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Regence Health & Life Insurance Company
Dollar-Based Dental | Incentive-Based Dental
| Individual Dental Insurance |
| Incentive 10 Dental Premium Rates |
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Monthly Premium
Per Member |
Quarterly Premium
Per Member |
Dental Only |
Dental & Vision |
Dental Only |
Dental & Vision |
| Under Age 18 |
$33.61 |
$36.49 |
$100.83 |
$109.47 |
| 18 through 64 |
$52.47 |
$57.72 |
$157.41 |
$173.16 |
| 65 and over |
$56.50 |
$63.50 |
$169.50 |
$190.50 |
You may enroll for Dental Only Coverage or Dental with Vision Coverage.
All members must be enrolled for the same coverage and preimum payment schedule
Rates expire 6/31/2011 |
| Individual Incentive 10 Dental Benefits |
$1,500 Annual Max |
| |
|
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$1,250 Annual Max |
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$1,000 Annual Max |
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100/80/50
Coinsurance |
100/80/50
Coinsurance |
$750 Annual Max |
90/70/40
Coinsurance |
80/60/30
Coinsurance |
Year 1 |
Year 2 |
Year 3 |
Year 4 |
| Preventive Services |
80% |
90% |
100% |
100% |
| Restorative Services |
60% |
70% |
80% |
80% |
| Major Dental Services |
30% |
40% |
50% |
50% |
Take care of yourself and watch your benefits grow
Individual Incentive 10 Dental rewards you for receiving routine preventive care. Each year that you visit the dentist for an annual exam and cleaning means greater benefits and fewer
out-of-pocket expenses the next year.
This plan features:
- Six-month waiting period for restorative services and 12-month waiting period for major services
- Deductible waived for exams and cleanings covered under Preventive Services
- $50 deductible for other covered services
- The ability to choose any dentist but save even more by using one of our network providers (find a network provider at regence.com)
- Optional vision rider available (reimburses up to $150 in vision services and/or hardware per member every two years)
Here’s how it works
When you get your teeth cleaned and examined every year, you’re rewarded with greater benefits the next year. Watch your annual benefits increase and your out-of-pocket coinsurance
decrease.
By year four, you can reach a maximum annual benefit of $1,500. And the percentage the plan pays in coinsurance can increase to 100/80/50 by year three. This means we’ll pay
100% of preventive care, such as routine cleanings; 80% of restorative care, such as fillings; and 50% of major dental care like crowns or root canals. |
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, limited to two per benefit year, whether they’re considered cleanings or periodontal maintenance (periodontal maintenance covered under major services)
- 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)
- 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 limited to two per benefit year in lieu of preventive cleaning
- 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 replacements made at least seven years from the most recent placement; limited to once in a seven-year period.
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
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