continued on next page
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Endodontic Services (cont.)
Benefit Limitations for Class B Endodontic Services
1. Pulpotomies are considered integral when performed by the same dentist within a 45-day period prior to the completion
of root canal therapy.
2. Pulpotomies performed on permanent teeth are considered integral to root canal therapy and are not reimbursable if root
canal therapy is not and will not be provided on the same tooth.
3. For reporting and benefit purposes, the completion date for endodontic therapy is the date the tooth is sealed.
4. An indirect pulp cap is payable only when a near exposure of the pulp is evident and when the final restoration is not
completed for at least 60 days.
5. Payment for gross pulpal debridement is limited to the relief of pain prior to conventional root canal therapy and when
performed by a dentist not completing the endodontic therapy.
Periodontic services
D4341 Periodontal scaling and root planing – four or more teeth per quadrant - Payable once per quadrant in 24 months
D4342 Periodontal scaling and root planing – one to three teeth, per quadrant - Payable once per quadrant in 24 months
D4346 Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation
D4910 Periodontal maintenance – Limited to four in a calendar year combined with D1110 and D4346
D7921 Collection and application of autologous blood concentrate product - Limited to one in 36 months
Benefit Limitations for Class B Periodontic Services
1. Documentation of the need for periodontal treatment includes periodontal pocket charting, case type, prognosis, amount
of existing attached gingiva, etc. Periodontal pocket charting should indicate the area/quadrants/teeth involved and is
required for most procedures.
2. A routine prophylaxis is considered integral when performed in conjunction with or as a finishing procedure to
periodontal scaling and root planing, periodontal maintenance, gingivectomy or gingivoplasty, gingival flap procedure
or osseous surgery.
3. A combination of up to four D4910 (periodontal maintenance procedures) or D4346 (scaling in the presence of
generalized moderate or severe gingival inflammation) or D1110 (adult prophylaxis) may be paid within a calendar year.
Note: Adult prophylaxis, including D4346, is limited to two in a calendar year (refer to Preventive Services section).
4. Periodontal maintenance is only covered when performed following active periodontal treatment.
5. An oral evaluation reported in addition to periodontal maintenance will be processed as a separate procedure subject to
the policies and limitations applicable to oral evaluation.
Prosthodontic services
D5410 Adjust complete denture – maxillary
D5411 Adjust complete denture – mandibular
D5421 Adjust partial denture – maxillary
D5422 Adjust partial denture – mandibular
D5511 Repair broken complete denture base, mandibular
D5512 Repair broken complete denture base, maxillary
D5520 Replace missing or broken teeth – complete denture (each tooth)
D5611 Repair resin partial denture base, mandibular
D5612 Repair resin partial denture base, maxillary
D5621 Repair cast partial framework, mandibular
D5622 Repair cast partial framework, maxillary
D5630 Repair or replace broken retentive clasping materials - per tooth
D5640 Replace broken teeth – per tooth
D5650 Add tooth to existing partial denture
D5660 Add clasp to existing partial denture - per tooth
Prosthodontic services - continued on next page
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Prosthodontic services (cont.)
D5670 Replace all teeth and acrylic on cast metal framework (maxillary)
D5671 Replace all teeth and acrylic on cast metal framework (mandibular)
D5710 Rebase complete maxillary denture – Limited to once in 36 months
D5711 Rebase complete mandibular denture – Limited to once in 36 months
D5720 Rebase maxillary partial denture – Limited to once in 36 months
D5721 Rebase mandibular partial denture – Limited to once in 36 months
D5730 Reline complete maxillary denture (chairside) – Limited to once in 36 months
D5731 Reline complete mandibular denture (chairside) – Limited to once in 36 months
D5740 Reline maxillary partial denture (chairside) – Limited to once in 36 months
D5741 Reline mandibular partial denture (chairside) – Limited to once in 36 months
D5750 Reline complete maxillary denture (laboratory) – Limited to once in 36 months
D5751 Reline complete mandibular denture (laboratory) – Limited to once in 36 months
D5760 Reline maxillary partial denture (laboratory) – Limited to once in 36 months
D5761 Reline mandibular partial denture (laboratory) – Limited to once in 36 months
D5850 Tissue conditioning, maxillary
D5851 Tissue conditioning, mandibular
D6930 Recement or rebond fixed partial denture
D6980 Fixed partial denture repair necessitated by restorative material failure
Benefit Limitations for Class B Prosthodontic Services
1. 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, however, the
provider who fabricated the dentures may be reimbursed for the dentures after insertion if another provider, typically an
oral surgeon, inserted the dentures.
2. The fee for diagnostic casts (study models) fabricated in conjunction with prosthetic and restorative procedures is
included in the fee for these procedures. A separate fee is not chargeable to the member by a participating dentist.
3. Tissue conditioning is considered integral when performed on the same day as the delivery of a denture or a reline/
rebase.
4. Recementation of crowns, fixed partial dentures, inlays, onlays, or cast posts within six months of their placement by the
same dentist/dental office is considered integral to the original procedure.
5. Adjustments to or relining or rebasing of an initial or replacement denture provided within six months of the insertion of
an initial or replacement denture are integral to the denture.
D5725 Rebase hybrid prosthesis
D5765 Soft liner for complete or partial removable denture-indirect
Oral surgery
D7111 Extraction coronal remnants, primary tooth
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
D7210 Extraction of 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 Removal of residual tooth roots (cutting procedure)
D7251 Coronectomy - intentional partial tooth removal
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
Oral surgery - continued on next page
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Oral surgery (cont.)
D7280 Exposure of an unerupted tooth – Payable once per tooth per lifetime
D7310 Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant
D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant
D7320 Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces, per quadrant
D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant
D7471 Removal of exostosis (maxilla or mandible)
D7510 Incision and drainage of abscess – intraoral soft tissue
D7910 Suture of recent small wounds up to 5 cm
D7971 Excision of pericoronal gingiva
D7999 Unspecified oral surgery procedure, by report
Benefit Limitations for Class B Oral Surgery Services
1. Simple incision and drainage reported with root canal therapy is considered integral to the root canal therapy.
2. Intraoral soft tissue incision and drainage is only covered when it is provided as the definitive treatment of an abscess.
Routine follow-up care is considered integral to the procedure.
3. Charges for related services such as necessary wires and splints, adjustments, and follow-up visits are considered
integral to the fee for reimplantation and/or stabilization (D7270).
4. The removal of impacted teeth is paid based on the anatomical position as determined from a review of x-rays. If the
degree of impaction is determined to be less than the reported degree, payment will be based on the allowance for the
lesser level.
5. Removal of impacted third molars in patients under age 15 and over age 30 is not covered unless specific documentation
is provided that substantiates the need for removal and is approved by the contractor.
6. Routine post-operative care, including office visits, local anesthesia and suture removal, is included in the fee for the
extraction.
7. The fee for root recovery is included in the fee for the extraction.
8. Incision and drainage on the same date of service with any palliative or oral surgery procedure is not payable. The
procedure is considered part of those services.
9. Simple incision and drainage reported with root canal therapy is considered integral to the root canal therapy.
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Class C Major
Important things you should keep in mind about these benefits:
•All benefits are subject to the definitions, limitations and exclusions in this plan 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 under both the High and Standard options when services are
rendered by an in-network provider.
•If an out-of-network provider renders the services, there is a $50.00 deductible per person per
calendar year for the High Option and a $75.00 deductible per person per calendar year for the
Standard Option. Each enrolled covered person must satisfy his/her own deductible; there is no
family deductible in either option.
•The annual benefit maximum in the High Option is Unlimited for non-orthodontic services when the
services are rendered by an in-network provider and $3,000 when services are rendered by an out-
of-network provider. The annual benefit maximum in the Standard Option is $1,500 for non-
orthodontic services when services are rendered by an in-network provider and $1,000 when
services are rendered by an out-of-network provider.
•Under no circumstances will Delta Dental's Federal Employees Dental Program allow more
than $3,000 out of network benefits under the High Option in any plan year or more than $1,500 in
combined benefits under the Standard Option in any plan year.
•Alternate benefits: If more than one service can be used to treat the dental condition, an alternate
benefit may be authorized for a less costly service as deemed appropriate by a dental professional.
Prior to receiving major services, we recommend that a precertification be submitted so you are
aware of your coverage before the services are rendered.
•Any dental service or treatment not listed as a covered service is not eligible for benefits. Also see
Section 7, General Exclusions – Things We Do Not Cover, for a list of exclusions and limitations.
•In-progress treatment for dependents of retiring TDP enrollees; active duty members who were
enrolled in the ADDP; and PHS Officers who were enrolled in the PHSADDP will be covered for
the 2022 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: 50% of the network allowance for covered services as defined by the plan and
subject to plan limitations and maximums.
