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.  Some TRICARE beneficiaries may not be eligible to enroll in both.  Visit www.opm.gov/dental or www.opm.gov/vision for more information.

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; (ie you or covered family members) cannot be covered by two FEDVIP dental plans or two FEDVIP vision plans.

If you sign up for a dental and/or vision plan during the 2022 Open Season, your coverage will begin on January 1, 2023.  Premium deductions will start with the first full pay period beginning on/after January 1, 2023.  You may use your benefits as soon as your enrollment is confirmed.

Employees automatically pay premiums through payroll deductions using pre-tax dollars.  Annuitants automatically pay premiums through annuity deductions using post-tax dollars.  TRICARE enrollees automatically pay premiums through payroll deduction or automatic bank withdrawal (ABW) using post-tax dollars.

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 14, 2022 through midnight EST December 12, 2022.  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.

There are no waiting periods is for this plan

You are eligible to enroll if you:

• retired on an immediate annuity under the Civil Service Retirement System (CSRS), the Federal Employees Retirement System (FERS) or another retirement system for employees of the Federal Government;
• retired for disability under CSRS, FERS, or another retirement system for employees of the Federal Government.

Your FEDVIP enrollment will continue into retirement, if you retire on an immediate annuity or for disability under CSRS, FERS or another retirement system for employees of the Government, regardless of the length of time you had FEDVIP coverage as an employee.  There is no requirement to have coverage for 5 years of service prior to retirement in order to continue coverage into retirement, as there is with the FEHB Program.

Your FEDVIP coverage will end if you retire on a Minimum Retirement Age (MRA) + 10 retirement and postpone receipt of your annuity.  You may enroll in FEDVIP again when you begin to receive your annuity.

An individual who is eligible for FEDVIP dental coverage based on the individual's eligibility to previously be covered under the TRICARE Retiree Dental Program or an individual eligible for FEDVIP vision coverage based on the individual's enrollment in a specified TRICARE health plan.

Retired members of the uniformed services and National Guard/Reserve components, including “gray-area” retirees under age 60 and their families are eligible for FEDVIP dental coverage. These individuals, if enrolled in a TRICARE health plan, are also eligible for FEDVIP vision coverage. In addition, uniformed services active duty family members who are enrolled in a TRICARE health plan are eligible for FEDVIP vision coverage.

Except with respect to TRICARE-eligible individuals, family members include your spouse and unmarried dependent children under age 22.  This includes legally adopted children and recognized natural children who meet certain dependency requirements.  This also includes stepchildren and foster children who live with you in a regular parent-child relationship.  Under certain circumstances, you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support.  FEDVIP rules and FEHB rules for family member eligibility are NOT the same.  For more information on family member eligibility visit the website at www.opm.gov/healthcare-insurance/dental-vision/ or contact your employing agency or retirement system.

With respect to TRICARE-eligible individuals, family members include your spouse, unremarried widow, unremarried widower, unmarried child, and certain unmarried persons placed in your legal custody by a court. Children include legally adopted children, stepchildren, and pre-adoptive children. Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity.

The following persons are not eligible to enroll in FEDVIP, regardless of FEHB eligibility or receipt of an annuity or portion of an annuity:

• Deferred annuitants
• Former spouses of employees or annuitants.  Note:  Former spouses of TRICARE-eligible individuals may enroll in a FEDVIP vision plan.
• FEHB Temporary Continuation of Coverage (TCC) enrollees
• Anyone receiving an insurable interest annuity who is not also an eligible family member
• Active duty uniformed service members.  Note:  If you are an active duty uniformed service member, your dental and vision coverage will be provided by TRICARE.  Your family members will still be eligible to enroll in the TRICARE Dental Plan (TDP). 

You must use BENEFEDS to enroll or change enrollment in a FEDVIP plan.  BENEFEDS is a secure enrollment website (www.BENEFEDS.com) sponsored by OPM.  If you do not have access to a computer, call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680, to enroll or change your enrollment.

If you are currently enrolled in FEDVIP and do not want to change plans, your enrollment will continue automatically.  Please Note:  your plans' premiums may change for 2023.

Note: You cannot enroll or change enrollment in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency self-service system, such as Employee Express, PostalEase, EBIS, MyPay, or Employee Personal Page.  However, those sites may provide a link to BENEFEDS.

