Oregon Medical Insurance > Regence BlueCross BlueShield of Oregon > Managed-Care Dental Rates & Benefits

• This is a brief summary of benefits. For full coverage provisions, including a description of limitations and exclusions, refer to your policy.
• There is a six-month waiting period for orthodontia and major services, including crowns, endodontics, periodontics, prosthetics and oral surgery.
• Please note: If you cancel Individual Managed Care Dental, there is a 12-month waiting period before you can re-enroll.
• The benefits of this plan are not subject to any coordination of benefits provision.

Exclusions

These services and supplies are not covered:

• Aesthetic dental procedures and complications arising out of such services
• Benefits not stated
• Charges by any person other than a participating provider except as otherwise indicated in the policy
• Cosmetic/reconstructive services and supplies (certain exceptions apply)
• Coverage available under any federal, state, or other governmental program, except where required by law
• Diagnostic casts or study models
• Endodontics, bridges, crowns, and other prosthetic devices or services if treatment was started or ordered prior to the member’s effective date or delivered more than 60 days after the member’s coverage under this policy has terminated
• Excision of a tumor; biopsy of soft or hard tissue; removal of a cyst
• Experimental/investigational treatments, procedures, services and supplies
• Extraction of permanent teeth for tooth guidance procedures; procedures for tooth movement
• Full-mouth reconstruction
• General Anesthesia, except as specified in the Schedule of Covered Services, Copays and Coinsurance.
• Habit-breaking or stress-breaking appliances
• Hospitalization for dentistry
• Maxillofacial prosthetic services
• Medication and supply charges
• Military service-related conditions
• Motor vehicle coverage and other insurance liability
• Non-direct patient care
• Occlusal treatment including complete occlusal adjustments and occlusal guards
• Personalized restorations, precision attachments, and special techniques
• Repair or replacement of lost, stolen, or broken items
• Replacement of sound restorations
• Services and supplies for treatment of an illness or injury caused by riot, rebellion, war and illegal acts
• Services for accidental injury to natural teeth that are provided more than 12 months after the date of the accident
• Services or supplies and related exams or consultations that are not within the prescribed treatment plan and/or are not recommended and approved a participating provider
• Temporomandibular Joint (TMJ) dysfunction treatment
• Transseptal fiberotomy
• Treatment started prior to the member’s effective date under this policy or completed after this policy terminates
• Work-related injuries

This is a brief summary of the individual dental plans available from Regence Life and Health Insurance Company. For full coverage provisions, including a complete list of Covered Services and Exclusions, please refer to your policy.