- Out-of-Network: 60% of the plan's out-of-network allowance along with a $50.00 deductible and
any difference between that allowance and the billed/approved amount.
•
Standard Option
- In-Network: 65% of the network allowance for covered services as defined by the plan and
subject to plan limitations and maximums.
- Out-of-Network: 80% of plan's out-of-network allowance along with a $75.00 deductible and
any difference between that allowance and the billed/approved amount.
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Major Restorative Services
D2510 Inlay – metallic – one surface
D2520 Inlay – metallic – two surfaces
D2530 Inlay – metallic – three or more surfaces
D2542 Onlay – metallic – two surfaces
D2543 Onlay – metallic – three surfaces
D2544 Onlay – metallic – four or more surfaces
D2740 Crown – porcelain/ceramic
D2750 Crown – porcelain fused to high noble metal
D2751 Crown – porcelain fused to predominantly base metal
D2752 Crown – porcelain fused to noble metal
D2753 Crown – porcelain fused to titanium or titanium alloy
D2780 Crown – 3/4 cast high noble metal
D2781 Crown – 3/4 cast predominantly base metal
D2782 Crown – 3/4 cast noble metal
D2783 Crown – 3/4 porcelain/ceramic
D2790 Crown – full cast high noble metal – Limited to once in five years
D2791 Crown – full cast predominantly base metal – Limited to once in five years
D2792 Crown – full cast noble metal – Limited to once in five years
D2794 Crown – titanium/titanium alloy – Limited to once in five years
D2950 Core buildup, including any pins when required
D2954 Prefabricated post and core in addition to crown
D2980 Crown repair necessitated by restorative material failure
D2981 Inlay repair necessitated by restorative material failure
D2982 Onlay repair necessitated by restorative material failure
D2983 Veneer repair necessitated by restorative material failure
D2990 Resin infiltration of incipient smooth surface lesions
Major Restorative Services - continued on next page
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Major Restorative Services (cont.)
Benefit Limitations for Class C Major Restorative Services
1. Diagnostic casts (study models) taken in conjunction with restorative procedures are considered integral
2. Pin retention is covered only when reported in conjunction with an eligible restoration.
3. An amalgam or resin restoration reported with a pin (D2951), in addition to a crown, is considered to be a pin buildup
(D2950).
4. The charge for a crown or onlay should include all charges for work related to its placement including, but not limited
to, preparation of gingival tissue, tooth preparation, temporary crown, diagnostic casts (study models), impressions, try-
in visits, and cementations of both temporary and permanent crowns.
5. Onlays, permanent single-crown restorations, and posts and cores for members 12 years of age or younger are excluded
from coverage unless specific rationale is provided indicating the reason for such treatment (e.g., fracture, endodontic
therapy, etc.) and if approved by the contractor.
6. Cast posts and cores (D2952) are processed as an alternate benefit of a prefabricated post and core. The patient is
responsible for the difference between the dentist's charge for the cast post and core and the amount paid by the
contractor for the prefabricated post and core.
7. Replacement of crowns, onlays, buildups, and posts and cores is covered only if the existing crown, onlay, buildup, or
post and core was inserted at least five years prior to the replacement and satisfactory evidence is presented that the
existing crown, onlay, buildup, or post and core is not and cannot be made serviceable. Satisfactory evidence must show
that the existing crown, onlay, buildup, or post and core is not and cannot be made serviceable. The five-year service
date is measured based on the actual date (day and month) of the initial services versus the first day of the initial service
month.
8. Onlays, crowns, and posts and cores are payable only when necessary due to decay or tooth fracture. However, if the
tooth can be adequately restored with amalgam or composite (resin) filling materials, payment will be made for that
service. This payment can be applied toward the cost of the onlay, crown, or post and core.
9. When performed as an independent procedure, the placement of a post is not a covered benefit. Posts are only eligible
when provided as part of a buildup for a crown and are considered integral to the buildup.
10. Services or treatment for the provision of an initial prosthodontic appliance (i.e., fixed bridge restoration, implants,
removable partial or complete denture, etc.) when it replaces natural teeth extracted or missing, including congenital
defects, prior to effective date of coverage are not eligible for coverage.
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.) – For
permanent teeth only
D3352 Apexification/recalcification – interim medication replacement – For permanent teeth only
D3353 Apexification/recalcification – final visit (includes completed root canal therapy - apical closure/calcific repair of
perforations, root resorption, etc.) – For permanent teeth only
D3410 Apicoectomy – anterior
D3421 Apicoectomy – premolar (first root)
D3425 Apicoectomy – molar (first root)
D3426 Apicoectomy (each additional root)
D3430 Retrograde filling – per root
D3450 Root amputation – per root
D3471 Surgical repair of root resorption – anterior
Endodontic Services - continued on next page
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Endodontic Services (cont.)
D3472 Surgical repair of root resorption – premolar
D3473 Surgical repair of root resorption – molar
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
Benefit Limitations for Class C Endodontic Services
1. Treatment of a root canal obstruction is considered an integral procedure.
2. For reporting and benefit purposes, the completion date for endodontic therapy is the date the tooth is sealed.
3. Placement of a final restoration following endodontic therapy is eligible as a separate procedure.
4. Retreatment of apical surgery or root canal therapy by the same dentist or group practice within 24 months is
considered part of the original procedure.
5. Apexification is payable only on permanent teeth with incomplete root development or for repair of perforation.
Otherwise, the fee is included in the fee for the root canal.
D3921 Decoronation or submergence of an erupted tooth.
Periodontic Services
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant
D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant
D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth
D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per
quadrant
D4241 Gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded spaces per
quadrant
D4249 Clinical crown lengthening – hard tissue – Payable once per tooth, per lifetime
D4260 Osseous surgery (including elevation of a full thickness flap entry and closure) - four or more contiguous teeth or
tooth bounded spaces per quadrant
D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth
bounded spaces per quadrant
D4268 Surgical revision procedure, per tooth
D4270 Pedicle soft tissue graft procedure
D4273 Autogenous connective tissue graft procedure (including donor and recipient sites), first tooth, implant or
edentulous tooth position in graft
D4275 Non-autogenous connective tissue graft (including recipient site and donor material), first tooth, implant or
edentulous tooth position in graft
D4276 Combined connective tissue andpedicle graft
D4277 Free soft tissue graft procedure (including recipient and donor site surgery), first tooth or edentulous tooth position
in graft
D4278 Free soft tissue graft procedure (including recipient and donor site surgery), each additional contiguous tooth or
edentulous tooth position in same graft site
D4283 Autogenous connective graft tissue procedure (including donor and recipient surgical sites) - each additional
contiguous tooth, implant or edentulous tooth position in same graft site
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
D4355 Full mouth debridement to enable comprehensive oral evaluation and diagnosis on subsequent visit
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth
D4999 Unspecified periodontal procedure, by report
Periodontic Services - continued on next page
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Periodontic Services (cont.)
Benefit Limitations for Class C Periodontic Services
1. Documentation of the need for periodontal treatment includes periodontal pocket charting, case type, prognosis, amount
of existing attached gingiva, etc. Periodontal pocket charting should indicate the area/quadrants/teeth involved and is
required for most procedures.
2. Gingivectomy or gingivoplasty, gingival flap procedures, guided tissue regeneration, soft tissue grafts, bone replacement
grafts and osseous surgery provided within 36 months of the same surgical periodontal procedure in the same area of the
mouth are not covered.
3. Gingivectomy or gingivoplasty performed in conjunction with the placement of crowns, onlays, crown buildups, post
and cores or basic restorations are considered integral to the restoration.
4. Gingival flap procedure is considered integral when provided on the same date of service by the same dentist in the
same area of the mouth as periodontal surgical procedures, endodontic procedures and oral surgery procedures.
5. A single site for reporting osseous grafts consists of one contiguous area, regardless of the number of teeth (e.g., crater)
or surfaces involved. Another site on the same tooth is considered integral to the first site reported. Non-contiguous
areas involving different teeth may be reported as additional sites.
6. Osseous surgery is not covered when provided within 36 months of osseous surgery in the same area of the mouth.
7. Osseous surgery performed in a limited area and in conjunction with crown lengthening on the same date of service by
the same dentist and in the same area of the mouth will be processed as crown lengthening.
8. One crown lengthening per tooth per lifetime is covered.
9. A routine prophylaxis is considered integral when performed in conjunction with or as a finishing procedure to
periodontal scaling and root planing, periodontal maintenance, gingivectomy or gingivoplasty, gingival flap procedure
or osseous surgery.
10. Payment for multiple periodontal surgical procedures (except soft tissue grafts, osseous grafts, and guided tissue
regeneration) provided in the same area of the mouth during the same course of treatment is based on the fee for the
greater surgical procedure. The lesser procedure is considered integral and its allowance is included in the allowance for
the greater procedure.