Self Only: A Self Only enrollment covers only you as the enrolled employee or annuitant.  You may choose a Self Only enrollment even though you have a family; however, your family members will not be covered under FEDVIP.

Self Plus One: A Self Plus One enrollment covers you as the enrolled employee or annuitant plus one eligible family member whom you specify.  You may choose a Self Plus One enrollment even though you have additional eligible family members, but the additional family members will not be covered under FEDVIP. 

Self and Family: A Self and Family enrollment covers you as the enrolled employee or annuitant and all of your eligible family members.  You must list all eligible family members when enrolling.

Open Season

If you are an eligible employee, annuitant, or TRICARE-eligible individual, you may enroll in a dental and/or vision plan during the November 14, 2022  through midnight EST December 12, 2022, Open Season.  Coverage is effective January 1, 2023.

During future annual Open Seasons, you may enroll in a plan, or change or cancel your dental and/or vision coverage.  The effective date of these Open Season enrollments and changes will be set by OPM.  If you want to continue your current enrollment, do nothing.  Your enrollment carries over from year to year, unless you change it.

New hire/Newly eligible

You may enroll within 60 days after you become eligible as:

• a new employee;
• a previously ineligible employee who transferred to a covered position;
• a survivor annuitant if not already covered under FEDVIP; or
• an employee returning to service following a break in service of at least 31 days.
• a TRICARE-eligible individual

Qualifying Life Event

A qualifying life event (QLE) is an event that allows you to enroll, or if you are already enrolled, allows you to change your enrollment outside of an Open Season. 

The following chart lists the QLEs and the enrollment actions you may take:

Qualifying Life Event: Marriage
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes

Qualifying Life Event: Acquiring an eligible family member (non-spouse)
From Not Enrolled to Enrolled: No
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Losing a covered family member
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: Yes
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Losing other dental/vision coverage (eligible or covered person)
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Moving out of regional plan's service area
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes

Qualifying Life Event: Going on active military duty, non- pay status (enrollee or spouse)
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: Yes
Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from active military duty (enrollee or spouse)
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from Leave without pay
From Not Enrolled to Enrolled: Yes (if enrollment cancelled during LWOP)
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes (if enrollment cancelled during LWOP)

Qualifying Life Event: Annuity/ compensation restored
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Transferring to an eligible position*
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: Yes
Change from One Plan to Another: No

*Position must be in a Federal agency that provides dental and/or vision coverage with 50 percent or more employer-paid premium.

The timeframe for requesting a QLE change is from 31 days before to 60 days after the event.  There are two exceptions:

• There is no time limit for a change based on moving from a regional plan’s service area and
• You cannot request a new enrollment based on a QLE before the QLE occurs, except for enrollment because of the loss of dental or vision insurance.  You must make the change no later than 60 days after the event.

Generally, enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives and confirms the enrollment or change.  BENEFEDS will send you confirmation of your new coverage effective date.

Once you enroll in a plan, your 60-day window for that type of plan ends, even if 60 calendar days have not yet elapsed.  That means once you have enrolled in either plan, you cannot change or cancel that particular enrollment until the next Open Season, unless you experience a QLE that allows such a change or cancellation.

Canceling an enrollment

You may cancel your enrollment only during the annual Open Season.  An eligible family member’s coverage also ends upon the effective date of the cancellation.

Your cancellation is effective at the end of the day before the date OPM sets as the Open Season effective date.

Coverage ends for active and retired Federal, U.S. Postal employees, and TRICARE-eligible individuals when you:

• no longer meet the definition of an eligible employee, annuitant, or TRICARE-eligible individual;
• as a Retired Reservist you begin active duty;
• as sponsor or primary enrollee leaves active duty
• begin a period of non-pay status or pay that is insufficient to have your FEDVIP premiums withheld and you do not make direct premium payments to BENEFEDS;
• are making direct premium payments to BENEFEDS and you stop making the payments;
• cancel the enrollment during Open Season;
• a Retired Reservist begins active duty; or
• the sponsor or primary enrollee leaves active duty.

Coverage for a family member ends when:

• you as the enrollee lose coverage; or
• the family member no longer meets the definition of an eligible family member.

Under FEDVIP, there is no 31-day extension of coverage.  The following are also NOT available under the FEDVIP plans

• Temporary Continuation of Coverage (TCC);
• spouse equity coverage; or
• right to convert to an individual policy (conversion policy).

