The EmblemHealth FEDVIP Dental Program

Preventive and Diagnostic Services

Covers services meant to maintain good dental health, including exams, x-rays, cleanings, and fluoride treatments. Two exams and two cleanings per covered person are payable in a calendar year.

Paid in full in-network. Deductible applies to out-of-network benefits only.

Intermediate Services and Periodontal and Endodontic Services

Covers fillings, extractions, denture/crown/bridge repair, emergency treatments, oral surgery, anesthesia/IV sedation, and specialist consultations.

Paid in full in-network. Deductible applies to out-of-network benefits only.

Major Services

Covers root canals, crowns, gingivectomy periodontal surgery, fixed bridgework, and dentures.

Implants (includes crowns)

Paid in full in-network. Deductible applies to out-of-network benefits only.

High Option: $4,500
Standard Option: $3,000
maximum allowance. Deductible applies to out-of-network benefits only.

Calendar Year Deductible

Applies to intermediate and major services received out-of-network only.

In-network: $0 individual/$0 family

Out-of-network: $50 individual/$150 family

Maximum Benefit Payout

Annual maximum per covered member (not including orthodontia)

Lifetime orthodontia maximum per covered member. (Orthodontia benefits are effective at the time coverage begins. Adults are covered for orthodonthia.)

Unlimited

High Option: $4,000
Standard Option: $3,000

Out-of-Network Reimbursement

The member pays the difference between EmblemHealth’s payment and the provider’s charge.

Refer to the plan’s Preferred Schedule.