11. Surgical revision procedure (D4268) is considered integral to all other periodontal procedures.
12. Subepithelial connective tissue grafts and combined connective tissue and pedicle grafts are payable at the level of free
soft tissue grafts. The difference between the allowance for the soft tissue graft and the dentist's charge is the patient's
responsibility.
13. Up to two tissue grafts are payable per quadrant per visit. Additional tissue grafts performed in a quadrant are not
covered benefits.
14. Localized delivery of antimicrobial agents via a controlled release vehicle is not a covered benefit when provided in
conjunction with scaling and root planing.
Prosthodontic Services
D5110 Complete denture – maxillary
D5120 Complete denture – mandibular
D5130 Immediate denture – maxillary
D5140 Immediate denture – mandibular
D5211 Maxillary partial denture – resin base (including retentive/clasping materials, rests and teeth)
D5212 Mandibular partial denture – resin base (including retentive/clasping materials, rests and teeth)
D5213 Maxillary partial denture – cast metal framework with resin denture bases (including any retentive/clasping
materials, rests and teeth)
D5214 Mandibular partial denture – cast metal framework with resin denture bases (including any retentive/clasping
materials, rests and teeth)
D5221 Immediate maxillary partial denture - resin base (including any retentive/clasping materials, rests and teeth)
D5222 Immediate mandibular partial denture - resin base (including any retentive/clasping materials, rests and teeth)
Prosthodontic Services - continued on next page
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Prosthodontic Services (cont.)
D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including any retentive/
clasping materials, rests and teeth)
D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including any retentive/
clasping materials, rests and teeth)
D5225 Maxillary partial denture-flexible base (including any retentive/clasping materials, rests and teeth)
D5226 Mandibular partial denture-flexible base (including any retentive/clasping materials, rests and teeth)
D5282 Removable unilateral partial denture – one-piece cast metal (including clasps and teeth), maxillary
D5283 Removable unilateral partial denture – one-piece cast metal (including clasps and teeth), mandibular
D5284 Removable unilateral partial denture – one piece flexible base (including clasps and teeth) – per quadrant
D5286 Removable unilateral partial denture – one piece resin (including clasps and teeth) - per quadrant
D5876 Add metal substructure to acrylic full denture (per arch)
D6010 Surgical placement of implant body: endosteal implant
D6013 Surgical placement of mini implant
D6040 Surgical placement: eposteal implant
D6050 Surgical placement: transosteal implant
D6055 Connecting Bar - implant supported or abutment supported
D6056 Prefabricated abutment - includes modification and placement
D6057 Custom fabricated abutment - includes placement
D6058 Abutment supported porcelain/ceramic crown
D6059 Abutment supported porcelain fused to metal crown (high noble metal)
D6060 Abutment supported porcelain fused to metal crown (predominantly base metal)
D6061 Abutment supported porcelain fused to metal crown (noble metal)
D6062 Abutment supported cast metal crown (high noble metal)
D6063 Abutment supported cast metal crown (predominantly base metal)
D6064 Abutment supported cast metal crown (noble metal)
D6065 Implant supported porcelain/ceramic crown
D6066 Implant supported porcelain fused to metal crown (high noble alloys)
D6067 Implant supported metal crown (high noble alloys)
D6068 Abutment supported retainer for porcelain/ceramic FPD
D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
D6070 Abutment retainer for porcelain fused to metal FPD (predominantly base metal)
D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal)
D6072 Abutment supported retainer for cast metal FPD (high noble metal)
D6073 Abutment supported retainer for cast metal FPD (predominantly base metal)
D6074 Abutment supported retainer for cast metal FPD (noble metal)
D6075 Implant supported retainer for ceramic FPD
D6076 Implant supported retainer for porcelain fused to metal FPD (high noble alloys)
D6077 Implant supported retainer for cast metal FPD (high noble alloys)
D6080 Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses
and abutments
D6082 Implant supported crown - porcelain fused to predominantly base alloys
D6083 Implant supported crown - porcelain fused to noble alloys
D6084 Implant supported crown - porcelain fused to titanium or titanium alloy
D6086 Implant supported crown - predominantly base alloys
D6087 Implant supported crown - noble alloys
Prosthodontic Services - continued on next page
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Prosthodontic Services (cont.)
D6088 Implant supported crown - titanium/titanium alloys
D6090 Repair implant supported prosthesis, by report
D6091 Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported
prosthesis, per attachment
D6092 Re-cement or re-bond implant/abutment supported crown
D6093 Re-cement or re-bond implant/abutment supported fixed partial denture
D6094 Abutment supported crown titanium or titanium alloys
D6095 Repair implant abutment
D6096 remove broken implant retaining screw
D6097 Abutment supported crown - porcelain fused to titanium or titanium alloys
D6098 Implant supported retainer for metal FPD - porcelain fused to predominantly base alloys
D6099 Implant supported retainer for metal FPD - porcelain fused to noble alloys
D6100 Surgical removal of implant body
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
D6104 Bone graft at time of implant placement
D6110 Implant/abutment supported removable denture for edentulous arch - maxillary
D6111 Implant/abutment supported removable denture for edentulous arch - mandibular
D6112 Implant/abutment supported removable denture for partially edentulous arch - maxillary
D6113 Implant/abutment supported removable denture for partially edentulous arch - mandibular
D6114 Implant/abutment supported fixed denture for edentulous arch - maxillary
D6115 Implant/abutment supported fixed denture for edentulous arch - mandibular
D6116 Implant/abutment supported fixed denture for partially edentulous arch - maxillary
D6117 Implant/abutment supported fixed denture for partially edentulous arch - mandibular
D6120 Implant supported retainer - porcelain fused to titanium or titanium alloy
D6121 Implant supported retainer for metal FPD - predominantly base alloys
D6122 Implant supported retainer for metal FPD - noble alloys
D6123 Implant supported retainer for metal FPD- titanium or titanium alloy
D6191 Semi-precision abutment – placement
D6192 Semi-precision attachment – placement
D6194 Abutment supported retainer crown for FPD metal titanium or titanium alloys
D6195 Abutment supported retainer - porcelain fused to titanium or titanium alloy
D6210 Pontic – cast high noble metal
D6211 Pontic – cast predominantly base metal
D6212 Pontic – cast noble metal
D6214 Pontic – titanium or titanium alloys
D6240 Pontic – porcelain fused to high noble metal
D6241 Pontic – porcelain fused to predominantly base metal
D6242 Pontic – porcelain fused to noble metal
D6243 Pontic – pontic - porcelain fused to titanium or titanium alloys
D6245 Pontic – porcelain/ceramic
D6545 Retainer - cast metal for resin bonded fixed prosthesis
D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis
D6549 Resin retainer - for resin-bonded fixed prosthesis
D6600 Retainer inlay – porcelain/ceramic, two surfaces
Prosthodontic Services - continued on next page
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Prosthodontic Services (cont.)
D6601 Retainer inlay – porcelain/ceramic, three or more surfaces
D6604 Retainer inlay - indirectly fabricated predominantly base metal, two surfaces
D6605 Retainer inlay - indirectly fabricated predominantly base metal, three or more surfaces
D6608 Retainer onlay – porcelain/ceramic, two surfaces
D6609 Retainer onlay - porcelain/ceramic, three or more surfaces
D6612 Retainer onlay - indirectly fabricated predominantly base metal, two surfaces
D6613 Retainer onlay - indirectly fabricated predominantly base metal, three or more surfaces
D6740 Retainer crown – porcelain/ceramic
D6750 Retainer crown – porcelain fused to high noble metal
D6751 Retainer crown – porcelain fused to predominantly base metal
D6752 Retainer crown – porcelain fused to noble metal
D6753 Retainer crown - porcelain fused to titanium or titanium alloys
D6784 Retainer crown ¾ - titanium and titanium alloys
D6780 Retainer crown – 3/4 cast high noble metal
D6781 Retainer crown – 3/4 cast predominantly base metal
D6782 Retainer crown – 3/4 cast noble metal
D6783 Retainer crown – 3/4 porcelain/ceramic
D6790 Retainer crown – full cast high noble metal
D6791 Retainer crown – full cast predominantly base metal
D6792 Retainer crown – full cast noble metal
D6794 Retainer crown – titanium or titanium alloys
D9932 Cleaning and inspection of removable complete denture, maxillary
D9933 Cleaning and inspection of removable complete denture, mandibular
D9934 Cleaning and inspection of removable partial denture, maxillary
D9935 Cleaning and inspection of removable partial denture, mandibular
D9999 Unspecified adjunctive procedure, by report
Prosthodontic Services - continued on next page
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Prosthodontic Services (cont.)
