|Plan 1||Plan 2|
|Member & Spouse/Partner||$90.60||$98.00|
|Member & Children||$92.90||$100.45|
|Member, Spouse/Partner & Children||$138.20||$149.45|
Premium Rates for Payments by EFT. Add $5.00 to the rates above if you want to pay by check
*Rates are valid for 12 months from the effective date of the policy. Rates are subject to change.
|Benefit||Plan 1 Copayments||Plan 2 Copayments|
|General Office Visit||You pay a $35 Copay||You pay a $25 Copay|
|Specialist Office Visit||You pay a $35 Copay||You pay a $30 Copay|
|Dental Exams and X-rays||You pay a $0 Copay||You pay a $0 Copay|
|Teeth Cleaning||You pay a $0 Copay||You pay a $0 Copay|
|Fluoride Treatment||You pay a $0 Copay||You pay a $15 Copay|
|Sealants per Tooth||You pay a $0 Copay||You pay a $15 Copay|
|Filling - Amalgam||You pay a $45 Copay||You pay a $25 Copay|
|Filling - Resin (Anterior)||You pay a $70 Copay||You pay a $50 Copay|
|Filling - Resin (Posterior Primary)||You pay a $80 Copay||You pay a $50 Copay|
|Filling - Resin (Posterior Permanent)||You pay a $132 Copay||You pay a $102 Copay|
|Stainless Steel Crown||You pay a $90 Copay||You pay a $70 Copay|
|Porcelain/Metal Crown1||You pay a $500 Copay||You pay a $400 Copay|
|Complete Denture1||You pay a $600 Copay||You pay a $500 Copay|
|Bridge (per tooth)1||You pay a $500 Copay||You pay a $400 Copay|
|Root Canal Therapy
– Anterior Tooth
|You pay a $225 Copay||You pay a $200 Copay|
|Root Canal Therapy
– Bicuspid Tooth
|You pay a $325 Copay||You pay a $225 Copay|
|Root Canal Therapy
|You pay a $425 Copay||You pay a $250 Copay|
|Osseous Surgery (Per Quadrant)||You pay a $325 Copay||You pay a $300 Copay|
|Root Planing (Per Quadrant)||You pay a $100 Copay||You pay a $75 Copay|
|Routine Extraction||You pay a $75 Copay||You pay a $50 Copay|
|Surgical Extraction||You pay a $190 Copay||You pay a $100 Copay|
|Pre-Orthodontic Service2||You pay a $150 Copay||You pay a $150 Copay|
|Comprehensive Orthodontia1||You pay a $3,000 Copay||You pay a $2,800 Copay|
|Nitrous Oxide Per Visit||You pay a $40 Copay||You pay a $40 Copay|
|Out-of-area emergency care (50 miles or more from a WDG office)||Out of area emergency treatment is reimbursed up to $100 minus applicable copayments.|
- Benefit available after a six month waiting period.
- Applies toward comprehensive orthodontic copayment if patient accepts treatment plan.
These services and supplies are not covered:
- Bridges, crowns, dentures or any prosthetic devices requiring multiple treatment dates or fittings if the prosthetic item is installed or delivered more than 60 days after termination of coverage.
- The completion or delivery of treatments, services, or supplies initiated prior to the effective date of coverage.
- Dental implants.
- Endodontic services, prosthetic services, and implants provided prior to the effective date of coverage.
- Endodontic therapy completed more than 60 days after termination of coverage.
- Experimental or investigational services or supplies.
- Exams or consultations needed solely in connection with a service or supply not listed as covered.
- Full mouth reconstruction.
- General anesthesia, including conscious, intravenous and moderate sedation.
- Hospital care or other care outside of a dental office or facility fees.
- Maxillofacial prosthetic services.
- Orthognathic surgery.
- Personalized restorations.
- Plastic, reconstructive, or cosmetic surgery.
- Prescription and over-the-counter drugs and pre-medications.
- Replacement of lost, missing, stolen or damaged dental appliances.
- Replacement of sound restorations.
- Services or supplies and related exams or consultations that are not within the prescribed treatment plan, are not recommended and approved by a Participating Dentist or are not necessary.
- Services or supplies by any person other than a licensed dentist, denturist, hygienist, or dental assistant.
- Services or supplies for the diagnosis or treatment of temporomandibular joint disorders.
- Services or supplies for the treatment of an occupational injury or disease.
- Services or supplies for treatment of injuries sustained while practicing for or competing in a professional athletic contest of any kind.
- Services or supplies for treatment of intentionally self-inflicted injuries.
- Services or supplies for which coverage is available under any federal, state, or other governmental program.
- Services or supplies that are not listed as covered in the policy.
- Services or supplies where there is no evidence of pathology, dysfunction, or disease.
This is a brief summary of benefits. For full coverage provisions, including a description of limitations and exclusions, refer to your policy.