Plan Features This plan is based and includes preventive and diagnostic services, as well as restorative and major services. Orthodontia is included for all ages. This plan features an Exclusive Provider Organization (EPO) and uses the Willamette Dental Network of dentists and specialists. Out-of-network services are not covered. Dental Plan Options Enliven A Enliven B Enliven C Annual Deductible None None None Annual Maximum None None None Office Visit Copay $10 $15 $20 Page 1 of 5
Member Responsibility Covered Services Enliven A Enliven B Enliven C Preventive and Diagnostic Services Preventive and emergency examinations X-rays Cleanings Fluoride treatment Sealants (per tooth) Head and neck cancer screening Oral hygiene instruction Periodontal charting and evaluation Restorative Services Fillings (amalgam) Crown (porcelain-metal) $150 $250 $350 Prosthodontics Denture (complete upper or lower) $200 $300 $400 Bridge (per tooth) $150 $250 $350 Endodontics and Periodontics Root Canal Therapy Anterior $50 $125 Root Canal Therapy Bicuspid $125 $175 Root Canal Therapy Molar $150 $175 $225 Osseous Surgery (per quadrant) $150 $200 $300 Root Planing (per quadrant) $50 $75 $85 Oral Surgery Routine extraction (single tooth) Surgical extraction $75 $85 $115 Orthodontia Treatment Pre-orthodontia treatment Copay credited towards the comprehensive $150 $150 $150 orthodontic treatment Comprehensive Orthodontia treatment $2,000 $2,500 $2,800 Page 2 of 5
Orthognathic Surgery Orthognathic surgery for treatment of congenital anomalies for members under age 19 Temporomandibular Joint Disorder (TMJ) Miscellaneous Services Local anesthesia Dental lab fees Nitrous oxide $40 $40 $40 Specialty Office Visit $30 $30 $30 Out-of-area emergency care reimbursement Member pays Member pays Member pays Limitations Alternate Services: If alternative services can be used to treat a condition, the service recommended by the Exclusive Provider is covered. Congenital Malformations: Services which are provided to correct congenital or developmental malformations of the teeth and supporting structure will be covered if primarily for the purpose of controlling or elimination infections, controlling or eliminating pain, or restoring function. Endodontic Retreatment: When initial root canal therapy is performed by an Exclusive Provider, the retreatment of such root canal therapy will be covered as part of the initial treatment for the first 24 months. After that time, the applicable ment will apply. When the initial root canal therapy was performed by an out-of-network provider, the retreatment of such root canal therapy by an Exclusive Provider will be subject to the applicable ments. General Anesthesia: Covered with the ments specified in the contract if it is performed in a dental office; provided in conjunction with a covered service; and dentally necessary because the enrollee is under the age of 7, developmentally disabled or physically handicapped. Hospital Setting: The services provided by a dentist in a hospital setting are covered if medically necessary; pre-authorized in writing by an Exclusive Provider; the services provided are the same services that would be provided in a dental office; and applicable ments are paid. Replacements: The replacement of an existing denture, crown, inlay, onlay, or other prosthetic appliance is covered if the appliance is more than 5 years old and replacement is dentally appropriate. TMJ: Benefits for TMJ treatment are provided only if the Exclusive Provider prepares the treatment plan prior to starting treatment and provides the treatment. The repair or replacement of lost, stolen, or broken TMJ appliances is not covered. To be covered, the Covered Services must be: 1) Reasonable and appropriate for the treatment of TMJ; 2) Effective for the control or elimination of pain, infection, disease, difficulty in speaking, or difficulty in chewing or swallowing food, which is caused by TMJ; 3) Recognized as effective, in accordance with the professional standard of care; 4) Not deemed Experimental or Investigational; and 5) Not primarily intended to improve, alter, or enhance appearance. Page 3 of 5