Benefit Limitations for Class C Prosthodontic Services
1. Services or treatment for the provision of an initial prosthodontic appliance (i.e., fixed bridge restoration, implants,
removable partial or complete denture, etc.) when it replaces natural teeth extracted or missing, including congenital
defects, prior to effective date of coverage are not eligible for coverage.
2. Replacement of implants is covered only if the existing implant was placed at least five years prior to the replacement
and the implant has failed.
3. Replacement of a removable prosthesis or fixed prosthesis is covered only if the existing prosthesis was inserted at least
five years prior to the replacement and satisfactory evidence is presented that the existing prosthesis cannot be made
serviceable.
4. Replacement of implant prostheses is covered only if the existing prostheses were placed at least five years prior to the
replacement and satisfactory evidence is presented that demonstrates they are not, and cannot be made,
serviceable. Implant procedures, including applicable restorations and repairs, are a covered benefit once in five years.
5. 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, however, the
provider who fabricated the dentures may be reimbursed for the dentures after insertion if another provider, typically an
oral surgeon, inserted the dentures.
6. The fee for diagnostic casts (study models) fabricated in conjunction with prosthetic and restorative procedures are
included in the fee for these procedures. A separate fee is not chargeable to the member by a participating dentist.
7. Removable cast-base partial dentures for members under 12 years of age are excluded from coverage unless specific
rationale is provided indicating the necessity for that treatment and is approved by the contractor.
8. Adjustments provided within six months of the insertion of an initial or replacement denture or implant are integral to
the denture or implant.
9. The relining or rebasing of a denture is considered integral when performed within six months following the insertion of
that denture.
10. Fixed partial dentures, buildups, and posts and cores for members under 16 years of age are not covered unless specific
rationale is provided indicating the necessity for such treatment and is approved by the contractor.
11. Payment for a denture or an overdenture made with precious metals is based on the allowance for a conventional
denture. Specialized procedures performed in conjunction with an overdenture are not covered. Any additional cost is
the member's responsibility.
12. A fixed partial denture and removable partial denture are not covered in the same arch. Payment will be made for a
removable partial denture to replace all missing teeth in the arch.
13. Temporary fixed partial dentures are not a covered benefit and, when done in conjunction with permanent fixed partial
dentures, are considered integral to the allowance for the fixed partial dentures.
14. Implants and related prosthetics may be covered and may be reimbursed as an alternative benefit as a three-unit fixed
partial denture.
15. Replacement of dentures that have been lost, stolen or misplaced is not a covered service.
D5227 Immediate maxillary partial denture-flexible base (including any clasps, rests and teeth)
D5228 Immediate mandibular partial denture-flexible base (including any clasps, rests and teeth)
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Class D Orthodontic
Important things you should keep in mind about these benefits:
•All benefits are subject to the definitions, limitations, and exclusions in this plan brochure and are
payable only when determined to be necessary for the prevention, diagnosis, care, or treatment of a
covered orthodontic condition and if they are determined to meet generally accepted dental
protocols.
•The calendar year deductible for orthodontic services is $0 per eligible enrollee under both the High
and Standard options. The Standard Plan only covers dependent children under age 19. The High
Plan includes orthodontic benefits for the enrollee/spouse and dependent children up to 21 for
TRICARE-eligible individuals (or 23 if they’re full-time college students) or 22 for civilian
dependents.
•There are no orthodontic waiting periods in either of our Plan options.
•The lifetime maximum for orthodontic services depends on the option in which you enroll and if
you chose to receive services from a network provider. If you are covered by the High Option, the
lifetime maximum is $3,500 for dependent children up to 21 for TRICARE-eligible individuals (or
23 if they’re full-time college students) or 22 for civilian dependents regardless of the participating
status of the provider and $2,000 for the enrollee/spouse. In the Standard Option, services rendered
by an in-network provider will be subject to a $2,000 lifetime maximum and services rendered by an
out-of-network provider will be subject to a $1,000 lifetime maximum, for eligible dependent
children only up to age 19.
•Covered services are limited to the maximum allowable charge as determined by Delta Dental and
are subject to alternative benefits, coinsurance, maximum benefit limits, waiting periods and the
other limitations described in this plan brochure.
•Any dental service or treatment not listed as a covered service is not eligible for benefits. Also see
Section 7, General Exclusions – Things We Do Not Cover, for a list of exclusions and limitations.
You Pay:
•
High Option
- In-Network: 50% of the network allowance up to the lifetime maximum. You are responsible for
all charges that exceed the lifetime maximum.
- Out-of-Network: 50% of the plan's out-of-network allowance and any difference between that
allowance and the billed amount.
•
Standard Option
- In-Network: 50% of the network allowance up to the lifetime maximum. You are responsible for
all charges that exceed the lifetime maximum.
- Out-of-Network: 50% of the plan's out-of-network allowance and any difference between that
allowance and the billed amount.
Orthodontic Services
D0340 2D cephalometric radiographic image- acquisition, measurement and analysis
D0350 2D oral/facial photographic image obtained intra-orally or extra-orally
D0351 3D photographic image
D0470 Diagnostic casts
D0702 2-D cephalometric radiographic image- image capture only
D0703 2-D oral/facial photographic image obtained intra-orally or extra-orally- image capture only
D0704 3-D photographic image- image capture only
D8010 Limited orthodontic treatment of the primary dentition
Orthodontic Services - continued on next page
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Orthodontic Services (cont.)
D8020 Limited orthodontic treatment of the transitional dentition
D8030 Limited orthodontic treatment of the adolescent dentition
D8040 Limited orthodontic treatment of the adult dentition (by report)
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
D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s))
D8681 Removable orthodontic retainer adjustment
Benefit Limitations for Class D Orthodontic Services
1. Orthodontic treatment in the Standard Plan is available only for dependent children up to, but not including, 19 years of
age. Orthodontic services for enrollees/spouses and for dependent children up to 21 for TRICARE-eligible individuals
(or 23 if they’re full-time college students) or 22 for civilian dependents, are only covered in the High Plan.
2. Payment for diagnostic services performed in conjunction with orthodontics is applied to the member's annual
maximum.
3. Orthodontic consultations will be processed as comprehensive or periodic evaluations and are subject to the same time
limitations.
4. Initial payment for orthodontic services will not be made until a banding date has been submitted to the contractor.
5. All retention and case-finishing procedures are integral to the total case fee. Observations and adjustments are integral to
the payment for retention appliances.
6. Repair of damaged, lost or missing orthodontic appliances is not covered.
7. Recementation of an orthodontic appliance by the same dentist who placed the appliance and/or who is responsible for
the ongoing care of the patient is not covered. However, recementation by a different dentist will be considered for
payment as palliative emergency treatment.
8. Periodic orthodontic treatment visits (as part of the contract) are considered an integral part of a complete orthodontic
treatment plan and are not reimbursable as a separate service.
9. It is the dentist's and the member's responsibility to notify the carrier if orthodontic treatment is discontinued or
completed sooner than anticipated.
10. When an enrollee becomes eligible for orthodontic coverage after orthodontic treatment has already begun (known as
“in-progress orthodontic treatment”), the Plan’s total amount payable is prorated according to the banding date and the
remaining portion of active treatment scheduled as of the patient’s date of eligibility for orthodontic coverage.
11. Cephalometric radiographs, 2D oral/facial photographic images, 3D photographic images, and diagnostic casts are only
covered benefits when provided in conjunction with orthodontic treatment.
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General Services
Important things you should keep in mind about these benefits:
•All benefits are subject to the definitions, limitations, and exclusions in this plan 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 under both the High and Standard options when services are
provided by an in-network provider.
•If an out-of-network provider renders services, there is a $50.00 deductible per person per calendar
year for the High Option and a $75.00 deductible per person per calendar year for the Standard
Option. Each enrolled covered person must satisfy his/her own deductible; there is no family
deductible in either option.
•The annual benefit maximum in the High Option is Unlimited for non-orthodontic services when the
services are rendered by an in-network provider and $3,000 when the services are rendered by an
out-of-network provider. The annual benefit maximum in the Standard Option is $1,500 when the
services are rendered by an in-network provider and $1,000 when the services are rendered by an
out-of-network provider.
•Under no circumstance will Delta Dental's Federal Employees Dental Program allow more than
$3,000 in out of network benefits under the High Option in any plan year or more than $1,500 in
combined benefits under the Standard Option in any plan year.
•Any dental service or treatment not listed as a covered service is not eligible for benefits. Also see
Section 7, General Exclusions – Things We Do Not Cover, for a list of exclusions and limitations.
You Pay:
•
High Option
- In-Network: 30% of the network allowance for covered services as defined by the plan and
subject to plan deductibles and maximums.
