Section 5(g). Dental benefits

What's in this Section:
•   Accidental injury benefit
•   Dental benefits
Important things you should keep in mind about these benefits:
  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.


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  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payer of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9. Coordinating benefits with other coverage.


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  • The calendar year deductible is: $250 per person ($500 per family) under the High Option and $300 per person ($600 per family) under the Standard Option. The calendar year deductible applies to almost all benefits in this Section. We added (No deductible) to show when the calendar year deductible does not apply.


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  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.


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  • Note: We cover hospitalization for dental proceduresonly when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. We do not cover the dental procedure. See Section 5(c) for inpatient hospital benefits.

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Benefit Description You Pay
Accidental injury benefit High Option Standard Option
We cover surgical and dental treatment of an accidental injury to sound natural teeth. Treatment must be rendered within 24 months of the accident.

Definition:

A sound, natural tooth is a tooth that is whole or properly restored and is without impairment, periodontal or other conditions and is not in need of the treatment provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously restored with a crown, inlay, onlay, or porcelain restoration or treated by endodontics is not considered a sound natural tooth.

Note: An injury to the teeth while chewing and/or eating is not considered to be an accidental injury.
 		PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
PPO: 15% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Dental benefits    
Orthodontic treatment
  • We cover charges of an orthodontist for treatment after surgery for closure of a cleft palate or cleft lip, or for correction of prognathism or micrognathism.

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Lifetime benefits per person are:
  • Cleft palate or cleft palate with cleft lip limited to $2,500


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  • Cleft lip, prognathism or micrognathism limited to $1,000

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PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Note: You pay charges above the Plan's limit.
 		All charges
Dental prosthetic appliances
  • We will pay covered charges for dental prosthetic appliances to treat conditions due to a congenital anomaly or defect up to a maximum lifetime benefit of $3,000 per person.

 		PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Note: You pay charges above the Plan's limit.
 		All charges
The diagnostic and preventive services listed below:
  • two examinations per person, per calendar year


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  • two prophylaxis (cleanings) per person, per calendar year


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  • X-rays


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Note: Benefits are limited to $400 per person per calendar year.
 		All charges
 		Any difference between our allowance and the billed amount and all charges after the Plan has paid $400 (No deductible)
Not covered
  • Dental appliances, study models, splints and other devices or services associated with the treatment of temporomandibular joint (TMJ) dysfunction


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  • Charges in excess of the $400 Plan limitation for diagnostic and preventive services


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  • Dental implants
 All charges
 		All charges



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