| Benefit Features |
| Choice of providers |
Willamette Dental |
| Deductible per calendar year |
No deductible |
| Maximum benefit per calendar year |
No maximum benefit |
| Office visit charge |
$15 per visit |
| Services subject to office visit charge: |
|
Routine and emergency exams
|
Fully covered after visit charge |
|
Bitewing x-rays
|
Fully covered after visit charge |
|
Cleanings for adults and children
|
Fully covered after visit charge |
|
Flouride treatment for children through age 12
|
Fully covered after visit charge |
|
Head and neck cancer screening
|
Fully covered after visit charge |
|
Oral hygiene instruction
|
Fully covered after visit charge |
|
Periodontal Screen
|
Fully covered after visit charge |
|
Periodontal Maintenance
|
Fully covered after visit charge |
| Services subject to additional service
fee of percentage: |
|
Sealant per quadrant
|
$20 service fee after visit charge |
|
After hours visits
|
$20 service fee after visit charge |
|
Panoramic x-rays
|
$20 service fee after visit charge |
|
Restorative fillings, amalgam, or anterior composite
|
$30 service fee after visit charge |
|
Simple extractions
|
$30 service fee after visit charge |
|
Simple denture/partial repairs
|
$30 service fee after visit charge |
|
Other dental services
|
20% discount after visit charge |
| Orthodontia Services: (Provided
only through Willamette Dental) |
|
Pre-orthodontia service fee
(credited toward comprehensive orthodontia fee if patient accepts treatment
plan)
|
$150 after visit charge |
|
Comprehensive orthodontia fee (no age limit)
|
$2,600 after visit charge |
| Miscellaneous Services: |
|
Local anesthesia (Novocain)
|
Fully covered |
|
Nitrous oxide (per visit fee)
|
$10 |
|
Fee for missed appointments
|
$30 |
| Please note: There is a six-month
waiting period for major services which includes crowns, bridges, partials,
and dentures. |
|
As a new patient of Willamette Dental, you can expect your first visit
to include:
- discussion of your medical and dental history
- necessary x-rays, a thorough examination, and the development of your
treatment plan
- review of causes of decay, gum disease, and a demonstration of effective
methods of brushing and flossing
- a cleaning along with flouride and decay reducing treatment up to
age 12
- the scheduling of a cleaning appointment for adults
|
|
Dental Limitations and Exclusions
|
| Once enrolled, your contract can
be viewed online at www.or.regence.com. Please refer to your
contract for a complete list of benefits and the limitations and exclusions
that apply. |
|
These Benefits Are Limited
- We will not duplicate benefits for which you are eligible under Medicare
except as required by law.
- We will not cover the replacement of an existing denture, crown, or
brider less than seven years after the date of the most recent placement.
We will not cover a denture replacement made necessary by loss, theft,
or breakage.
- The benefits of this plan are not subject to any coordination of benefits
provision.
Services And Supplies Not Covered
- Services or supplies you receive before your coverage starts or after
your coverage ends. The date artificial teeth are prepared
is considered as the date of service.
- Services that are not necessary dental care.
- Services and supplies related to the diagnosis or treatment of temporomandibular
joint.
- Dental Implants
- Lost, stolen, or broken appliances
- Splints, nightguards, and other appliances used to indrease vertial
dimensions, restore bite, or correct habits such as toungue thrusting
or teeth grinding.
- Treatment(s), procedures, equipment, medications, devices, and supplies
that are experimental or investigational even when provided by foreign
providers.
- Services or supplies not received from a Willamette Dental dentist
(except as specifically listed).
- Surgery for fractures, cysts, or tumors.
- Models of teeth and surrounding tissue for purposes of study and treatment
planning.
- Services provided by a dentist or denturist that are beyond the scope
of his or her license.
- Cosmetic dental services including complications arising out of such
services.
- General anesthesia, unless recommended by the referring or attending
dentist for a medical condition which requires general anesthesia before
services can be performed.
- Recording of jaw movements or positions.
- Services or supplies you receive from a dental or medical department
maintained by or on behalf of any employer, or mutual benefit association,
labor union, trustee, or similar person or group.
- Services and supplies not specifically listed.
|
Plan Updates 
