For residents of King and Snohomish counties, Wash.

Optional supplemental dental benefit highlights

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  Basic Option Washington Enhanced Option Washington
Monthly premium  $35.50 $49.60
Plan Benefits In-Network Member Responsibility Out-of-Network Member Responsibility* In-Network Member Responsibility Out-of-Network Member Responsibility*
Office visit copay No copay No copay
Annual deductible1 $50 $150 $50 $150
Annual maximum $1,000 $1,500
Waiting periods None None
Provider network Any licensed dentist2 Any licensed dentist2
Out-of-network reimbursement Maximum allowable charge Maximum allowable charge
Diagnostic and Preventive Services
Oral examinations3 0% 20% 0% 20%
Semiannual teeth cleaning4 0% 20% 0% 20%
Bitewing X-rays5 0% 20% 0% 20%
Full, panoramic and other diagnostic X-rays6 0% 20% 0% 20%
Comprehensive Dental Services
Basic fillings and simple extractions 50% 60% 50% 60%
Dentures7 50% 60% 50% 60%
Crowns and bridges8,9 50% 60% 50% 60%
Oral surgery Not covered 50% 60%
Endodontics (root canals) Not covered 50% 60%
Periodontics Not covered 50% 60%
Prosthodontics, other oral/maxillofacial surgery Not covered 50% 60%

* Important notes: Out-of-network dentists may charge more than the amount allowed by Providence Medicare Advantage Plans. If this happens, they may send members a "balance bill" for the difference between their charged amount and the amount paid by the plan.

1 Deductibles are waived for diagnostic and preventive services.
2 Seeking care from a participating in-network dentist will reduce out-of-pocket costs and prevent a balance bill.
3 Oral examinations – limited to two per calendar year
4 Teeth cleanings (prophylaxis: cleaning and polishing teeth) – limited to two per calendar year
5 Bitewing X-rays – limited to two per calendar year
6 Full, panoramic or other diagnostic X-rays – limited to one per five years
7 $250 lifetime denture benefit
8 Crown/bridge maximum (Basic) – $100 per tooth per year
9 Crown/bridge maximum (Enhanced) – $500 per year

Dental coverage becomes effective the month following receipt of the dental application (on the first); i.e., if a dental application is submitted on Jan. 8, the effective date will be Feb. 1.

Providence Medicare Advantage Plans is an HMO, HMO‐POS and HMO SNP with Medicare and Oregon Health Plan contracts. Enrollment in Providence Medicare Advantage Plans depends on contract renewal.

Out-of-network/non-contracted providers are under no obligation to treat Providence Medicare Advantage Plan members, except in emergency situations. Please call customer service or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

This information is not a complete description of benefits. Call 1-800-603-2340 TTY: 711 for more information.