- Out-of-Network: 40% of the plan's out-of-network allowance along with a $50.00 deductible and
any difference between that allowance and the billed/approved amount..
•
Standard Option
- In-Network: 45% of the network allowance for covered services as defined by the plan and
subject to plan deductibles and maximums.
- Out-of-Network: 60% of the plan's out-of-network allowance along with a $75.00 deductible and
any difference between that allowance and the billed/approved amount.
Anesthesia Services
D9219 Evaluation for moderate sedation, deep sedation or general anesthesia
D9222 Deep sedation/general anesthesia – first 15 minutes
D9223 Deep sedation/general anesthesia - each subsequent 15-minute increment
Intravenous Sedation
D9239 Intravenous moderate (conscious) sedation/analgesia- first 15 minutes
D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment
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Consultations
D9310 Consultation (diagnostic service provided by dentist or physician other than the requesting dentist or physician)
Office Visits
D9440 Office visit – after regular scheduled hours
Medications
D9610 Therapeutic drug injection, by report
D9612 Therapeutic parenteral drugs, two or more administrations, different medications
D9613 Infiltration of sustained release therapeutic drug- per quadrant
Post-Surgical Services
D9930 Treatment of complications (post-surgical) unusual circumstances, by report
Miscellaneous Services
D9941 Fabrication of athletic mouth guard -- Limited to one in a 12-consecutive-month period
D9943 Occlusal guard adjustment
D9944 Occlusal guard – hard appliance, full arch
D9945 Occlusal guard – soft appliance, full arch
D9946 Occlusal guard – hard appliance, partial arch
D9974 Internal bleaching, by report - per tooth -- Limited to once per tooth per three-year period
D9997 Dental case management – patients with special health care needs
Miscellaneous Services - continued on next page
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Miscellaneous Services (cont.)
Benefit Limitations for General Services
1. Deep sedation/general anesthesia and intravenous conscious sedation are covered only by report when provided in
connection with a covered surgical procedure(s) and when rendered by a dentist or other professional provider licensed
and approved to provide anesthesia in the state where the service is rendered.
2. Deep sedation/general anesthesia and intravenous sedation are covered only by report when determined to be medically
or dentally necessary for documented/handicapped or uncontrollable patients or justifiable medical or dental conditions.
3. In order for deep sedation/general anesthesia and intravenous conscious sedation to be covered, the procedure for which
it was provided must be submitted.
4. For palliative (emergency) treatment to be covered, the dentist must provide treatment to alleviate a problem or
symptom that occurred suddenly and unexpectedly and that requires immediate attention. If the only service provided is
to evaluate the patient and refer the patient to another dentist and/or prescribe medication, it would be considered a
"Limited oral evaluation - problem-focused" (D0140).
5. Consultations are covered only when provided by a dentist other than the practitioner requesting the treatment.
6. Consultations reported for a non-covered benefit, such as temporomandibular joint dysfunction (TMJD), are not
covered.
7. After-hours visits are covered only when the dentist must return to the office after regularly scheduled hours to treat the
patient in an emergency situation.
8. Therapeutic drug injections are only payable in unusual circumstances, which must be documented by report. They are
not benefits if performed routinely or in conjunction with, or for the purposes of, general anesthesia, analgesia, sedation
or premedication.
9. Occlusal guards are covered for the treatment of bruxism or diagnoses other than temporomandibular joint dysfunction
(TMJD). Limited to one every 5 years and for patients 13 years of age and older.
10. Internal bleaching of discolored teeth (D9974) is covered by report for endodontically treated anterior teeth. A
postoperative endodontic x-ray is required for consideration if the endodontic therapy has not been submitted to the
contractor for payment.
11. Dental case management for patients with special health care needs is only payable once per lifetime to the same dentist
or dental office. A statement from the patient’s physician documenting the patient’s medical condition may be requested.
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Adjunctive Services
1. Adjunctive dental care is dental care that is:
• Medically necessary in the treatment of an otherwise covered medical (not dental) condition
• An integral part of the treatment of such medical condition
• Essential to the control of the primary medical condition
• Required in preparation for, or as the result of, dental trauma which may or may not be caused by medically necessary
treatment of an injury or disease (iatrogenic).
2. The Federal Employees Dental and Vision Insurance Program does not cover adjunctive care services. These are
medical services that may be covered under the FEHB medical policy even when provided by a general dentist or oral
surgeon. The following diagnoses or conditions may fall under this category:
• Treatment for relief of Myofacial Pain Dysfunction Syndrome or Temporomandibular Joint Dysfunction (TMJD)
• Orthodontic treatment for cleft lip or cleft palate, or when required in preparation for, or as a result of, trauma to teeth
and supporting structures caused by medically necessary treatment of an injury or disease.
• Procedures associated with preventive and restorative dental care when associated with radiation therapy to the head
or neck unless otherwise covered as routine preventive procedures under this plan
• Total or complete ankyloglossia
• Intraoral abscesses which extend beyond the dental alveolus
• Extraoral abscesses
• Cellulitis and osteitis which is clearly exacerbating and directly affecting a medical condition currently under
treatment
• Removal of teeth and tooth fragments in order to treat and repair facial trauma resulting from an accidental injury
• Prosthetic replacement of either the maxilla or mandible due to reduction of body tissues associated with
traumatic injury (such as a gunshot wound) in addition to services related to treating neoplasms or iatrogenic dental
trauma
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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. All payments will be made in U.S. currency.
International Claims
Payment
International employees and their dependents may contact Delta Dental’s international
referral service for referral to dental providers outside of the continental United States, the
District of Columbia and Puerto Rico or may use the dentist of their choice. Plan
participants may call 312-356-5971 (collect from outside the U.S.) or 888-558-2705 (toll-
free if inside the U.S.) to find a local provider in their country. International participants
will receive out-of-network benefits when services are performed by an internationally
located provider.
Finding an International
Provider
The plan participant will be responsible for paying the dentist and submitting the claims to
Delta Dental’s Federal Employee Dental Program for reimbursement. Mail completed
claim forms to:
Delta Dental of California
Federal Employees Dental Program
PO Box 537007
Sacramento, CA 95853-7007
Filing International
Claims
There is one international region. Please see the rate table for the actual premium amount. International Rates
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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 it is determined necessary for the prevention, diagnosis, care, or treatment of a covered condition. All out-of-network
services listed in Section 5 are subject to the usual and customary maximum allowable fee charges as defined by Delta
Dental's Federal Employees Dental Program. The member is responsible for all remaining charges that exceed the allowable
maximum. Additionally, any dental service or treatment not listed in Section 5 as a covered service is not eligible for
benefits.
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 which are experimental or investigational;
• Services and treatment which are for any illness or bodily injury which 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 which are not dentally necessary or which do not meet generally accepted standards of dental
practice.
• Services and treatment resulting from your failure to comply with professionally prescribed treatment;
• Telephone consultations;
• 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 (TMJD);
• 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 x-rays, or any costs associated with forwarding/mailing copies of your records,
charts or x-rays;
• State or territorial taxes on dental services performed;
• Those services submitted by a dentist, which are 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 which are for specialized procedures and techniques;
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• 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;
• 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 instruments;
• 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 provider for completing dental forms;
• Adjustment of a denture or bridgework which 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 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;
• Oral sedation;
• Topical medicament center;
• Bone grafts when done in connection with extractions, apicoectomies or non-covered/non eligible implants;
• When two or more services are submitted and the services are considered part of the same service to one another the Plan
will pay the most comprehensive service (the service that includes the other non-benefited service) as determined by Delta
Dental's Federal Employees Dental Program.
• 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), the Plan will pay for the service that represents the final treatment as
determined by this plan.
• Any self-administered (mail order or do-it yourself) type of orthodontics are not covered.
• Laser Assisted New Attachment Procedure (LANAP), considered investigational in nature as determined by generally
accepted dental practice standards.
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General Policies
All covered services are subject to the following general policies:
1. Services must be necessary to preserve functionality and maintenance of oral health to the teeth and supporting structures
and must meet accepted standards of dental practice. Services determined to be unnecessary or which do not meet accepted
standards of practice are not billable to the patient by a participating dentist unless the dentist notifies the patient of his/her
liability prior to treatment and the patient chooses to receive the treatment. Participating dentists shall document such
notification in their records.
2. The plan must provide an alternate benefit provision for benefits beyond the least expensive professionally accepted
standard of care, whereby the patient pays the difference between the covered benefit and the more expensive treatment
option.
3. An appeal is not available when the services are determined to be unnecessary or do not meet accepted standards of dental
practice unless the dentist notifies the patient of his/her liability prior to treatment and the patient chooses to receive the
treatment. This is because such services are not billable to the patient, and there would be no amount to dispute to consider
an appeal.
