Blue Cross Blue Shield FEP Dental Brochure - 2022

Blue Cross Blue Shield FEP Dental
Section 3 How You Obtain Care
Example 3: High Option coverage (In-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 In-Network Provider
2-surface filling: $121.00
Maximum Allowable Amount: $73.00
FEHB payment (estimated): $60.50
BCBS FEP Dental benefits payable in the absence of FEHB coverage: $51.10 ($73.00 at 70%)
Payment by BCBS FEP Dental: $12.50
Member’s responsibility*: $0.00 ($73-$60.50-$12.50=$0.00)
*Assumes provider does not have a contractual relationship regarding fees with the primary carrier