| What you pay each month for dental coverage | Additional $33 per month |
Plan details
Providence Dental Basic
Overview
|
Monthly premium |
$33.00 |
|
Medical Deductible |
$50 In-network |
Important note about these benefits
Below you will find the amount you will pay for in-network and out-of-network services after you have met your calendar year deductible.
Benefits include: Preventive Dental and comprehensive dental
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Monthly Premium*
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Benefits
In-network Out-of-network Deductible* $50 $150 Annual Benefit Maximum $1,000 every calendar year $1,000 every calendar year Diagnostic and Preventative Care* You pay 0% You pay 20% Basic Care* You pay 50% You pay 60% Fillings You pay 30% You pay 60% Major Restorative Care* You pay 50% You pay 60%
*Limitations and exclusions apply. Please refer to your Evidence of Coverage for a complete list of covered dental services.
Please Note: You must pay an extra premium each month for these benefits additional to your Medicare Part B Premium. Also, while you can see any dentist, our in-network providers have agreed to accept a contracted rate for the services they provide. This means that cost-sharing will be lower if you see an in-network provider.
Portland Metro – Clackamas, Multnomah, Washington, and Yamhill Counties in Oregon
Prime + Rx (HMO), Bridge + Rx (HMO-POS), Extra + Rx (HMO) and Choice + Rx (HMO-POS)
Washington Counties – Snohomish, Spokane, Walla Walla, Benton, and Franklin Counties in Washington
Cottonwood + Rx (HMO-POS) and Pine + Rx (HMO)
Western OR & SW WA – Columbia, Lane, Marion, Polk Counties in Oregon, and Clark County in Washington
Timber + Rx (HMO), Bridge + Rx (HMO-POS), Choice + Rx (HMO-POS) and Extra + Rx (HMO)
Central OR – Crook, Deschutes, Hood River, Jefferson, and Wheeler Counties in Oregon
Timber + Rx (HMO), Bridge + Rx (HMO-POS), Choice + Rx (HMO-POS) and Extra + Rx (HMO)
Benton and Linn Counties in Oregon
Extra + Rx (HMO)
Orange County in California
Sycamore + Rx (HMO)
Dual Plus (HMO D-SNP) is available in Clackamas, Multnomah, and Washington Counties in Oregon
Medical only/No Rx – Clackamas, Multnomah, Washington, Yamhill, Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Polk, Wheeler Counties in Oregon and Clark, Benton, Franklin, Snohomish, Spokane, and Walla Walla Counties in Washington
Focus Medical (HMO) is available in Clackamas, Multnomah, Washington, Yamhill, Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Polk, and Wheeler Counties in Oregon and Clark County in Washington
Reverence (HMO-POS) is available in Clackamas, Multnomah, Washington, Yamhill, Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Polk, and Wheeler Counties in Oregon and Clark, Benton, Franklin, Snohomish, Spokane, and Walla Walla Counties in Washington
Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.
You must continue to pay your Medicare Part B premium.