|Managed Care Dental summary of benefits|
|Visit charge||$15 per visit|
|SUMMARY OF COVERED SERVICES AND SERVICE COPAYS||WHAT YOU PAY (Please note: Service copays and coinsurance are charged per service)|
|SERVICES COVERED WITH NO SERVICE COPAY|
|Routine and emergency oral evaluations||$15 visit charge|
|SERVICES PROVIDED WITH ADDITIONAL $10 SERVICE COPAY|
|Nitrous oxide (per visit)||$15 visit charge plus $10 service copay|
|SERVICES PROVIDED WITH ADDITIONAL $20 SERVICE COPAY|
|Panoramic X-rays||$15 visit charge plus $20 service copay|
|Sealant (per tooth)|
|SERVICES PROVIDED WITH ADDITIONAL $30 SERVICE COPAY|
|Filings - amalgam, anterior composite, or posterior primary composite (per tooth)||$15 visit charge plus $30 service copay|
|Simple denture/partial repairs|
|Pre-orthodontic service||Pre-orthodontic service copay will be deducted from the comprehensive orthodontic copay if the member elects orthodontic treatment|
|Initial orthodontic exam||$15 visit charge plus $25 service copay|
|Study models and X-rays||$15 visit charge plus $125 service copay|
|Comprehensive orthodontia||$2,600 service copay per case|
|Out-of-area emergency care (50 miles or more from a WDG office)||You pay applicable service copays and fees. Willamette Dental covers up to $100 of covered services.|
|Additional services covered by this policy (Please see the Schedule of Covered Services, Copays and Coinsurance for a complete list.)||$15 visit charge plus 80% coinsurance|
|OPTIONAL VISION BENEFIT RIDER|
|You may elect to add vision benefits to with your dental coverage. The vision benefit reimburses up to $150 per member for vision exams and/or hardware 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.
- There is a six-month waiting period for orthodontia and major services, including crowns, endodontics, periodontics, prosthetics and oral surgery.
- 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.
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
- 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
- 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.