With Managed Care Dental, you get a variety of services covered at predictable copays. You’ll work with a participating provider to maintain your oral health and enhance your overall health through routine exams and other preventive care.
| Individual Managed Care Dental Summary of Benefits | |
| Annual maximum | None |
| Deductible | None |
| 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 |
| Teeth cleanings for children under age 13 | $15 visit charge |
| Bitewing X-rays | $15 visit charge |
| Periodontal screenings | $15 visit charge |
| Periodontal maintenance | $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 |
| After-hours visit | $15 visit charge plus $20 service copay |
| SERVICES PROVIDED WITH ADDITIONAL $30 SERVICE COPAY | |
| Teeth cleanings for members age 13 and over | $15 visit charge plus $30 service copay |
| Filings – amalgam, anterior composite, or posterior primary composite (per tooth) | $15 visit charge plus $30 service copay |
| Simple denture/partial repairs | $15 visit charge plus $30 service copay |
| Simple extractions | $15 visit charge plus $30 service copay |
| ORTHODONTIA | |
| 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 |
| OTHER | |
| Out-of-area emergency care (50 miles or more from a WDG office) | You pay applicable service copays and fees. Willamette Dental reimburses 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.) | |
| OPTIONAL VISION BENEFIT RIDER | |
| 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 every 24 months. | |
| OPTIONAL VISION BENEFIT RIDER | |
| 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 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 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.
Services must be rendered by a participating provider. For the purposes of this plan, participating providers are Willamette Dental Group, and the providers who are employed by or are under contract with Willamette Dental Group, or any of its affiliates. Participating provider offices are conveniently located throughout the area. You can find addresses and directions at WillametteDental.com.
Exclusions
Click here for Individual Managed Care Dental Policy Exclusions.