4. Procedures should be reported using the American Dental Association's (ADA) current dental procedure codes and
terminology.
5. Claims submitted for payment more than 12 months after the month in which a service is provided are not eligible for
payment. A participating dentist may not bill the enrollee for services that are denied for this reason.
6. Services, including evaluations, which are routinely performed in conjunction with or as part of another service, are
considered integral. Participating dentists may not bill members for services denied if they are considered integral to
another service.
7. Charges for the completion of claim forms and submission of required information for determination of benefits are not
payable to participating dentists by either the contractor or enrollee.
8. Local anesthesia is considered integral to the procedure(s) for which it is provided.
9. Payment for diagnostic services performed in conjunction with orthodontics may be applied to the member's annual
maximum.
Class A Preventive Services
• Space maintainers for missing permanent teeth or primary anterior teeth (except primary cuspids)
• Repair of a damaged space maintainer;
Class B Minor Restorative Services
• Sedative restorations;
• Restorations performed after the placement of any type of crown or onlay on the same tooth and by the same dentist;
• Restorations placed due to abrasion, attrition, erosion, congenital or developmental malformations or to restore vertical
dimension;
• Glass ionomer restorations;
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Class B Periodontic Services
• Periodontal scaling and root planing provided within 24 months of periodontal scaling and root planing or periodontal
surgical procedures in the same area of the mouth;
Class B Prosthodontic Services
• 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, however, the provider
who fabricated the dentures may be reimbursed for the dentures after insertion if another provider, typically an Oral Surgeon,
inserted the dentures.
Class B Oral Surgery Services
• Unsuccessful extractions;
• Removal of impacted third molars in patients under age 15 and over age 30 unless specific documentation is provided that
substantiates the need for removal and it is approved by the contractor.
Class C Major Restorative Services
• Sedative restorations;
• Cast crowns with resin facings;
• Protective restoration;
• Composite resin inlays;
• Services or treatment for the provision of an initial prosthodontic appliance (i.e., fixed bridge restoration, implants,
removable partial or complete denture, etc.) when it replaces natural teeth extracted or missing, including congenital defects,
prior to the effective date of coverage are not eligible for coverage.
Class C Endodontic Services
• Incomplete endodontic therapy due to the patient's discontinuation of treatment;
• A paste-type root canal filling incorporating formaldehyde or paraformaldehyde;
• Endodontic procedures in conjunction with overdentures;
• Incompletely filled root canals, other than for reason of an inoperable or fractured tooth;
Class C Prosthodontic Services
• Services or treatment for the provision of an initial prosthodontic appliance (i.e., fixed bridge restoration, implants,
removable partial or complete denture, etc.) when it replaces natural teeth extracted or missing, including congenital defects,
prior to the effective date of coverage are not eligible for coverage.
Class D Orthodontic Services
• Myofunctional therapy is integral to orthodontic treatment and is not payable as a separate benefit;
• Orthodontic services for dependent children age 19 and older are not covered in the Standard Plan;
• Orthodontic services for dependent children in the High Plan are only covered up to age 21 for TRICARE-eligible
individuals (or 23 if they’re full-time college students) or 22 for civilian dependents. Orthodontic services for enrollees and
spouses are only covered in the High Plan.
General Services
• Deep sedation/general anesthesia and intravenous conscious sedation without a report;
Adjunctive Services
• Adjunctive dental services, except as described in the General Services section of this plan brochure.
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Section 8 Claims Filing and Disputed Claims Processes
To avoid delay in the payment of your claims please have your dental provider submit
your claims directly to Delta Dental's Federal Employees Dental Program for payment.
Delta Dental's Federal Employees Dental Program network providers will submit your
claims directly to Delta Dental's Federal Employees Dental Program. If you would like to
submit a paper claim, you may download a claim form from the website at deltadentalins.
com/fedvip. Mail completed claim forms to:
Delta Dental of California
Federal Employees Dental Program
PO Box 537007
Sacramento, CA 95853-7007
When a claimant files a claim for dental insurance benefits described in this plan
brochure, the claim should be sent to us within 12 months of the date of service. If the
claim is not submitted within the time limits described in this section, the delay may cause
a claim to be denied or reduced.
How to File a Claim for
Covered Services
For services you receive outside of the 50 United States, the District of Columbia or
Puerto Rico, send itemized bills/receipts that include an English translation and the date
the services were rendered. Benefits will be calculated using the daily rate of exchange
for the date of service and reimbursed in United States currency. International participants
will receive out-of-network benefits when services are performed by an internationally
located provider. All international claims should be submitted to Delta Dental of
California, Federal Employees Dental Program, PO Box 537007, Sacramento, CA
95853-7007.
It is to your benefit to reply promptly when we ask for additional information. We may
delay processing or deny your claim if you do not respond. See Section 6 International
Services and Supplies for more information.
International Claims
Send us all of the documents for your claims as soon as possible. You must submit your
claim to us within 12 months following the delivery of the services in order for them to be
considered for plan benefits, unless timely filing was prevented by administrative
operations of the Government or legal incapacity, provided the claim was submitted as
soon as reasonably possible. Once we pay benefits, there is a three-year limitation on the
reissuance of uncashed checks.
We may require, at our option, supporting documentation such as clinical reports, charts,
and/or x-rays.
Deadline for Filing Your
Claim
Follow this disputed claims process if you disagree with our decision on your claim or
request for services. The FEDVIP law does not provide a role for OPM to review
disputed claims.
Disputed Claim Steps:
1. Ask us in writing to reconsider our initial decision. You must include any pertinent
information omitted from the initial claim filing and mail your additional proof to us
within 90 days from the date of receipt of our decision.
2. Send your request for reconsideration to:
Delta Dental of California
Federal Employees Dental Program
Claims Appeals
PO Box 537015
Sacramento, CA 95853-7015
Disputed Claims Process
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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. 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 Delta Dental's Federal
Employees Dental Program and OPM, to 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 plan's alternate benefit provision; for example, a bridge being given
an alternate benefit of a partial denture.
The decision of the independent third party is binding and constitutes the final review of
your claim.
CONFIDENTIALITY OF YOUR HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
This notice is required by law to inform you of how Delta Dental and its affiliates ("Delta
Dental") protect the confidentiality of your health care information in our possession.
Protected Health Information (PHI) is defined as individually identifiable information
regarding a patient's health care history, mental or physical condition or treatment. Some
examples of PHI include your name, address, telephone and/or fax number, electronic
mail address, social security number or other identification number, date of birth, date of
treatment, treatment records, x-rays, enrollment and claims records. Delta Dental receives,
uses and discloses your PHI to administer your benefit plan or as permitted or required by
law. Any other disclosure of your PHI without your authorization is prohibited.
We follow the privacy practices described in this notice and federal and state privacy
requirements that apply to our administration of your benefits. Delta Dental reserves the
right to change our privacy practice effective for all PHI maintained. We will update this
notice if there are material changes and redistribute it to you within 60 days of the change
to our practices. We will also promptly post a revised notice on our website. A copy may
be requested anytime by contacting the address or phone number at the end of this notice.
You should receive a copy of this notice at the time of enrollment in a Delta Dental
program and will be informed on how to obtain a copy at least every three years.
PERMITTED USES AND DISCLOSURES OF YOUR PHI
Uses and disclosures of your PHI for treatment, payment or health care operations
For example, Delta Dental may use and disclose your PHI to review the quality of
care provided by our network of providers
.
HIPAA Notice of Privacy
Practices
47 2022 Delta Dental's
Federal Employees Dental Program
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Your explicit authorization is not required to disclose information about yourself for
purposes of health care treatment, payment of claims, billing of premiums, and other
health care operations. If your benefit plan is sponsored by your employer or another
party, we may provide PHI to your employer or plan sponsor to administer your benefits.
As permitted by law, we may disclose PHI to third-party affiliates that perform services
for Delta Dental to administer your benefits, and who have signed a contract agreeing to
protect the confidentiality of your PHI, and have implemented privacy policies and
procedures that comply with applicable federal and state law.
Some examples of disclosure and use for treatment, payment or operations include:
processing your claims, collecting enrollment information and premiums, reviewing the
quality of health care you receive, providing customer service, resolving your grievances,
and sharing payment information with other insurers. Some other examples are:
• Uses and/or disclosures of PHI in facilitating treatment.
For example, Delta Dental
may use or disclose your PHI to determine eligibility for services requested by your
provider.
• Uses and/or disclosures of PHI for payment.
For example, Delta Dental may use and
disclose your PHI to bill you or your plan sponsor.
• Uses and/or disclosures of PHI for health care operations.
For example, Delta Dental
may use and disclose your PHI to review the quality of care provided by our network
of providers.
