The MetLife Federal Dental Plan

MetLife.com/FEDVIP-Dental

(888) 865-6854

2023

IMPORTANT

• Rates: Back Cover

• Changes for 2023: Page 6

• Summary of Benefits: Page 59

A Nationwide Dental PPO Plan

•High Option – Self Only

•High Option – Self Plus One

•High Option – Self and Family

•Standard Option – Self Only

•Standard Option – Self Plus One

On December 23, 2004, President George W. Bush signed the Federal Employee Dental and Vision Benefits Enhancement

Act of 2004 (Public Law 108-496). The law directed the Office of Personnel Management (OPM) to establish supplemental

dental and vision benefit programs to be made available to Federal employees, annuitants, and their eligible family members.

In response to the legislation, OPM established the Federal Employees Dental and Vision Insurance Program (FEDVIP).

OPM has contracted with dental and vision insurers to offer an array of choices to Federal employees and annuitants. Section

715 of the National Defense Authorization Act for Fiscal Year 2017 (FY 2017 NDAA), Public Law 114-38, expanded

FEDVIP eligibility to certain TRICARE-eligible individuals.

This brochure describes the benefits of The MetLife Federal Dental Plan under Metropolitan Life Insurance Company

(MetLife) contract OPM02-FEDVIP-02AP-11 with OPM, as authorized by the FEDVIP law. The address for our

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations,

and exclusions of this brochure. It is your responsibility to be informed about your benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus

One, you and your designated family member are entitled to these benefits. If you are enrolled in Self and Family coverage,

OPM negotiates rates with each carrier annually. Rates are shown at the end of this brochure.

The MetLife Federal Dental Insurance Plan is responsible for the selection of In-Network providers in your area. Contact us

at (888) 865-6854* for the names of participating providers or to request a provider directory. You may also view current In-

network.

Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialty

in all areas. If you require the services of a specialist and one is not available in your area, please contact us for assistance.

*Hearing and Speech impaired individuals may communicate using a text telephone device and Relay Services by dialing the

MetLife Federal Dental number of “888-865-6854”. Relay Services is immediate assistance. The Message Relay Service

enables customers who are deaf, hard of hearing, or speech impaired, and who use a Teletypewriter (TTY), to communicate

with others via the telephone. You simply type your conversation to a Relay Agent who then reads the typed conversation to

the other party. The text telephone is used through a callers wireless provider as long as they have a TTY compatible phone.

The MetLife Federal Dental Plan complies with all applicable Federal civil rights laws, to include both Title VII of the Civil

Rights Act of 1964 and Section 1557 of the Affordable Care Act. Pursuant to Section 1557, MetLife does not discriminate,

exclude people, or treat them differently on the basis of race, color, national origin, age, disability, or sex.

Introduction ...................................................................................................................................................................................2

Table of Contents ..........................................................................................................................................................................4

How We Have Changed for 2023 .................................................................................................................................................6

FEDVIP Program Highlights ........................................................................................................................................................7

Section 1 Eligibility ......................................................................................................................................................................8

Section 2 Enrollment ...................................................................................................................................................................10

Section 3 How You Obtain Care .................................................................................................................................................15

Section 4 Your Cost For Covered Services .................................................................................................................................20

Section 7 General Exclusions – Things We Do Not Cover .........................................................................................................47

Section 8 Claims Filing and Disputed Claims Processes ............................................................................................................49

Section 9 Definitions of Terms We Use in This Brochure ..........................................................................................................55

Non-FEDVIP Benefits Available to Members ............................................................................................................................57

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).

This is what you will pay out-of-pocket for covered services:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are necessary for the prevention, diagnosis,

care, or treatment of a covered condition and meet generally accepted dental protocols.

combined, for both In-Network and Out-of-Network services. The Standard Option Annual Benefit

Maximum for non-orthodontia services is $1,500 for In-Network services and $1,000 for Out-of-

Network services. In no instance will MetLife allow more than $1,500 in combined benefits under

the Standard Option in any plan year.

