Document list

Document Name Document Number
Cover page D26.00.1.1
Introduction D26.00.1.2
Table of Contents D26.00.1.3
Changes for 2026 D26.00.1.4
A Choice of Plans and Options D26.00.2.1
Enroll Through BENEFEDS D26.00.2.2
Dual Enrollment D26.00.2.3
Coverage Effective Date D26.00.2.4
Pre-Tax Salary Deduction for Employees D26.00.2.5
Annual Enrollment Opportunity D26.00.2.6
Continued Group Coverage After Retirement D26.00.2.7
Compliance with the American Dental Association (ADA) D26.00.2.8
Federal Employees D26.01.1
Temporary/Seasonal Employees D26.01.1.1
Federal Annuitants D26.01.2
Survivor Annuitants D26.01.3
Compensationers D26.01.4
TRICARE-eligible individual D26.01.5
Family Members D26.01.6
Not Eligible D26.01.7
Enroll Through BENEFEDS D26.02.1
Enrollment Types D26.02.2
Dual Enrollment D26.02.3
Opportunities to Enroll or Change Enrollment D26.02.4
When Coverage Stops D26.02.5
Continuation of Coverage D26.02.6
FSAFEDS/High Deductible Health Plans and FEDVIP D26.02.7
Identification Cards/Enrollment Confirmation D26.03.01
Where You Get Covered Care D26.03.02
Plan Dentists D26.03.03
In-Network D26.03.04
Out-of-Network D26.03.05
Emergency Services D26.03.06
Pre-treatment Estimate D26.03.08
Alternate Benefit D26.03.09
Dental Review D26.03.10
FEHB/PSHB First Payor D26.03.11
Example 1: High Option coverage (In-Network provider) D26.03.12
Example 2: High Option coverage (Out-of-Network provider) D26.03.13
Coordination of Benefits D26.03.14
Example 1: High Option coverage (In-Network provider) D26.03.15
Example 2: High Option coverage (Out-of-Network provider) D26.03.16
Rating Areas D26.03.17
Limited Access Area D26.03.18
Section 4 Your Cost For Covered Services D26.04.0
Deductible D26.04.1
Coinsurance D26.04.2
Annual Benefit Maximum D26.04.3
Lifetime Benefit Maximum D26.04.4
In-Network Services D26.04.5
Out-of-Network Services D26.04.6
Plan Allowance D26.04.6.1
Calendar Year D26.04.7
Emergency Services D26.04.8
In-Progress Treatment D26.04.9
Section 5 Dental Services and Supplies Class A Basic D26.05A.0
Diagnostic Services D26.05A.1
Preventive Services D26.05A.2
Additional Procedures Covered as Basic Services D26.05A.3
Services Not Covered D26.05A.4
Class B Intermediate D26.05B.0
Minor Restorative Services D26.05B.1
Endodontic Services D26.05B.2
Periodontal Services D26.05B.3
Prosthodontic Services D26.05B.4
Oral Surgery D26.05B.5
Services Not Covered D26.05B.6
Class C Major D26.05C.0
Major Restorative Services D26.05C.1
Endodontic Services D26.05C.2
Periodontal Services D26.05C.3
Prosthodontic Services D26.05C.4
Implant Services D26.05C.4.1
Oral Surgery D26.05C.5
Services Not Covered D26.05C.6
Class D Orthodontic D26.05D.0
Orthodontic Services D26.05D.1
Services Not Covered D26.05D.2
General Services D26.05G.0
Anesthesia Services D26.05G.1
Medications D26.05G.3
Post-Surgical Services D26.05G.4
Miscellaneous Services D26.05G.5
Services Not Covered D26.05G.6
International Claims Payment D26.06.1
Finding an International Dentist D26.06.2
Filing International Claims D26.06.3
International Rates D26.06.4
Section 7 General Exclusions – Things We Do Not Cover D26.07
How to File a Claim For Covered Services D26.08.1
Deadline for Filing Your Claim D26.08.2
Disputed Claims Process D26.08.3
Section 9 Definitions of Terms We Use in This Brochure D26.09
Discounts D26.10.1
Tools and Resources D26.10.2
Summary of Benefits D26.11.0
High Option Benefits D26.11.1
Standard Option Benefits D26.11.2
Stop Health Care Fraud! D26.12
Rate Information D26.13
Rates D26.14
Terms and Conditions and Privacy Policy SB-FBF-002