If you are planning to enroll in an FSAFEDS Health Care Flexible Spending Account (HCFSA) or Limited Expense Health Care Flexible Spending Account (LEX HCFSA), you should consider how coverage under a FEDVIP plan will affect your annual expenses, and thus the amount that you should allot to an FSAFEDS account.  Please note that insurance premiums are not eligible expenses for either type of FSA.

If you have an HCFSA or LEX HCFSA FSAFEDS account and you haven’t exhausted your funds by December 31st of the plan year, FSAFEDS can automatically carry over up to $610 of unspent funds into another health care or limited expense account for the subsequent year. To be eligible for carryover, you must be employed by an agency that participates in FSAFEDS and actively making allotments from your pay through December 31.  You must also actively reenroll in a health care or limited expense account during the NEXT Open Season to be carryover eligible. Your reenrollment must be for at least the minimum of $100.  If you do not reenroll, or if you are not employed by an agency that participates in FSAFEDS and actively making allotments from your pay through December 31st, your funds will not be carried over.

Because of the tax benefits an FSA provides, the IRS requires that you forfeit any money for which you did not incur an eligible expense and file a claim in the time period permitted.  This is known as the “Use-it-or-Lose-it” rule.  Carefully consider the amount you will elect. 

For a health care or limited expense account, each participant must contribute a minimum of $100 to a maximum of $3,050.

Current FSAFEDS participants must re-enroll to participate next year.  See www.fsafeds.com or call 1-877-FSAFEDS (372-3337) or TTY: 1-866-353-8058.  Note: FSAFEDS is not open to retired employees, or to TRICARE eligible individuals.

If you enroll or are enrolled in a high deductible health plan with a health savings account (HSA) or health reimbursement arrangement (HRA), you may use your HSA or HRA to pay for qualified dental/vision costs not covered by your FEHB and FEDVIP plans.

We will send you an identification (ID) card when you enroll.  You should carry your ID card with you at all times.  You must show it whenever you receive services from a plan provider.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-877-842-3625. You may also request replacement cards through the EmblemHealth website, www.EMBLEMHEALTH.com.

It is important to bring your FEDVIP and FEHB identification cards to every dental appointment because most FEHB plans offer some level of dental benefits separate from your FEDVIP coverage. Presenting both identification cards can ensure that you receive the maximum allowable benefit under each Program.

When you get care from “plan providers" you will not have to file claims.

We list plan providers in the provider directory, which we update periodically.  The list is on our website at: www.EMBLEMHEALTH.com/Federal or you may call us at 1-877-842-3625. 

Members must submit claim forms to EmblemHealth and EmblemHealth will reimburse members for covered services at the out of network allowance.  You are responsible for paying the provider the difference between EmblemHealth's Preferred Fee Allowance reimbursement and the non-network providers charge for covered services.  The Preferred Schedule of Allowance is the amount we pay our in-network, participating dentists. 

If more than one service or procedure can be used to treat the covered person’s dental condition, EmblemHealth may decide to authorize coverage only for the less costly covered service or procedure when that service is an appropriate method of treatment and the service meets broadly accepted national standards of dental practice. The alternate benefit could result in additional out-of-pocket expense.

When you visit a provider who participates with both, your FEHB plan and your FEDVIP plan, the FEHB plan will pay benefit s first. The FEDVIP plan allowance will be the prevailing charge in these cases.  You are responsible for the difference between the FEHB and FEDVIP benefit payments and the FEDVIP plan allowance.  We are responsible for facilitating the process with the FEHB first payor.

It is important to bring your FEDVIP and FEHB identification cards to every dental appointment because most FEHB plans offer some level of dental benefits separate from your FEDVIP coverage. Presenting both identification cards can ensure that you receive the maximum allowable benefit under each Program.

We will coordinate benefit payments with the payment of benefits under other group health benefits coverage you may have and the payment of dental costs under no-fault insurance that pays benefits without regard to fault. 

We may request that you verify/identify your health insurance plan(s) annually or at time of service.  

To enroll in this plan, you must live in our service area.  This is where our providers practice.  Our service area is: All of New York and the New Jersey counties of Bergen, Essex, Hudson, Middlesex, Monmouth, Morris, Passaic, Somerset, Sussex and Union. Connecticut counties of Fairfield, Litchfield, New Haven. Pennsylvania counties Pike and Monroe.

