General Services
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 necessary for the prevention, diagnosis,
care, or treatment of a covered condition and meet generally accepted dental protocols.
•
There is no calendar year deductible.
•
The is no annual benefit maximum.
•
See Section 7 of this brochure for plan limitations.
You Pay:
•
In-Network: The co-payment shown in the Benefit Schedule along with a $10 office visit copay
(please note that the office visit copay is charged per office visit, not per procedure).
•
Out-of-Network: In full for all charges. There are no out-of-network benefits available except for
emergency services when the services of an in-network provider are not available.
Anesthesia Services
Standard
Option
Copay
Amount
High
Option
Copay
Amount
D9110 Palliative treatment of dental pain – minor procedure
$43
$35
D9223 Deep sedation/general anesthesia – each 15 minute increment
$119
$87
Intravenous Sedation
Standard
Option
Copay
Amount
High
Option
Copay
Amount
D9243 Intravenous conscious sedation/analgesia – each 15 minute increment
$114
$81
Consultations
Standard
Option
Copay
Amount
High
Option
Copay
Amount
D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner
providing treatment)
$0
$0
Office Visits
Standard
Option
Copay
Amount
High
Option
Copay
Amount
D9439 Office visit
$10
$10
D9440 Office visit – after regularly scheduled hours
$10
$10
D9986 Missed appointment
$50
$50
24
2018
Enroll at www.BENEFEDS.com
Medications
Standard
Option
Copay
Amount
High
Option
Copay
Amount
D9610 Therapeutic drug injection, by report
$31
$20
D9612 Therapeutic parenteral drugs, two or more administrations, different medications
$49
$31
Post Surgical Services
Standard
Option
Copay
Amount
High
Option
Copay
Amount
D9930 Treatment of complications (post-surgical) unusual circumstances, by report
$43
$42
Miscellaneous Services
Standard
Option
Copay
Amount
High
Option
Copay
Amount
D9940 Occlusal guard, by report
$285
$191
D9941 Fabrication of athletic mouthguard
$65
$42
D9972 External bleaching – per arch – performed in office
15%
Discount
15%
Discount
D9973 External bleaching – per tooth
15%
Discount
15%
Discount
D9974 Internal bleaching – per tooth
$131
$84
D9975 External bleaching for home application - per arch (includes materials and fabrication of
custom trays)
15%
Discount
15%
Discount
Not covered:
•
Nitrous oxide
•
Oral sedation
•
Any exclusions or limitations listed under Section 7 of this plan document
25
2018
Enroll at www.BENEFEDS.com
Section 6 International Services and Supplies
This plan provides a benefit for emergency services when overseas. Emergency services
are defined as treatment due to injury, accident or severe pain requiring the services of a
dentist which occurs under circumstances where it is neither medically or physically
possible for you to be treated by an in-network assigned plan provider. We will reimburse
you for emergency services up to $100 per member per year.
International Claims
Payment
This plan provides a benefit for international emergency services when services are
received from a licensed dentist. The Dominion Dental Services Network does not extend
outside of the United States. You have the right to choose any licensed dental practitioner;
you do not need to contact Dominion first.
Note: Because international claims do not have the consideration of stateside cost
containment, members must be cautious to guard against inappropriate/excessive services.
Finding an International
Provider
The following should be provided when submitting a claim for International emergency
services:
• Name of country where services were received
• American Dental Association procedure codes
• Translation of language to English
• Translation into US currency or accurate day rate
• Tooth number(s) and/or quadrants
• Date(s) of service
• Dentist name
Filing International
Claims
Our plan website is FederalDentalPlans.com. You may also contact us by phone at
855-836-6337.
Customer Service
Website and Phone
Numbers
26
2018
Enroll at www.BENEFEDS.com
