2010 Benefits and Rates

For Federal Employees with Standard Option Medical

Federal DentalBlue Standard Option Dental
Benefits	Network Dentist	Non-Network Dentist
Deductible individual/Family (Deductible applies to Type III Services Only)	$50/$150	$50/$150
Annual Maximum	$1,500	$1,500
Type I Services Cleanings Examinations X-Rays Sealants Space maintainers	100% of Maximum Allowance	70% of Maximum Allowance
Type II Services Fillings Simple Extractions	80% of Maximum Allowance	50% of Maximum Allowance
Type III Services Crowns* Bridges* Dentures* Endodontics Oral Surgery Periodontics	50% of Maximum Allowance	30% of Maximum Allowance
* A 12-month waiting period for new enrollees will apply to Major Restorative and Prosthodontic Services.
Type IV Services Orthodontics	Up to $1,000 savings	Not available
Orthodontia services will be billed at a 20% discount, with up to $1,000 in lifetime savings off network providers' usual charge. This non-insured discount benefit is available only through network providers.

 

Monthly Rates - Standard Option
Employee	Employee +1	family
$27.05	$45.95	$75.65

 

For Federal Employees with Basic Option Medical

Federal DentalBlue Basic Option Dental
Benefits	Network Dentist	Non-Network Dentist
Deductible individual/Family (Deductible applies to Type III Services Only)	$50/$150	$50/$150
Annual Maximum	$1,500	$1,500
Type I Services Cleanings Examinations X-Rays Sealants Space maintainers	Not available (Preventive & Diagnostic are covered under your Basic Option medical plan.)	Not available
Type II Services Fillings Simple Extractions	80% of Maximum Allowance	50% of Maximum Allowance
Type III Services Crowns* Bridges* Dentures* Endodontics Oral Surgery Periodontics	50% of Maximum Allowance	30% of Maximum Allowance
* A 12-month waiting period for new enrollees will apply to Major Restorative and Prosthodontic Services.
Type IV Services Orthodontics	Up to $1,000 savings	Not available
Orthodontia services will be billed at a 20% discount, with up to $1,000 in lifetime savings off network providers’ usual charge. This non-insured discount benefit is available only through network providers.

 

Monthly Rates - Basic Option
Employee	Employee +1	family
$18.10	$30.85	$50.80

 

1 For services received from a non-network dentist, the claimant will be responsible for any difference between the dentist's charges and the maximum allowable charge. The maximum allowable charge is based on our network prevailing negotiated fees. Further information regarding the maximum allowable charge and network status of dentists is available by calling the toll free telephone number on the back of your dental identification card.