Ordinarily, you must get your care from providers who contract with us.  If you receive care outside our service area, we will pay only for emergency care benefits.  We will not pay for any other services out of our service area unless the services have prior plan approval.

If you move outside of our service area, you may enroll in another plan.  If your family members live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a nationwide plan.  If you move outside of our service area, you do not have to wait until Open Season to change plans.  Contact BENEFEDS at www.BENEFEDS.com or call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680 to change plans.

A deductible is a fixed expense you must incur for certain out-of-network covered services and supplies before we start paying benefits for them.  Copayments do not count toward any deductible.

Example: In our plan, the out-of-network calendar year deductible for an individual is $50 and family $150.

Once you reach this amount, you are responsible for all charges.

This plan’s annual maximum is unlimited per covered person.

High Option:  EmblemHealth pays 100% of the Premier schedule of allowances to the EmblemHealth network provider for covered services.

Standard Option:  EmblemHealth pays 100% of the Preferred schedule of allowances to the EmblemHealth network provider for covered services.

Member must pay the difference of the EmblemHealth Preferred Schedule of Allowances and the dentist’s normal charges.

In-progress treatment for dependents of retiring active duty service members who were enrolled in the TRICARE Dental Program (TDP)  will be covered for the 2023 plan year; regardless of any current plan exclusion for care initiated prior to the enrollee's effective date.

This requirement includes assumption of payments for covered orthodontia services up to the FEDVIP policy limits, and full payment where applicable up to the terms of FEDVIP policy for covered services completed (but not initiated) in the 2023 plan year such as crowns and implants.

FEDVIP carriers will not cover in-progress treatment if you enroll in a FEDVIP plan that has a waiting period, or does not cover the service. Several FEDVIP dental plans have options that offer orthodontia coverage without a 12-month waiting period, and without age limits.

Note - There are no waiting periods for any benefits on this plan.

D0160 Detailed and extensive oral evaluation - problem focused, by report

D0425 Caries susceptibility tests

D0330 Panoramic film – Limited to one every 36 consecutive months.

D1510 Space maintainer – fixed - unilateral - per quadrant – Limited to one space maintainer per quadrant per covered dependent child per lifetime.  Eligible until the end of the calendar year in which the child reaches 19.

D1516 Space maintainer – fixed – bilateral, maxillary – Limited to one space maintainer per covered dependent child per lifetime.  Eligible until the end of the calendar year in which the child reaches 19.

D1517 Space maintainer – fixed – bilateral, mandibular – Limited to one space maintainer per covered dependent child per lifetime.  Eligible until the end of the calendar year in which the child reaches 19.

D1526 Space maintainer – removable – bilateral, maxillary – Limited to one space maintainer per covered dependent child per lifetime.  Eligible until the end of the calendar year in which the child reaches 19.

D1527 Space maintainer – removable – bilateral, mandibular – Limited to one space maintainer per covered dependent child per lifetime.  Eligible until the end of the calendar year in which the child reaches 19.

D1551 Re-cement or re-bond bilateral space maintainer - maxillary.  Eligible until the end of the calendar year in which the child reaches 19.

D1552 Re-cement or re-bond bilateral space maintainer - mandibular.  Eligible until the end of the calendar year in which the child reaches 19.

D1553 Re-cement or re-bond unilateral space maintainer - per quadrant.  Eligible until the end of the calendar year in which the child reaches 19.

D9110 Palliative treatment of dental pain – minor procedure – Limited to one palliative service for each member in each calendar year.

Not covered:

• Plaque control programs
• Oral hygiene instruction
• Dietary instructions
• Sealants for teeth other than permanent molars
• Over-the-counter dental products, such as teeth whiteners, toothpaste, dental floss

Not Covered:

• Restorations, including veneers, which are placed for cosmetic purposes only 
• Gold foil restorations
• Temporary fillings
• The Schedule of Allowances imposes a maximum benefit for fillings done on the same tooth by the same Dentist or Provider within a six (6) month period.  GHI will not pay more than this maximum benefit for fillings for each Member in any six (6) month period.
• If two (2) fillings are done on the same posterior tooth on the same day, GHI's allowance will be up to the Scheduled or Allowed amount for a three (3) surface amalgam.

