LifeMap Exclusive Provider Organization 16

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.

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