Select Standard & HighDental Benefi t Options 2020

TOP REASONS TO CHOOSE DOMINIONFind Out More at FederalDentalPlans.com

SELECTING A DENTISTYou must choose a primary care dentist before you utilize the plan. Prior to your eff ective date, you will receive a notifi cation prompting you to select a dentist. After your eff ective date, simply call the dental offi ce you selected to make an appointment. Except for out-of-area emergency care, you must receive treatment at the dental offi ce you selected.

PLAN FEATURESNO Annual Maximums

NO Deductibles

NO Waiting Periods

NO Claim Forms1

NO Pre-authorization Paperwork

Rate reduction of up to 6% as

compared to last year

• Enrollment, including Qualifying Life Events

• Eligibility• Billing and payment • Updates to contact information

CONTACTING BENEFEDS

877.888.3337; TTY 877.889.5680

IMPORTANT INFORMATION

Dominion Dental Services FederalDentalPlans.com251 18th Street South Suite 900Arlington, VA 22202

CONTACTING DOMINION

• Plan information• ID card requests• Dentist search • Dental offi ce transfers

855.836.6337; TTY 711

BENEFEDS.com FederalDentalPlans.com

Rates starting as low as $5.66

Extensive coverage at predictable,

pre-determined fees

No annual maximums, deductibles or

waiting periods

Orthodontic coverage for children and adults

(no lifetime maximum)

Access to digital ID card, dentist search and more via

Go mobile notifi cations

Discounts on Invisalign and teeth whitening

procedures

One of the largest Dental HMO networks in the

Mid-Atlantic2

Prevention Rewards Program

Third annual cleaning provided at a reduced fee

Select StandardRating Area

Bi-Weekly

Self Only

Bi-Weekly

Self Plus One

Bi-Weekly

Self and Family

Monthly

Self Only

Monthly

Self Plus One

Monthly

Self and Family

1 $5.66 $11.30 $16.96 $12.26 $24.48 $36.75

2 $5.90 $11.80 $17.69 $12.78 $25.57 $38.33

3 $6.58 $13.15 $19.73 $14.26 $28.49 $42.75

4 $7.30 $14.59 $21.89 $15.82 $31.61 $47.43

5 $8.36 $16.72 $25.08 $18.11 $36.23 $54.34

Savings Comparison Select Standard Select High Procedure Area Charge3 Your Fee4 Your Savings Your Fee4 Your Savings

Office Visit Fee --- $10 --- $10 ---

Oral Exam $71 No Charge 100% No Charge 100%

Complete Series X-rays $189 No Charge 100% No Charge 100%

Bitewing X-rays (2 Films) $61 No Charge 100% No Charge 100%

Semiannual (2) Teeth Cleanings $120 No Charge 100% No Charge 100%

Topical Fluoride for Children $49 No Charge 100% No Charge 100%

Sealants $74 No Charge 100% No Charge 100%

Filling (3-Surface/Silver) $338 $76 78% No Charge 100%

Crown (Porcelain/Metal) $1,291 $555 57% $380 71%

Implants $2,825 $1,292 54% $830 71%

Complete Denture $2,164 $702 68% $455 79%

Root Canal (Anterior Tooth) $1,134 $391 66% $260 77%

Perio Scaling/Root Planing $342 $105 69% $31 91%

Extraction, Erupted Tooth $232 $58 75% $47 80%

Child Orthodontics $6,233 $3,422 45% $3,422 45%

Adult Orthodontics $6,420 $3,658 43% $3,658 43%

Select HighRating Area

Bi-Weekly

Self Only

Bi-Weekly

Self Plus One

Bi-Weekly

Self and Family

Monthly

Self Only

Monthly

Self Plus One

Monthly

Self and Family

1 $9.58 $19.15 $28.73 $20.76 $41.49 $62.25

2 $9.94 $19.88 $29.80 $21.54 $43.07 $64.57

3 $10.30 $20.60 $30.90 $22.32 $44.63 $66.95

4 $10.69 $21.37 $32.07 $23.16 $46.30 $69.49

5 $14.21 $28.41 $42.62 $30.79 $61.56 $92.34

State 3 Digit Zip

Rating Area

DC Entire State 4

DE Entire State 5

MD 206-212, 214, 217

4

MD 219 5

MD Rest of State 2

NJ 080-084 5

PA 173-174 4

PA 189-196 5

PA Rest of State 1

VA 231-232, 238 3

VA 201, 220-227, 233-237

4

DETERMINE YOUR RATING REGION

2020 RATES & RATING AREAS

Refer to the exclusions and limitations on FederalDentalPlans.com.

1. Out-of-area emergency care reimbursement requires a receipt or other proof of loss.2. Dominion Dental Services, Inc. Network Analysis Report, 2018. Mid-Atlantic includes D.C., Delaware, Maryland, Pennsylvania and Virginia. Participating

dentists are subject to change.3. Based on the Context4Healthcare’s 80th percentile. Coverage for orthodontia is based on the 80th percentile of Dominion Dental Services’ out-of-

network claims data for D8080 and D8090 (excluding Invisalign) from 2015 to 2018. Based on zip 223.4. There is an additional $10 for the office visit fee (per visit, not per procedure).5. The Dominion group of companies includes Dominion Dental Services, Inc., a licensed issuer of dental plans, and Dominion Dental Services USA, Inc., a

licensed administrator of dental and vision benefits.

DDS.FV.MF.082919