D3220 Therapeutic pulpotomy (excluding final restoration)

D5511 Repair broken complete denture base, mandibular

D5512 Repair broken complete denture base, maxillary

D5611 Repair resin partial denture base, mandibular

D5612 Repair resin partial denture base, maxillary

D5621 Repair cast partial framework, mandibular

D5622 Repair cast partial framework, maxillary

D5630 Repair or replace broken clasp

D5650 Add tooth to existing partial denture

D5660 Add clasp to existing partial denture

D5710 Rebase complete maxillary denture

D5720 Rebase maxillary partial denture

D5721 Rebase mandibular partial denture

D5730 Reline complete maxillary denture (chairside)

D5731 Reline complete mandibular denture (chairside)

D5740 Reline maxillary partial denture (chairside)

D5741 Reline mandibular partial denture (chairside)

D5750 Reline complete maxillary denture (laboratory)

D5751 Reline complete mandibular denture (laboratory)

D5760 Reline maxillary partial denture (laboratory)

D5850 Tissue conditioning (maxillary)

D5851 Tissue conditioning (mandibular)

D6930 Recement fixed partial denture

D6980 Fixed partial denture repair, by report

Not Covered:

• Denture rebase or repair within six months of the insertion date of a new denture.

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth

D7250 Surgical removal of residual tooth roots (cutting procedure)

D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth

D7280 Surgical access of an unerupted tooth

D7471 Removal of exostosis

D7910 Suture of recent small wounds up to 5 cm

D7971 Excision of pericoronal gingiva

D2542 Onlay - metallic - two surfaces

D2543 Onlay - metallic - three surfaces

D2544 Onlay - metallic - four or more surfaces

D2740 Crown - porcelain/ceramic substrate

D2750 Crown - porcelain fused to high noble metal

D2751 Crown - porcelain fused to predominately base metal

D2752 Crown - porcelain fused to noble metal

D2780 Crown - 3/4 cast high noble metal

D2781 Crown - 3/4 cast predominately base metal

D2783 Crown - 3/4 porcelain/ceramic

D2790 Crown - full cast high noble metal

D2791 Crown - full cast predominately base metal

D2792 Crown - full cast noble metal

D2950 Core buildup, including any pins

D2954 Prefabricated post and core, in addition to crown

D2980 Crown repair, by report

Not covered:

• Gold foil restorations
• Sedative restorations
• Restorations for cosmetic purposes only
• Composite resin inlays
• Temporary crowns  
• Precisionattachments, personalization, precious metal bases, and other specialized techniques
• Removable or fixed prostheses initiated prior to the effective date of coverage or inserted/cemented after the coverage ending date

Limitations:

• EmblemHealth will pay the allowance for restorative crowns only if the tooth cannot otherwise be restored.
• EmblemHealth reimburses crowns other than porcelain fused to predominantly base metal at the allowance for predominantly base metal.
• EmblemHealth reimburses abutment crowns and pontics other than porcelain fused to predominantly base metal at the allowance for predominantly base metal.
• EmblemHealth reimburses crowns over implants at the allowance for single crowns, predominantly base metal. Submitted diagnostics must support the prospect for a successful implant. Other implant-related procedures are non-covered services.
• When restorative crowns, fixed bridge crowns and pontics and implant crowns are done with other than base metal, the patient is responsible for the difference between the dentist’s charge and  our payment amount.
• Class C major restorative services are only covered once every five (5) years per tooth.

D3310 Anterior root canal (excluding final restoration)

D3320 Bicuspid root canal (excluding final restoration)

D3330 Molar root canal (excluding final restoration)

D3346 Retreatment of previous root canal therapy-anterior

D3347 Retreatment of previous root canal therapy-bicuspid

D3348 Retreatment of previous root canal therapy-molar

D3352 Apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.)

D3353 Apexification/recalcification - final visit (includes completed root canal therapy, apical closure/calcific repair of perforations, root resorption, etc.)

