Dominion Dental Services FederalDentalPlans com

Emergency Services ..........................................................................................................................................................12 

Plan Allowance .................................................................................................................................................................12 

Section 5 Dental Services and Supplies Class A Basic ...............................................................................................................13 

Class B Intermediate ...................................................................................................................................................................15 

Class C Major ..............................................................................................................................................................................18 

Class D Orthodontic ....................................................................................................................................................................23 

General Services .........................................................................................................................................................................24 

Section 6 International Services and Supplies ............................................................................................................................26 

Section 7 General Exclusions – Things We Do Not Cover .........................................................................................................27 

Section 8 Claims Filing and Disputed Claims Processes ............................................................................................................30 

How to File a Claim for Covered Services .......................................................................................................................30 

Deadline for Filing Your Claim .........................................................................................................................................30 

Disputed Claims Process ...................................................................................................................................................30 

Section 9 Definitions of Terms We Use in This Brochure ..........................................................................................................31 

Stop Health Care Fraud! .............................................................................................................................................................32 

Summary of Benefits ..................................................................................................................................................................33 

Rate Information .........................................................................................................................................................................34 

2 

2018  

Enroll at www.BENEFEDS.com 

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How We Have Changed For 2018 

We have made the following modifications for 2018:

Class A Services: Added the following procedure code: 

•

D1575 Distal shoe space maintainer – fixed - unilateral 

•

D9995 Teledentistry – synchronous; real-time encounter (when available) 

•

D9996 Teledentistry – asynchronous; information store and forwarded to dentist for subsequent review (when available) 

 Class B Services: Added the following procedure code: 

•

D4346 Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation 

 Class C Services: Added the following procedure codes: 

•

 D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of 

the implant surfaces, without flap entry and closure 

3 

2018  

Enroll at www.BENEFEDS.com 

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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.  Visit www.opm.gov/healthcare-

insurance/dental-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 2017 Open Season, your coverage 

will begin on January 1, 2018.  Premium deductions will start with the first full pay period 

beginning on/after January 1, 2018.  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. 

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 13, 

2017 through midnight EST December 11, 2017.  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 is no waiting period associated with this plan. 

Waiting Period

4 

2018  

Enroll at www.BENEFEDS.com 

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