Willamette Dental Washington Rates
  Monthly
Member Only $48.45
Member & Spouse or Partner $96.91
Member & Children $87.22
Member, Spouse or Partner & Children $135.67

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

*Rates are valid through December 31, 2014 and 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.