Other permitted uses and disclosures without an authorization
We are permitted to disclose your PHI upon your request or to your authorized personal
representative (with certain exceptions) when required by the U. S. Secretary of Health
and Human Services to investigate or determine our compliance with law, and when
otherwise required by law. Delta Dental may disclose your PHI without your prior
authorization in response to the following:
• Court order;
• Order of a board, commission, or administrative agency for purposes of adjudication
pursuant to its lawful authority;
• Subpoena in a civil action;
• Investigative subpoena of a government board, commission, or agency;
• Subpoena in an arbitration;
• Law enforcement search warrant; or
• Coroner's request during investigations.
Some other examples include: to notify or assist in notifying a family member, another
person, or a personal representative of your condition; to assist in disaster relief efforts; to
report victims of abuse, neglect or domestic violence to appropriate authorities; for organ
donation purposes; to avert a serious threat to health or safety; for specialized government
functions such as military and veterans activities; for workers' compensation purposes;
and, with certain restrictions, we are permitted to use and/or disclose your PHI for
underwriting, provided it does not contain genetic information. Information can also be
de-identified or summarized so it cannot be traced to you and, in selected instances, for
research purposes with the proper oversight.
Disclosures Delta Dental makes with your authorization
Delta Dental will not use or disclose your PHI without your prior written authorization
unless permitted by law. You can later revoke that authorization, in writing, to stop the
future use and disclosure. The authorization will be obtained from you by Delta Dental or
by a person requesting your PHI from Delta Dental.
48 2022 Delta Dental's
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YOUR RIGHTS REGARDING PHI
You have the right to request an inspection of and obtain a copy of your PHI.
You may access your PHI by contacting Delta Dental at the address at the bottom of this
notice. You must include (1) your name, address, telephone number and identification
number, and (2) the PHI you are requesting. Delta Dental may charge a reasonable fee for
providing you copies of your PHI. Delta Dental will only maintain that PHI that we obtain
or utilize in providing your health care benefits. Most PHI, such as treatment records or x-
rays, is returned by Delta Dental to the dentist after we have completed our review of that
information. You may need to contact your health care provider to obtain PHI that Delta
Dental does not possess.
You may not inspect or copy PHI compiled in reasonable anticipation of, or use in, a civil,
criminal, or administrative action or proceeding, or PHI that is otherwise not subject to
disclosure under federal or state law. In some circumstances, you may have a right to have
this decision reviewed. Please contact Delta Dental as noted below if you have questions
about access to your PHI.
You have the right to request a restriction of your PHI.
You have the right to ask that we limit how we use and disclose your PHI, however, you
may not restrict our legal or permitted uses and disclosures of PHI. While we will
consider your request, we are not legally required to accept those requests that we cannot
reasonably implement or comply with during an emergency. If we accept your request,
we will put our understanding in writing.
You have the right to correct or update your PHI.
You may request to make an amendment of PHI we maintain about you. In certain cases,
we may deny your request for an amendment. If we deny your request for amendment,
you have the right to file a statement of disagreement with us and we may prepare a
rebuttal to your statement and will provide you with a copy of any such rebuttal. If your
PHI was sent to us by another, we may refer you to that person to amend your PHI. For
example, we may refer you to your dentist to amend your treatment chart or to your
employer, if applicable, to amend your enrollment information. Please contact the privacy
office as noted below if you have questions about amending your PHI.
You have rights related to the use and disclosure of your PHI for marketing.
Delta Dental agrees to obtain your authorization for the use or disclosure of PHI for
marketing when required by law. You have the opportunity to opt out of marketing that is
permitted by law without an authorization. Delta Dental does not use your PHI for
fundraising purposes.
You have the right to request or receive confidential communications from us by
alternative means or at a different address.
Alternate or confidential communication is available if disclosure of your PHI to the
address on file could endanger you. You may be required to provide us with a statement of
possible danger, as well as specify a different address or another method of contact. Please
make this request in writing to the address noted at the end of this notice.
You have the right to receive an accounting of certain disclosures we have made, if
any, of your PHI.
49 2022 Delta Dental's
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You have a right to an accounting of disclosures with some restrictions. This right does
not apply to disclosures for purposes of treatment, payment, or health care operations or
for information we disclosed after we received a valid authorization from you.
Additionally, we do not need to account for disclosures made to you, to family members
or friends involved in your care, or for notification purposes. We do not need to account
for disclosures made for national security reasons, certain law enforcement purposes or
disclosures made as part of a limited data set. Please contact us at the number at the end of
this notice if you would like to receive an accounting of disclosures or if you have
questions about this right.
You have the right to get this notice by email.
A copy of this notice is posted on the Delta Dental website. You may also request an email
copy or paper copy of this notice by calling our Customer Service number listed at the
bottom of this notice.
You have the right to be notified following a breach of unsecured protected health
information.
Delta Dental will notify you in writing, at the address on file, if we discover we
compromised the privacy of your PHI.
COMPLAINTS
You may file a complaint to Delta Dental and/or to the U. S. Secretary of Health and
Human Services if you believe Delta Dental has violated your privacy rights. Complaints
to Delta Dental may be filed by notifying the contact below. We will not retaliate against
you for filing a complaint.
CONTACTS
You may contact Delta Dental at 866-530-9675, or you may write to the address listed
below for further information about the complaint process or any of the information
contained in this notice.
Delta Dental
PO Box 997330
Sacramento, CA 95899-7330
This notice is effective on and after January 1, 2016.
Note: Delta Dental's privacy practices reflect applicable federal law as well as known
state law and regulations. If applicable state law is more protective of information
than the federal privacy laws, Delta Dental protects information in accordance with
the state law.
LANGUAGE ASSISTANCE
IMPORTANT: Can you read this letter? If not, we can have somebody help you read it.
You may also be able to get this letter written in your language. For free help, please call
right away at the Member/Customer Service telephone number on the back of your Delta
Dental ID card, or 1-866-530-9675.
IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a
leerla. También puede recibir esta carta en su idioma. Para ayuda gratuita, por favor llame
inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de
su tarjeta de identificación de Delta Dental o al 1-866-530-9675. (Spanish)
Last Significant Changes to this Notice:
50 2022 Delta Dental's
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• Clarified that Delta Dental does not used your PHI for fundraising purposes – effective
January 1, 2016
• Clarified that Delta Dental’s privacy policy reflect federal and state requirements –
effective January 1, 2015
• Updated contact information (mailing address and phone number) – effective July 1,
2013
• Updated Delta Dental’s duty to notify affected individuals if a breach of their
unsecured PHI occurs – effective July 1, 2013
• Clarified that Delta Dental does not and will not sell your information without your
express written authorization – effective July 1, 2013
• Clarified several instances where the law requires individual authorization to use and
disclose information (e.g., fundraising and marketing as noted above) – effective July
1, 2013
DELTA DENTAL AND ITS AFFILIATES
Delta Dental of California offers and administers fee-for-service dental programs for
groups headquartered in the state of California.
Delta Dental of New York offers and administers fee-for-service programs in New York.
Delta Dental of Pennsylvania and its affiliates offer and administer fee for-service dental
programs in Delaware, Maryland, Pennsylvania, West Virginia and the District of
Columbia. Delta Dental of Pennsylvania's affiliates are Delta Dental of Delaware; Delta
Dental of the District of Columbia and Delta Dental of West Virginia.
Delta Dental Insurance Company offers and administers fee-for-service dental programs
to groups headquartered or located in Alabama, Florida, Georgia, Louisiana, Mississippi,
Montana, Nevada, Texas and Utah and vision programs to groups headquartered in West
Virginia.
DeltaCare USA is underwritten in these states by these entities: AL — Alpha Dental of
Alabama, Inc.; AZ — Alpha Dental of Arizona, Inc.; CA — Delta Dental of California;
AR, CO, IA, ME, MI, NC, NH, OK, OR, RI, SC, SD, VT, WA, WI, WY — Dentegra
Insurance Company; AK, CT, DC, DE, FL, GA, KS, LA, MS, MT, TN and WV — Delta
Dental Insurance Company; HI, ID, IL, IN, KY, MD, MO, NJ, OH, TX — Alpha Dental
Programs, Inc.; NV — Alpha Dental of Nevada, Inc.; UT — Alpha Dental of Utah, Inc.;
NM — Alpha Dental of New Mexico, Inc.; NY — Delta Dental of New York, Inc.; PA —
Delta Dental of Pennsylvania; VA — Delta Dental of Virginia. Delta Dental Insurance
Company acts as the DeltaCare USA administrator in all these states. These companies are
financially responsible for their own products.
Dentegra Insurance Company.
51 2022 Delta Dental's
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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 for a definition of alternate benefit.
Alternate Benefit
The maximum annual benefit that you can receive per person. 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, 2022 through December 31, 2022. Also referred to as the plan year. Calendar Year
Basic services, which include oral examinations, prophylaxis, diagnostic evaluations,
sealants, and X-rays.
