Regence Health & Life Insurance Company

Dollar-Based Dental | Incentive-Based Dental

Covered Services

Subject to the limitations and conditions described in the policy, the following will be considered covered services under your policy:

Preventive and Diagnostic Services

• Cleanings allowed two per benefit year (includes cleanings and periodontal maintenance
• Oral exams allowed two per benefit year
• Fluoride Treatment allowed two applications per benefit year for members age 17 and under
• X-rays bite wings:  allowed one set limited to twice per benefit year; panoramic and full mouth series:  limited to once every three years
• Sealants allowed for permanent bicuspid and molars for members age 17 and under
• Space Maintainers allowed for members age 11 and under

Restorative Services

• Fillings composite and amalgam
• Emergency treatment for pain relief only
• Oral surgery including surgical extractions, removal of teeth, biopsies and incision and drainage
• General anesthesia or intravenous sedation allowed for surgical extractions of teeth and for members age 6 and under
• Direct pulp capping

Major Services

• Crowns or onlays and related services
• Bridges (fixed partial dentures) limited to one in a 7-year period
• Dentures (full or partial) and related services
• Endosteal Implants and related services implants are limited to 4 per lifetime per member
• Endodontics including root canal treatment, pulpotomy, apicoectomy
• Periodontal Maintenance allowed two per benefit year (includes cleanings and periodontal maintenance)
• Gingivectomy and gingivoplasty allowed once every three years per quadrant
• Osseous and mucogingival surgery allowed once every five years per quadrant
• Debridement allowed once every 3 years
• Scaling and root planing allowed once every two years per quadrant '

Replacement of prosthetics is limited to once in a seven year period from the date of the most recent placement.

Exclusions

Your policy does not cover:

• Additional procedures to construct new crown under existing partial denture framework
• Application of desensitizing resin for cervical and/or root surface
• Bleaching of teeth
• Collection of cultures or specimens
• Connector bar or stress breaker
• Cosmetic/Reconstructive Services and Supplies (certain exceptions apply)
• Diagnostic casts or study models
• Duplicate x-rays
• Endodontic endosseous implants
• Expenses payable to motor vehicle insurance or other liability insurance coverage
• Exfoliate cytology sample collection or brush biopsy
• Fees, Taxes, Interest
• Gold foil restorations
• Hospitalization for dentistry
• Implant maintenance procedures, including:  removal of prosthesis, cleansing of prosthesis and abutments, reinsertion of prosthesis
• Incision and drainage of abscess extraoral soft tissue, complicated or non-complicated
• Indirect pulp capping
• Interim partial or complete dentures
• Labial veneers
• Local anesthesia, sterilization, and supplies billed as separate charges (these procedures are considered inclusive of billed procedures)
• Localized delivery of anti microbial agents via a controlled release vehicle into diseased crevicular tissue per tooth
• Maxillofacial prosthetic procedures
• Military Service Related Conditions:  Any condition resulting from military service in armed forces of any country
• Modification of removable prosthesis following implant surgery
• Nitrous oxide
• Occlusal analysis and adjustments
• Occlusal guards
• Oral hygiene instructions
• Oral/facial photographic images
• Orthodontic services, including craniomandibular orthopedic treatment; procedures for tooth movement, regardless of purpose; correction of malocclusion; preventive orthodontic procedures; and other orthodontic treatment
• Pediatric dentures
• Pin retention in addition to restoration
• Precision attachments
• Prescription drugs, including take home prescription drugs, pre-medications, therapeutic drug injections, or supplies
• Provisional splinting
• Pulp vitality tests
• Radical resection of maxilla or mandible
• Radiographic/surgical implant index
• Removal of nonodontogenic cyst, tumor or lesion
• Replacement of lost, stolen or broken dental appliances
• Self-Help, Non Dental Self-Care, Training, or Instructional Programs
• Services and Supplies provided by Family Member:  Services and supplies provided to a member by an immediate family member
• Surgical procedures for isolation of a tooth with rubber dam
• Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)
• Treatment of simple or compound fractures of the mandible
• Treatment of Temporomandibular Joint Dysfunction
• Unspecified implant procedures
• Work-related injuries