Blue Cross Blue Shield FEP Dental Brochure - 2022

Blue Cross Blue Shield FEP Dental
Section 3 How You Obtain Care
Example 4: High Option coverage (Out-of-Network provider). This example assumes all deductibles have been met and annual maximums have not been reached.
BCBS FEP Dental coverage is secondary to non-FEHB coverage
Services are provided by an Out-of-Network Provider
2-surface filling: $121.00
FEHB payment (estimated): $96.80
BCBS FEP Dental benefits payable in the absence of FEHB coverage: $72.60 ($121.00 at 60%)
Payment by BCBS FEP Dental: $24.20
Member’s responsibility*: $0.00 ($121-$96.80-$24.20=$0.00)
*Assumes provider charge is within the Maximum Allowed Amount