Class A Services
Intermediate services, which include restorative procedures such as fillings, prefabricated
stainless steel crowns, periodontal scaling, tooth 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 to the provider when you receive
services.
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 meet acceptable standards of dental practice
as determined by us.
Covered Service
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
Dental Necessity means that a dental service or treatment is performed in accordance with
generally accepted dental standards, 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
52 2022 Delta Dental's
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Dental services that initiated in 2021 that will be completed in 2022. In-Progress Treatment
A covered service is deemed incurred on the date care, treatment or service is received. Incur/Incurred
Maximum Allowed Charge means the contracted or billed amount of the dental charge
whichever is the lesser.
Maximum Allowable
Charge
Network Allowance means the allowance per procedure that Delta Dental's Federal
Employees Dental Program has negotiated with the provider and they have agreed to
accept as payment in full for his/her services.
Network Allowance
Delta Dental's Federal Employees Dental Program Plan
The amount we use to determine our payment for services. If services are provided by an
in-network dentist the Plan Allowance is based on the discounted fee he or she accepts as
payment in full for the procedure or procedures. If services are provided by an out-of-
network dentist the Plan Allowance is based on Delta Dental's Federal Employees Dental
Program’s determination of usual and customary charges for the procedure or procedures.
Plan Allowance
This is the procedure used by the plan to estimate covered services and the amount that
the plan will cover. It is not a guarantee of payment.
Pre-Treatment Estimate
The installation of complete or partial removable dentures, fixed partial dentures
(bridges), implants, and other prosthodontic services will be covered when replacing or
repairing a pre-existing, failed prosthodontic appliance/device that was in existence prior
to your coverage effective date under Delta Dental's Federal Employees Dental Program.
Initial prosthodontic services to replace natural teeth that were missing prior to your Delta
Dental Federal Employees Dental Program date of coverage are not covered.
"Tooth Missing but Not
Replaced" Rule
There are no waiting periods in either of our Plan options, not even for orthodontics. Waiting Period
Delta Dental's Federal Employees Dental Program We/Us
Enrollee or eligible family member. You
Generally, a sponsor means the individual who is eligible for medical or dental benefits
under 10 U.S.C. chapter 55 based on his or her 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
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
53 2022 Delta Dental's
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Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Dental 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
providers, Delta Dental's Federal Employees Dental Program, BENEFEDS or OPM.
•Let only the appropriate providers review your clinical record or recommend services.
•Avoid using providers 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 (EOB) statements.
•Do not ask your provider 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 provider 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 provider and ask for an explanation. There may be an error.
- If the provider does not resolve the matter, call us at 800-526-1852 and explain the situation, you will be required to
state your complaint in writing to us.
•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 he/she is disabled and incapable of self- support) or for TRICARE families, your
children who are older than 21 or 23 if in college.
If you have any questions about the eligibility of a dependent, please contact BENEFEDS.
Be sure to review Section 1 Eligibility of this plan 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.
54 2022 Delta Dental's
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Summary of Benefits
•Do not rely on this chart alone. This page summarizes specific expenses we cover; for more details, please review the
individual sections of this plan brochure.
•If you want to enroll or change your enrollment in this plan, please visit www.BENEFEDS.com or call 1-877-888-FEDS
(1-877-888-3337), TTY number 1-877-889-5680.
High Option Benefits: Class A Basic Services – preventive and diagnostic
You Pay In-network: 0%
You Pay Out-of-network: 10% of the plan allowance and any difference between our allowance and the billed amount.
Page: 16
High Option Benefits: Class B Intermediate Services – includes minor restorative services
You Pay In-network: 30%
You Pay Out-of-network: 40% of the plan allowance and any difference between our allowance and the billed amount.
Page: 19
High Option Benefits: Class C Major Services – includes major restorative, endodontic, and prosthodontic services
You Pay In-network: 50%
You Pay Out-of-network: 60% of the plan allowance and any difference between our allowance and the billed amount.
Page: 24
High Option Benefits: Class D Orthodontic Services. $3,500 for dependents up to 21 for TRICARE-eligible individuals
(or 23 if they’re full-time college students) or 22 for civilian dependents; $2,000 for members and spouses
You Pay In-network: 50%
You Pay Out-of-network: 50% of the plan allowance and any difference between our allowance and the billed amount.
Page: 31
Please Note: Class A, B, and C services in the High Option are subject to an Unlimited annual maximum benefit in-network
and a $3,000 annual maximum benefit out-of-network.
Standard Option Benefits: Class A Basic Services – preventive and diagnostic
You Pay In-network: 0%
You Pay Out-of-network: 40% of the plan allowance and any difference between our allowance and the billed amount.
Page: 16
Standard Option Benefits: Class B Intermediate Services – includes minor restorative services
You Pay In-network: 45%
You Pay Out-of-network: 60% of the plan allowance and any difference between our allowance and the billed amount.
Page: 19
Standard Option Benefits: Class C Major Services – includes major restorative, endodontic, and prosthodontic
services
You Pay In-network: 65%
You Pay Out-of-network: 80% of the plan allowance and any difference between our allowance and the billed amount.
Page: 24
Standard Option Benefits:Class D Orthodontic. Services $2,000 Lifetime Maximum for dependent children up to age 19
or a $1,000 Lifetime Maximum for out-of- network for dependent children up to age 19
You Pay In-network: 50%
You Pay Out-of-network: 50% of the plan allowance and any difference between our allowance and the billed amount.
Page: 31
Please Note: Class A, B, and C Services in the Standard Option are subject to a $1,500 annual maximum benefit in-
network and a $1,000 annual maximum benefit out-of-network .
55 2022 Delta Dental's
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Notes
56 2022 Delta Dental's
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Notes
57 2022 Delta Dental's
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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 below, match your Rating Area to your enrollment type and plan option.
Premium Rating Areas by State/ZIP Code (first three digits)
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 MA Entire State 5 OR Entire State 5
AL Entire State 1 MD 219 4 PA 150-171, 175-179,
182, 184-188
2
AR Entire State 2 MD Rest of State 5 PA 189-196 4
AZ Entire State 5 ME Entire State 5 PA Rest of State 5
CA Entire State 5 MI Entire State 4 PR Entire Area 1
CO 807, 811, 813-816
4 MN Entire State 5 RI Entire State 5
CO Rest of State 5 MO 630-631, 633, 726 2 SC 297 4
CT Entire State 5 MO Rest of State 4 SC Rest of State 5
DC Entire Area 5 MS Entire State 1 SD Entire State 5
DE Entire State 4 MT Entire State 1 TN Entire State 4
FL Entire State 4 NC 279 3 TX 739 4
GA Entire State 2 NC Rest of State 4 TX 733, 786-787 3
GU Entire Area 5 ND Entire State 3 TX Rest of State 2
HI Entire State 5 NE 680-681 3 UT Entire State 5
IA 527-528 2 NE Rest of State 2 VA 201, 203, 205,
220-227
5
IA 515 3 NH Entire State 5 VA Rest of State 3
IA Rest of State 4 NJ 080-084 4 VI Entire Area 5
ID Entire State 5 NJ Rest of State 5 VT Entire State 5
IL Entire State 2 NM 874, 877-884 4 WA Entire State 5
IN 463-471, 474-479 2 NM Rest of State 5 WI Entire State 5
IN Rest of State 3 NV Entire State 5 WV 254 5
KS Entire State 4 NY Entire State 5 WV Rest of State 2
KY 410, 459 2 OH 430-433, 437,
453-455
3 WY Entire State 5
KY Rest of State 1 OH Rest of State 2 INTER INTERNATIONAL 5
LA Entire State 1 OK Entire State 4
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High & Standard 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 $17.67 $35.35 $53.02 $38.29 $76.59 $114.88
2 $19.38 $38.76 $58.13 $41.99 $83.98 $125.95
3 $21.26 $42.52 $63.79 $46.06 $92.13 $138.21
4 $22.63 $45.25 $67.88 $49.03 $98.04 $147.07
5 $26.37 $52.73 $79.10 $57.14 $114.25 $171.38
Rating Area
Standard - Bi-Weekly Standard - Monthly
Self Only Self Plus One Self and Family Self Only Self Plus One Self and Family
1 $9.20 $18.40 $27.61 $19.93 $39.87 $59.82
2 $10.02 $20.05 $30.07 $21.71 $43.44 $65.15
3 $10.81 $21.61 $32.42 $23.42 $46.82 $70.24
4 $11.40 $22.80 $34.19 $24.70 $49.40 $74.08
5 $13.05 $26.10 $39.16 $28.28 $56.55 $84.85
59 2022 Delta Dental's
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