FEP BlueDental Reasons to Smile Benefits High Option Standard Option In-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 Network ü No Waiting Period for Ortho Under our High Option ü No Calendar Year Deductible for In-Network Benefits ü 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 person No 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 NEW No waiting period! ® Did You Know... See your FEP BlueDental Brochure for more details; do not rely on this chart alone.

Reasons to Smile - FEP Blue€¦ · Reasons to Smile Benefits High Option Standard Option In-Network Out-of-Network In-Network Out-of-Network Class A (Basic) Services – e.g., exams,

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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.

Page 2: Reasons to Smile - FEP Blue€¦ · Reasons to Smile Benefits High Option Standard Option In-Network Out-of-Network In-Network Out-of-Network Class A (Basic) Services – e.g., exams,

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.