Table of Contents
Introduction 1
Table of Contents 1
Changes for 2022 3
FEDVIP Program Highlights 4
Class B Intermediate 22
Class C Major 27
Class D Orthodontic 35
General Services 37
Section 6 International Services and Supplies 39
Section 7 General Exclusions – Things We Do Not Cover 40
Section 8 Claims Filing and Disputed Claims Processes 42
Section 9 Definitions of Terms We Use in This Brochure 44
Discounts and Features 46
Summary of Benefits 48
Stop Health Care Fraud! 51
Rate Information 52
Rates 53
Table of Contents 1
Changes for 2022 3
FEDVIP Program Highlights 4
A Choice of Plans and Options 4
Enroll Through BENEFEDS 4
Dual Enrollment 4
Coverage Effective Date 4
Pre-Tax Salary Deduction for Employees 4
Annual Enrollment Opportunity 4
Continued Group Coverage After Retirement 4
Waiting Period 4
Section 1 Eligibility 5Enroll Through BENEFEDS 4
Dual Enrollment 4
Coverage Effective Date 4
Pre-Tax Salary Deduction for Employees 4
Annual Enrollment Opportunity 4
Continued Group Coverage After Retirement 4
Waiting Period 4
Federal Employees 5
Federal Annuitants 5
Survivor Annuitants 5
Compensationers 5
TRICARE-eligible individual 5
Family Members 5
Not Eligible 6
Section 2 Enrollment 7Federal Annuitants 5
Survivor Annuitants 5
Compensationers 5
TRICARE-eligible individual 5
Family Members 5
Not Eligible 6
Enroll Through BENEFEDS 7
Enrollment Types 7
Dual Enrollment 7
Opportunities to Enroll or Change Enrollment 7
When Coverage Stops 9
Continuation of Coverage 10
FSAFEDS/High Deductible Health Plans and FEDVIP 10
Section 3 How You Obtain Care 11Enrollment Types 7
Dual Enrollment 7
Opportunities to Enroll or Change Enrollment 7
When Coverage Stops 9
Continuation of Coverage 10
FSAFEDS/High Deductible Health Plans and FEDVIP 10
Identification Cards/Enrollment Confirmation 11
Where You Get Covered Care 11
Plan Providers 11
In-Network 11
Out-of-Network 12
Emergency Services 12
Maximum Amount Allowed 12
Precertification 12
Alternate Benefit 12
Dental Review 13
FEHB First Payor 13
Coordination of Benefits 14
Rating Areas 15
Limited Access Area 15
Section 4 Your Cost For Covered Services 16Where You Get Covered Care 11
Plan Providers 11
In-Network 11
Out-of-Network 12
Emergency Services 12
Maximum Amount Allowed 12
Precertification 12
Alternate Benefit 12
Dental Review 13
FEHB First Payor 13
Coordination of Benefits 14
Rating Areas 15
Limited Access Area 15
Deductible 16
Coinsurance 16
Annual Benefit Maximum 17
Lifetime Benefit Maximum 17
In-Network Services 17
Out-of-Network Services 17
Calendar Year 17
Emergency Services 17
Section 5 Dental Services and Supplies Class A Basic 19Coinsurance 16
Annual Benefit Maximum 17
Lifetime Benefit Maximum 17
In-Network Services 17
Out-of-Network Services 17
Calendar Year 17
Emergency Services 17
Class B Intermediate 22
Class C Major 27
Class D Orthodontic 35
General Services 37
Section 6 International Services and Supplies 39
Section 7 General Exclusions – Things We Do Not Cover 40
Section 8 Claims Filing and Disputed Claims Processes 42
Section 9 Definitions of Terms We Use in This Brochure 44
Discounts and Features 46
Summary of Benefits 48
Stop Health Care Fraud! 51
Rate Information 52
Rates 53