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Verify CDA Insurance LLC
Individual EPO Dental summary of benefits
Annual maximum None
Deductible None
Visit charge $35 per visit
BENEFIT WAITING PERIODS
Diagnostic and preventive services None
Restorative services None
Major dental services 6 months
Orthodontic services 6 months
BRIEF SUMMARY OF COVERED SERVICES AND SERVICE COPAYS
DIAGNOSTIC AND PREVENTIVE SERVICES
Routine and emergency oral evaluations Covered with the office visit copay
Teeth cleanings (adult and child)
X-rays
Fluoride treatment
Sealants (per tooth)
Head and neck cancer screening
Oral hygiene instruction
Periodontal charting
Periodontal evaluation
RESTORATIVE DENTISTRY (Member is also responsible for office visit copay)
Fillings, amalgam (per tooth) $45 copay
MAJOR AND OTHER SERVICES (Member is also responsible for office visit copay)
Porcelain-metal crown $500 copay
Out-of-area emergency care reimbursement (50 miles or more from a WDG office) You pay charges in excess of $100
Complete upper or lower denture $600 copay
Bridge (per tooth) $500 copay
Routine extraction (single tooth) $75 copay
Surgical extraction $190 copay
ORTHODONTIA (Member is also responsible for office visit copay)
Pre-orthodontic service $150 copay; applies toward comprehensive orthodontic copayment if patient accepts treatment plan
Comprehensive orthodontia $3,000 copay per case
OPTIONAL VISION BENEFIT RIDER (Administered directly through LifeMap)
You may elect to add vision benefits to your dental coverage. The vision benefit reimburses up to $150 per member for vision exams and/or hardware, including LASIK, every 24 months.
  • This is a brief summary of benefits. For full coverage provisions, including a description of limitations and exclusions, refer to your policy. Underwritten by LifeMap Assurance Company with dental services provided by Willamette Dental Group, P.C.
  • There is a six-month waiting period for all orthodontic services and some major services, including permanent crowns and some prosthetic services and supplies.
  • Please note: If you cancel Individual Exclusive Provider Organization Dental, there is a 12-month waiting period before you can re-enroll.
  • The benefits of this plan are not subject to any coordination of benefits provision.

Exclusions

These services and supplies are not covered:

  • Aesthetic dental procedures and complications arising out of such services
  • Benefits not stated
  • Charges by any person other than a participating provider except as otherwise indicated in the policy
  • Cosmetic/reconstructive services and supplies (certain exceptions apply)
  • Coverage available under any federal, state, or other governmental program, except where required by law
  • Dental implants
  • Dental services that are not Necessary Dental Services as defined in the policy
  • Diagnostic casts or study models
  • Endodontics, bridges, crowns, and other prosthetic devices or services if treatment was started or ordered prior to the member’s effective date or delivered more than 60 days after the member’s coverage under this policy has terminated
  • Excision of a tumor; biopsy of soft or hard tissue; removal of a cyst
  • Experimental/investigational treatments, procedures, services and supplies
  • Extraction of permanent teeth for tooth guidance procedures; procedures for tooth movement
  • Full-mouth reconstruction
  • General Anesthesia, except as specified in the Schedule of Covered Services, Copays and Coinsurance.
  • Habit-breaking or stress-breaking appliances
  • Hospitalization for dentistry
  • Maxillofacial prosthetic services
  • Medication and supply charges
  • Military service-related conditions
  • Motor vehicle coverage and other insurance liability
  • Non-direct patient care
  • Occlusal treatment including complete occlusal adjustments and occlusal guards
  • Personalized restorations, precision attachments, and special techniques
  • Repair or replacement of lost, stolen, or broken items
  • Replacement of sound restorations
  • Services and supplies for treatment of an illness or injury caused by riot, rebellion, war and illegal acts
  • Services for accidental injury to natural teeth that are provided more than 12 months after the date of the accident
  • Services or supplies and related exams or consultations that are not within the prescribed treatment plan and/or are not recommended and approved a participating provider
  • Services or supplies where there is no evidence of pathology, dysfunction, or disease other than covered preventive services
  • Temporomandibular Joint (TMJ) dysfunction treatment
  • Transseptal fiberotomy
  • Treatment started prior to the member’s effective date under this policy or completed after this policy terminates
  • Work-related injuries

This is a brief summary of benefits. For full coverage provisions, including a description of limitations and exclusions, refer to your policy.

There is a six-month waiting period for all Orthodontic Services and some Major Services, including Permanent Crowns and some Prosthetic Services and Supplies. Please note: If you cancel Individual Managed Care Dental, there is a 12-month waiting period before you can re-enroll. The benefits of this plan are not subject to any coordination of benefits provision.