For residents of Oregon and Clark County, Wash.

Optional supplemental dental benefit highlights

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  Basic Option Enhanced Option
Monthly premium  $33.70 $46.50
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 plan with a Medicare and Oregon Health Plan contract. Enrollment in Providence Medicare Advantage Plans depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. The provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B premium.