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FEP BlueDentalReasons to Smile
Benefits High Option Standard OptionIn-Network Out-of-Network In-Network Out-of-Network
Class A (Basic) Services – e.g., exams, cleanings, X-rays, sealants
100% 90% 100% 60%
Class B (Intermediate) Services – e.g., oral surgery, fillings, gum scaling
70% 60% 55% 40%
Class C (Major) Services – e.g., crowns, bridges, implants, root canals, dentures
50% 40% 35% 20%
Class D (Orthodontic) Services – Adults & Children
50% Up to $3,500
lifetime maximum per person
50% Up to $2,000 lifetime maximum per person
50% Up to $1,000 lifetime maximum per person
12-month waiting period
Contact Us Today: FEP BlueDental Customer Service / Phone: 1-855-504-BLUE (2583), 8 a.m. – 8 p.m. EST Monday – Friday TTY 1-888-853-7570 or visit www.fepblue.org (click on Benefit Plans then FEP BlueDental) to access: • Find a Dentist • Benefit Information • Member FAQ • Oral Health Tips • Claims Information • And Much More To Enroll:Visit www.BENEFEDS.com or call 1-877-888-FEDS (3337), TTY 1-877-889-5680. Open enrollment is November 9 - December 14, 2015 EST.
ü No Charge for Routine Preventive Services in Networkü No Waiting Period for Ortho Under our High Optionü No Calendar Year Deductible for In-Network Benefitsü Nearly 100,000 Dental Providers Nationwide ü Dental Exams can Detect Signs of Oral Cancer
Benefits High Option Standard Option
In-Network Out-of-Network In-Network Out-of-Network
Deductible for Class A, B and C Services No Deductible$50 per calendar year
per personNo Deductible
$75 per calendar year per person
Annual Maximum Benefits for Class A, B and C Services
$15,000 per person $3,000 per person $1,500 per person $750 per person
NEWNo waiting
period!
®
Did You Know...
See your FEP BlueDental Brochure for more details; do not rely on this chart alone.
RatingArea
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
Bi-Weekly Monthly Bi-Weekly Monthly Bi-Weekly Monthly Bi-Weekly Monthly Bi-Weekly Monthly Bi-Weekly Monthly
1 $17.34 $37.57 $34.69 $75.16 $52.03 $112.73 $9.70 $21.02 $19.41 $42.06 $29.11 $63.07
2 $19.73 $42.75 $39.46 $85.50 $59.19 $128.25 $11.03 $23.90 $22.05 $47.78 $33.08 $71.67
3 $21.86 $47.36 $43.73 $94.75 $65.59 $142.11 $12.22 $26.48 $24.44 $52.95 $36.66 $79.43
4 $23.10 $50.05 $46.19 $100.08 $69.29 $150.13 $12.89 $27.93 $25.78 $55.86 $38.67 $83.79
5 / INTL $25.54 $55.34 $51.09 $110.70 $76.63 $166.03 $14.26 $30.90 $28.51 $61.77 $42.77 $92.67
2. The Rating Area is the same for both High and Standard Options. Match your Rating Area to your enrollment type (i.e., High Option Self Only) to determine your premium.
2016 Bi-Weekly and Monthly Rates For FEP BlueDental 1. How to use this chart: Locate your state and/or the first 3 digits of your ZIP code to determine your Rating Area.