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Plan Details & Options:
:
| Plan Options | Rates |
|---|---|
| Dollar-Based | Rate Chart |
| Incentive 10 | Rate Chart |
| Managed Care | Rate Chart |
Regence Incentive 10
Preventive and Diagnostic Services
- Cleanings allowed two per benefit year (includes cleanings and periodontal maintenance
- Oral exams allowed two per benefit year
- Fluoride Treatment allowed two applications per benefit year for members age 17 and under
- X-rays bite wings: allowed one set limited to twice per benefit year; panoramic and full mouth series: limited to once every three years
- Sealants allowed for permanent bicuspid and molars for members age 17 and under
- Space Maintainers allowed for members age 11 and under
Restorative Services
- Fillings composite and amalgam
- Emergency treatment for pain relief only
- Oral surgery including surgical extractions, removal of teeth, biopsies and incision and drainage
- General anesthesia or intravenous sedation allowed for surgical extractions of teeth and for members age 6 and under
- Direct pulp capping
Major Services
- Crowns or onlays and related services
- Bridges (fixed partial dentures) limited to one in a 7-year period
- Dentures (full or partial) and related services
- Endosteal Implants and related services implants are limited to 4 per lifetime per member
- Endodontics including root canal treatment, pulpotomy, apicoectomy
- Periodontal Maintenance allowed two per benefit year (includes cleanings and periodontal maintenance)
- Gingivectomy and gingivoplasty allowed once every three years per quadrant
- Osseous and mucogingival surgery allowed once every five years per quadrant
- Debridement allowed once every 3 years
- Scaling and root planing allowed once every two years per quadrant
Regence Dollar-Based
Incentive: You control your benefit increase by receiving at least one cleaning and exam during the benefit year.
- No deductibles
- No limitations or exclusions for covered services, except orthodontia, theeth bleaching and veneers
- Six month waiting period
- Optional Vision Rider available: $150 in services and/or hardware every 24 months