•All exams, oral evaluations and treatments such as fluorides and some images are combined under

one limitation under the plan. Complete set of radiographic images (D0210) and /or panoramic

radiographic image (D0330) are combined and limited to one every 60 months. Periodic oral exam,

(D0120) Oral evaluations (D0140, D0145), and Comprehensive oral exam (D0150, D0180) are

combined and limited to one exam in every 6 months from the date services were last rendered. For

example, if you have a periodic oral evaluation and a limited oral examination both services are

codes not included in the following list, subject to the exclusions and limitations shown in this

section and Section 7.

•

High Option

•In-Network: Nothing.

•Out-of-Network: 10% of the Plan Allowance plus any amount above the Plan Allowance billed by

the provider.

•Standard Option

•In-Network: Preventive and Diagnostic Services - Nothing.

•Out-of-Network: 40% of the Plan Allowance plus any amount above the Plan Allowance billed by

Preventive Services

Endodontic Services

Services Not Covered: (Please refer to Section 7 for a list of General Exclusions)

•High Option

•In-Network: 30% of the Plan Allowance

•Out-of-Network: 30% of the Plan Allowance plus any amount above the Plan Allowance billed by

the provider.

•Standard Option

•In-Network: 50% of the Plan Allowance.

•Out-of-Network: 50% of the Plan Allowance plus any amount over the Plan Allowance billed by

the provider.

Orthodontia Services

limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth.

section and Section 7.

•

High Option

•In-Network: 30% of the Plan Allowance

•Out-of-Network: 40% of the Plan Allowance plus any amount above the Plan Allowance billed by

the provider.

•

Standard Option

•In-Network: 45% of the Plan Allowance

•Out-of-Network: 60% of the Plan Allowance plus any amount above the Plan Allowance billed by

the provider.

Anesthesia Services

•Gold foil restorations;

•Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is

•Treatment of services for injuries resulting from war or act of war, whether declared or undeclared, or from police or

•Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or

•Sealants for teeth other than permanent molars;

•Precision attachments, personalization, precious metal bases and other specialized techniques;

•Replacement of dentures that have been lost, stolen or misplaced;

•Orthodontic care for dependent children age 22 and over for federal civilian employees.

•Orthodontic care for dependent children age 21 and over OR full-time students age 23 and over for TRICARE eligible

•Repair of damaged orthodontic appliances;

•Replacement of lost or missing appliances;

•Fabrication of athletic mouth guard;

•Internal and external bleaching;

• payment we made should have been made by another group plan

• any other insurance company;

• maintain the privacy of your Personal Health Information;

• provide you notice of our legal duties and privacy practices with respect to your

Personal Health Information; and notify affected individuals following a breach of

Information is no longer available to make the amendment;

• is not part of the Personal Health Information kept by or for us; or

• is not part of the Personal Health Information, which you would be permitted to

inspect and copy.

We are now introducing our MetLifeFederalBenefits.com platform as a non-FEDVIP benefit. Being eligible for FEDVIP

means that you now have year-round access to even more benefit options through MetLifeFederalBenefits.com, your new

source for innovative benefit solutions at discounted rates. This platform gives participants access to solutions and choice

that have proven to be valued by other Federal agencies.

2 $19.43 $38.86 $58.28 $42.10 $84.20 $126.27

3 $21.58 $43.17 $64.75 $46.76 $93.54 $140.29

4 $23.48 $46.96 $70.43 $50.87 $101.75 $152.60

5 $26.13 $52.27 $78.40 $56.62 $113.25 $169.87

Self Only Self Plus One Self and Family Self Only Self Plus One Self and Family

1 $10.22 $20.45 $30.67 $22.14 $44.31 $66.45

2 $10.87 $21.73 $32.60 $23.55 $47.08 $70.63

3 $12.12 $24.24 $36.36 $26.26 $52.52 $78.78