D3410 Apicoectomy/periradicular surgery - anterior

D3421 Apicoectomy/periradicular surgery - bicuspid (first root)

D3425 Apicoectomy/periradicular surgery - molar (first root)

D3426 Apicoectomy/periradicular surgery (each additional root)

D3450 Root amputation - per root

D3920 Hemisection (including any root removal) - not including root canal therapy

D4249 Clinical crown lengthening-hard tissue

D4270 Pedicle soft tissue graft procedure

D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant, or edentulous tooth position in graft

D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site

D4273 Subepithelial connective tissue graft procedures (including donor site surgery)

D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis - Limited to once per lifetime

D5110 Complete denture - maxillary

D5120 Complete denture - mandibular

D5130 Immediate denture - maxillary

D5140 Immediate denture - mandibular

D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth)

D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth)

D5213 Maxillary partial denture - cast metal framework with resin denture base (including any conventional clasps, rests and teeth)

D5214 Mandibular partial denture - cast metal framework with resin denture base (including any conventional clasps, rests and teeth)

D5282 Removable unilateral partial denture-one piece cast metal (including retentive/clasping materials, rests, and teeth), maxillary

D5283 Removable unilateral partial denture-one piece cast metal (including retentive/clasping materials, rests, and teeth), mandibular

D6210 Pontic - cast high noble metal

D6211 Pontic - cast predominately base metal

D6212 Pontic - cast noble metal

D6214 Pontic – titanium

D6240 Pontic - porcelain fused to high noble metal

D6241 Pontic - porcelain fused to predominately base metal

D6242 Pontic - porcelain fused to noble metal

D6245 Pontic - porcelain/ceramic

D6545 Retainer - cast metal for resin bonded fixed prosthesis

D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis

D6740 Crown - porcelain/ceramic

D6750 Crown - porcelain fused to high noble metal

D6751 Crown - porcelain fused to predominately base metal

D6752 Crown - porcelain fused to noble metal

D6780 Crown - 3/4 cast high noble metal

D6781 Crown - 3/4 cast predominately base metal

D6782 Crown - 3/4 cast noble metal

D6783 Crown - 3/4 porcelain/ceramic

D6790 Crown - full cast high noble metal

D6791 Crown - full cast predominately base metal

D6792 Crown - full cast noble metal

D6973 Core buildup for retainer, including any pins

Not covered:

• Gold foil restorations
• Sedative restorations
• Restorations for cosmetic purposes only
• Composite resin inlays
• Temporary crowns  
• Cast unilateral removable partial dentures
• Precision attachments, personalization, precious metal bases, and other specialized techniques
• Replacement of dentures that have been lost, stolen or misplaced

Limitations:

• Removable or fixed prostheses initiated prior to the effective date of coverage or inserted/cemented after the coverage ending date. EmblemHealth will pay the allowance for restorative crowns only if the tooth cannot otherwise be restored.
• EmblemHealth reimburses crowns other than porcelain fused to predominantly base metal at the allowance for predominantly base metal..
• EmblemHealth reimburses abutment crowns and pontics other than porcelain fused to predominantly base metal at the allowance for predominantly base metal.
• EmblemHealth reimburses crowns over implants at the allowance for single crowns, predominantly base metal. Submitted diagnostics must support the prospect for a successful implant. Other implant-related procedures are non-covered services
• Each abutment and each pontic in a fixed bridge constitutes a unit in a bridge.
• When restorative crowns, fixed bridge crowns and pontics and implant crowns are done with other than base metal, the patient is responsible for the difference between the dentist’s charge and  our payment amount.
• Class C major prosthodontic services are only covered once every five (5) years per tooth or per arch.

D8010 Limited orthodontic treatment of the primary dentition

D8020 Limited orthodontic treatment of the transitional dentition

D8030 Limited orthodontic treatment of the adolescent dentition

D8050 Interceptive orthodontic treatment of the primary dentition

D8060 Interceptive orthodontic treatment of the transitional dentition

D8070 Comprehensive orthodontic treatment of the transitional dentition

D8080 Comprehensive orthodontic treatment of the adolescent dentition

D8210 Removable appliance therapy

D8220 Fixed appliance therapy

D8660 Pre-orthodontic treatment visit

D8670 Periodic orthodontic treatment visit (as part of contract)

D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s))

Not covered:

• Repair of damaged orthodontic appliances
• Replacement of lost or missing appliance
• Missed appointments
• Habit control appliances
• Addition charges for cosmetic banding options
• Services to alter vertical dimension and/or restore or maintain the occlusion.  Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth

D9222 Deep sedation/general anesthesia - first 15 minutes

D9223 Deep sedation/general anesthesia - each subsequent 15 minute increment

D9239 Intravenous moderate (conscious) sedation/analgesia - first 15 minutes

D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment

D9941 Fabrication of athletic mouthguard - Limited to one per 12 month period

D9944 Occlusal guard - hard appliance, full arch

D9945 Occlusal guard - soft appliance, full arch

D9974 Internal bleaching - per tooth - Limited to once per tooth per three year period

Not covered:

• Nitrous oxide
• Oral sedation

Bills and receipts should be itemized and show:

• Covered member’s name and ID number
• Name and address of the physician or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each services or supply
• A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN), and
• Receipts, if you paid for your services.

