Willamette Dental Washington Rates
  Monthly Quarterly Semi-Annually Annually
Member Only $43.75 $131.25 $262.50 $525.00
Member & Spouse or Partner $87.50 $262.50 $525.00 $1050.00
Member & Children $78.75 $236.25 $472.50 $975.00
Member, Spouse or Partner & Children $122.50 $367.50 $735.00 $1470.00

Premium Rates for Payments by EFT. Add $5.00 to the rates above if you want to pay by check.

Rates are valid for 12 months from effective date of policy.


Willamette Dental Benefit Summary
Annual maximum None
Deductible None
Benefit Copayment
General Office Visit $25 per visit
Specialist Office Visit $30 per visit
Emergency Office Visit $50 per visit
Dental Exams and X-rays $0
Teeth Cleaning $0
Fluoride Treatment $15
Sealants per Tooth $15
Filling - Amalgam $25
Permanent Crown1 $400
Complete Denture1 $500
Bridge (per tooth)1 $400
Root Canal Therapy
– Anterior Tooth
$200
Root Canal Therapy
– Bicuspid Tooth
$225
Root Canal Therapy
– Molar
$250
Osseous Surgery Per Quadrant $300
Root Planing Per Quadrant $75
Routine Extraction $50
Surgical Extraction $100
Pre-Orthodontic Service2 3 $150
Comprehensive Orthodontia2 3 $2,800
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.
  1. Benefit available after a twelve month waiting period.
  2. Applies toward comprehensive orthodontic copayment if patient accepts treatment plan.
  3. Benefit available after a six month waiting period

Exclusions

These services and supplies are not covered:

  • Bridges, crowns, dentures or any prosthetic devices requiring multiple treatment dates or fittings if the prosthetic item is installed or delivered more than 60 days after termination of coverage.
  • The completion or delivery of treatments, services, or supplies initiated prior to the effective date of coverage.
  • Dental implants.
  • Endodontic services, prosthetic services, and implants provided prior to the effective date of coverage.
  • Endodontic therapy completed more than 60 days after termination of coverage.
  • Experimental or investigational services or supplies.
  • Exams or consultations needed solely in connection with a service or supply not listed as covered.
  • Full mouth reconstruction.
  • General anesthesia, including conscious, intravenous and moderate sedation.
  • Hospital care or other care outside of a dental office or facility fees.
  • Maxillofacial prosthetic services.
  • Nightguards.
  • Orthognathic surgery.
  • Personalized restorations.
  • Plastic, reconstructive, or cosmetic surgery.
  • Prescription and over-the-counter drugs and pre-medications.
  • Replacement of lost, missing, stolen or damaged dental appliances.
  • Replacement of sound restorations.
  • Services or supplies and related exams or consultations that are not within the prescribed treatment plan, are not recommended and approved by a Participating Dentist or are not necessary.
  • Services or supplies by any person other than a licensed dentist, denturist, hygienist, or dental assistant.
  • Services or supplies for the diagnosis or treatment of temporomandibular joint disorders.
  • Services or supplies for the treatment of an occupational injury or disease.
  • Services or supplies for treatment of injuries sustained while practicing for or competing in a professional athletic contest of any kind.
  • Services or supplies for treatment of intentionally self-inflicted injuries.
  • Services or supplies for which coverage is available under any federal, state, or other governmental program.
  • Services or supplies that are not listed as covered in the policy.
  • Services or supplies where there is no evidence of pathology, dysfunction, or disease.

This is a brief summary of benefits. For full coverage provisions, including a description of limitations and exclusions, refer to your policy.