Exclusions Coverage is not provided for any of the following, including direct complications or consequences that arise from: Bridges, Crowns, Dentures or any Prosthetic Device: When the device requires multiple treatment dates or fittings, if the prosthetic item is installed or delivered more than 60 days after termination of coverage. Completion or Delivery of Treatments, Services, or Supplies Initiated Prior to the Effective Date of Coverage, Including the Following: Endodontic services and prosthetic services; an appliance or modification of one, if an impression for it was made prior to the effective date of coverage under this plan; or a crown, bridge, or cast or processed restoration, if the tooth was prepared prior to the effective date of coverage under this plan. Such services are the liability of the Member, prior dental insurance carrier, and/or provider. Conditions Caused by Active Participation in a War or Insurrection: The treatment of any condition caused by or arising out of a member's active participation in a war or insurrection. Condition Incurred In or Aggravated during Performances in the Uniformed Services: The treatment of any member's condition that the Secretary of Veterans Affairs determined to have been incurred in, or aggravated during, performance of service in the uniformed services of the United States. Cosmetic Services and Supplies: Services and supplies for beautification, cosmetic, or aesthetic purposes. Costs For Services and/or Supplies Exceeding Benefit Limits Dental Implants including attachment devices and their maintenance and any dental implant-related service. Endodontic Therapy Completed More than 60 Days After Termination of Coverage Exams or Consultations Needed Solely in Connection With a Service Not Listed as Covered Under this Plan. Expenses Before Coverage Begins or After Coverage Ends Experimental or Investigational Services or Supplies and Related Exams or Consultations Facility Charges: Services and supplies provided in connection with facility services. Fees, Taxes, Interest: Charges for shipping and handling, postage, interest or finance charges that a dentist might bill. Full Mouth Reconstruction or Occlusal Rehabilitation including extensive restoration of the mouth with crowns, and involving the use of crowns, bridges, or implants for the purpose of splinting, altering vertical dimension, restoring occlusions or correcting attrition, abrasion, or erosion. Maxillofacial Prosthetic Services Motor Vehicle Coverage and Other Available Insurance Nightguards Non-Direct Patient Care including appointments scheduled and not kept, charges for preparing or duplicating medical reports/chart notes and visits or consultations that are not in person, including telephone consultations and email exchanges. Personal Comfort Items: Items that are primarily used for personal comfort or convenience, contentment, personal hygiene, aesthetics or other nontherapeutic purpose. Personalized Restorations Prescription and Over-the-Counter Drugs and Pre-medications Replacement of Dental Appliances that are Damaged Due to Abuse, Misuse, or Neglect Replacement of Lost, Missing or Stolen Dental Appliances Replacement of Sound Restorations Riot, Rebellion and Illegal Acts: Services and Supplies for treatment of an illness, injury or condition cause by a member's voluntary participation in a riot, armed invasion, aggression, insurrection or rebellion or sustained by a member arising directly from an act deemed illegal by an officer or a court of law. Self-Help, Self-Care, Training or Instructional Programs Page 4 of 5
Services and Related Exams or Consultations that are not Within the Prescribed Treatment Plan and/or are not Recommended and Approved By The Exclusive Provider Services and Related Exams or Consultation to the Extent they are not Necessary for the Diagnosis, Care, or Treatment of the Condition Involved. Services and Supplies that are not Dentally Necessary Services by any Person Other than a Dentist, Denturist, Hygienist, or Dental Assistant Within the Scope of His or Her License. Services for Treatment of Injuries Sustained while Practicing for or Competing in a Professional Athletic Contest of any Kind. Services for Treatment of Intentionally Self-inflicted Injuries. Services for Which Coverage is Available Under any Federal, State, or Other Governmental Program, Unless Required by Law Services Not Listed as Covered. Services Where There is no Evidence of Pathology, Dysfunction, or Disease Other than Covered Preventive Services. Third-Party Liability: Services and supplies for treatment of illness for which a third party is or may be responsible. Travel and Transportation Expenses Work-Related Conditions: Expenses for services and supplies incurred as a result of any work related injury or illness, including any claims that are resoled related to a dispute claim settlement. The only exception is if an enrolled employee and their dependents are exempt from state or federal worker's compensation law. Page 5 of 5