Appendix I
FEDVIP Plan Comparison Charts

RI 70-01 For Federal Civilian Employees

This is a brief summary of the features of the dental and vision plans. Before making a final decision, please read the plan brochures and provider directories thoroughly. All plans are not the same. All benefits are subject to the definitions, limitations, co-payments, annual maximums and exclusions set forth in the individual plan brochures. Go to our website at www.opm.gov/insure/dentalvision to find the rating region assigned to the area where you live and the related premium cost you will pay.

Reading the Chart:

The table on the following pages highlights the selected features/classes of dental and/or vision services. Always consult plan brochures before making a decision. The chart does not show all of your possible out-of-pocket costs.

Dental Insurance

The deductibles shown for the dental plans are the amount of covered expenses that you pay before the plan begins to pay. Service Class refers to the level of benefits for each plan. The Service Classes are listed below. Calendar year maximum refers to the annual amount of benefits that you can receive per person.

Please Note: Most plans require that you be continuously enrolled in the same dental plan for the full waiting period before accessing orthodontia services. There are no other waiting periods for services.

Dental plans provide a comprehensive range of services, including but not limited to the following:

• Class A (Basic) services, which include oral examinations, prophylaxis, diagnostic evaluations, sealants and x-rays.
• Class B (Intermediate) services, which include restorative procedures such as fillings, prefabricated stainless steel crowns, periodontal scaling, tooth extractions, and denture adjustments.
• Class C (Major) services, which include endodontic services such as root canals, periodontal services such as gingivectomy, major restorative services such as crowns, oral surgery, bridges and prosthodontic services such as complete dentures.
• Class D (Orthodontic) services with up to a 24-month waiting period for dependents up to age 19.

Please review the dental plans' benefits material for detailed information on the benefits covered, costsharing requirements and provider directories.

Vision Insurance

Vision plans provide comprehensive eye examinations and coverage for lenses, frames and contact lenses (in lieu of eye glasses). Other benefits, such as discounts on lasik surgery, may also be available.

Please review the vision plans' benefits material for detailed information on the benefits covered, cost-sharing requirements and provider directories.

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