Optional Benefits Available
(Optional benefits that are not elected are excluded from coverage)
|
| Regence Evolve Dental Option 1 |
| Deductible per calendar year |
$50 per insured $150 per family (3 times the insured amount) |
| Maximum benefit per calendar year |
$750 per insured |
| Important note: The dental deductible is calculated separately from any other deductible of the policy. |
Understanding your dental benefits |
We will begin to pay benefits for covered services in any calendar year only after your deductible is satisfied unless otherwise specified.
Once you have satisfied any applicable deductible, we pay a percentage of the allowed amount for covered services up to the maximum benefit. When our payment is less than 100%, you pay the remaining
percentage. This is your coinsurance (insured responsibility).
Under the policy, you have the opportunity to qualify for a reward increase and add certain unused portions of the maximum benefit for the current calendar year to the maximum benefit for the
following calendar year. For more information please refer to the policy.
We do not reimburse dentists for charges above the allowed amount. A participating dentist will not charge you for any balances for covered services beyond your deductible and/or coinsurance amount.
Nonparticipating dentists, however, may bill you for any balances over our payment level in addition to any deductible and/or coinsurance amount. You can find a list of providers at our Web site
or by calling Customer Service. |
Covered dental services (per insured) |
Insured responsibility |
Preventive dental services
Bitewing X-rays: 2 per calendar year
Complete intra-oral mouth X-rays: Once in a 3-year period
Cleanings: 2 per calendar year (including periodontal maintenance)
Oral examinations: 2 per calendar year
Panoramic mouth X-rays: Once in a 3-year period
Sealants (permanent bicuspids and molars only): Under 18 years of age
Space maintainers: Under 12 years of age
Topical fluoride application: Under 18 years of age, 2 treatments per calendar year |
0%
deductible waived |
Basic dental services (six-month waiting period)
Endodontic services including root canal treatment, pulpotomy and apicoectomy
Emergency treatment for pain relief
Fillings consisting of composite and amalgam restorations
General dental anesthesia
Uncomplicated and complex oral surgery procedures
Periodontal maintenance: 2 per calendar year (including prophylaxis)
Periodontal debridement: Once in a 3-year period
Periodontal scaling and root planing: Once per quadrant in a 2-year period |
20% |
Major dental services (12-month waiting period)
Bridges: Except no benefits are provided for replacement made fewer than seven-years after placement
Crowns, inlays and onlays: Except no benefits are provided for replacement made fewer than seven-years after placement
Dentures (full and partial): Except no benefits are provided for replacement made fewer than seven-years after placement
Implants (endosteal): 4 per insured lifetime |
50% |
| Regence Evolve Dental Option 2 |
| Deductible per calendar year |
N/A |
| Maximum benefit per calendar |
$750 per insured |
| Important note: You will not be eligible for any dental benefits until the first day of the seventh month of continuous coverage under the policy. |
Understanding your dental benefits |
We pay a percentage of the allowed amount for covered services up to the maximum benefit. When our payment is less than 100%, you pay the remaining percentage.
This is your coinsurance (insured responsibility).
We do not reimburse dentists for charges above the allowed amount. A participating dentist will not charge you for any balances for covered services beyond your deductible and/or coinsurance
amount. Nonparticipating dentists, however, may bill you for any balances over our payment level in addition to any deductible and/or coinsurance amount. You can find a list of providers at our
Web site or by calling Customer Service.
There are no age limits or frequency limits for Dental Option 2. |
Covered dental services (per insured) |
Insured responsibility |
Preventive, basic and major dental services
The first $200 of covered services per calendar year |
0% |
Preventive, basic and major dental services
After the first $200 of covered services each calendar year |
50% |
Asuris NW Health 
