Individual Dental Copay Plans

Adding a LifeWise dental plan to your health plan means you’ll have complete high-quality coverage. Since research indicates that good oral health is key to your overall health, there’s really no reason not to enroll. Especially when you consider our new dental plans offer predictable costs on over 200 dental procedures. With a strong and growing provider network, you’re sure to find a preferred dentist conveniently located near you.*

LifeWise offers plans for adults (age 19 and older) with a range of monthly rates, deductibles, and member cost share options. Our dental plans offer predictable costs on more than 200 dental procedures, including common preventive, diagnostic, basic, and major dental services. With a strong and growing provider network, you’re sure to find a preferred dentist conveniently located near you.

LifeWise Dental plans feature:

  • Choice of deductible - choose either a $50 or $75 annual deductible plan.
  • Predictability of costs - you’ll pay one set copay for each of the over 200 covered services
  • Easy plan administration - one application, one bill, one ID card, one customer service line and one resource rich website.
  • Wide range of coverage - you’ll be covered for the most commonly used preventive, minor and major dental services.
  • Choice of providers - use our “find a doctor” tool to find a dentist in your area. Choose “Dental-Individual Copay Plans” from the Network drop-down list.
Individual Adult Dental Copay Plan Benefits and Deductibles
Annual Deductible PCY Individual: $50 / $75
Family: $150 / $225
Benefit Maximum per person, PCY $1,000
DIAGNOSTIC and PREVENTIVE Deductible* waived, copay only
Oral Exams Limited to 2 PCY $0
Bitewing X-rays $0
Cleanings Limited to 2 PCY $20
Fluoride Treatments Limited to 2 applications PCY for members under the age of 20 $0
BASIC Deductible*, then copay
Emergency Palliative Treatment $5
Fillings One surface, amalgam; primary or permanent; limited to once per tooth surface every 24 consecutive months $30
Periodontal Maintenance Limited to 4 visits per calendar year $40
Recementing of Crowns $20
Crown Repair $25
Simple Extractions Erupted tooth or exposed root $30
Space Maintainers Fixed, unilateral; for members under age 20 $65
MAJOR (12-month waiting period) Deductible*, then copay
Crowns, Onlays, Dentures, Partials, and Bridges Copays vary based on the tooth location and type of material used. Visit lifewiseor.com/dental for a complete list of covered services and copays for more information.
Fillings One surface, amalgam; primary or permanent; limited to once per tooth surface every 24 consecutive months $30
Endodontic (Root Canal) Treatment Limited to 2 per arch when performed in conjunction with overdentures Anterior tooth: $385
Molar tooth: $515
Bicuspid tooth: $435
General Anesthesia For first 30 minutes; limited to covered dental procedures at a dental care provider’s office when dentally necessary $165
Oral Surgery For surgical removal of residual tooth roots $115
Periodontal Scaling One to three teeth; limited to once per quadrant every 2 calendar years $60
Periodontal Surgery Osseous surgery; one to three contiguous teeth covered in the same quadrant once every 3 calendar years $350

Effective January 1, 2014

PCY = per calendar year

* If you visit a non-preferred provider, you’ll pay the non-preferred coinsurance based on the type of service provided. You’ll also be responsible for amounts charged above the allowable charge. Visit lifewiseor.com/dental for details of non-preferred provider coverage.

Lifewise Optional Dental Rates
Age Band $50 Deductible $75 Deductible
19-25 $35.00 $29.60
26-34 $37.60 $31.70
35-44 $39.80 $33.50
45-49 $45.60 $38.40
50-54 $50.70 $42.80
55-59 $54.60 $46.10
60-64 $61.30 $51.70
65+ $68.10 $57.40