Submit your claims to:

EmblemHealth Inc.
P.O. Box 3000
New York, New York 10116-3000

For claims questions and assistance, call us at 1-877-842-3625, or visit us at www.EMBLEMHEALTH.com.

You must file a claim for services you received outside the plan’s service area.  Submit the ADA claim form that includes the information shown below.  Bills and receipts should be itemized and show:

• Covered member’s name and ID number
• Name and address of the physician or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice (MSN), and
• Receipts, if you paid for your services.

Submit your claims to:

EmblemHealth 
P.O. Box 2838
New York, New York 10116-2838

Follow this disputed claims process if you disagree with our decision on your claim or request for services.  The FEDVIP law does not provide a role for OPM to review disputed claims.

Disputed Claim Steps:

1 Ask us in writing to reconsider our initial decision.  You must:

(a) Write to us within 6 months from the date of our decision; and

(b) Send your request to us at: EmblemHealth Customer Service Department, 55 Water St, New York, NY 10041; and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

(d) Include copies of documents that support your claim, such as physicians'

letters, operative reports, bills, dental records, and explanation of benefits

(EOB) forms.

2 We have 30 days from the date we received your request to:

(a) Pay the claim (or, if applicable, arrange for the dental care provider to give

you the care); or

(b) Write to you and maintain our denial -- go to step 4; or

(c) Ask you or your provider for more information.  If we ask your provider, we

will send you a copy of our request—go to step 3.

3 If the dispute is not resolved through the reconsideration process, you may request a review of the denial.  You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.

We will write to you with our decision.

4 If you do not agree with our final decision, you may request an independent third party, mutually agreed upon by us and OPM, review the decision.

The decision of the independent third party is binding and is the final review of your claim.  This decision is not subject to judicial review.

The Federal employee, annuitant, or TRICARE-eligible individual enrolled in this plan.

Dental care that is necessary and:

• In accordance with the generally accepted standards of good dental practice in the community
• Not in excess of the care indicated by generally accepted standards of good dental practice in the community
• Not experimental or investigational
• Consistent with the symptoms or diagnosis and treatment of the dental condition, disease, injury or ailment
• Provided for the diagnosis, or direct care or treatment of the condition, illness, disease or injury that the patient is suffering from.

Generally, a sponsor means the individual who is eligible for medical or dental benefits under 10 U.S.C. chapter 55 based on their direct affiliation with the uniformed services (including military members of the National Guard and Reserves).

Under circumstances where a sponsor is not an enrollee, a TEI family member may accept responsibility to self-certify as an enrollee and enroll TEI family members

TEI family members include a sponsor’s spouse, unremarried widow, unremarried widower, unmarried child, and certain unmarried persons placed in a sponsor’s legal custody by a court. Children include legally adopted children, stepchildren, and pre- adoptive children. Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity.

Dental services that initiated in 2022 that will be completed in 2023.

In-Network: Nothing

Out-of-Network: After you meet the annual deductible, EmblemHealth pays 100% of the Preferred Schedule of Allowances. The Preferred Schedule of Allowances is the amount we pay our in-network, participating dentists. You are responsible for paying the provider the difference between EmblemHealth's reimbursement and the non-network providers charge for covered service.

In-Network: Nothing

Out-of-Network: After you meet the annual deductible, EmblemHealth pays 100% of the Preferred Schedule of Allowances.  The Preferred Schedule of Allowances is the amount we pay our in-network, participating dentists. You are responsible for paying the provider the difference between EmblemHealth's reimbursement and the non-network providers charge for covered service.  

In-Network: Nothing

Out-of-Network: After you meet the annual deductible, EmblemHealth pays 100% of the Preferred Schedule of Allowances. The Preferred Schedule of Allowances is the amount we pay our in-network, participating dentists. You are responsible for paying the provider the difference between EmblemHealth's reimbursement and the non-network providers charge for covered service.

 subject to an unlimited annual maximum benefit

Class D Services – orthodontic

High Option:  $4,000 Lifetime Maximum

Standard Option:$3,000 Lifetime Maximum