Customer Service: 800.722.1471
Group Number: 4024205
PREMERA PREFERRED CHOICE: DENTAL OPTIMA - $50/150 DED $2,000 MAXIMUM WITH ORTHODONTIA
| Dental Cost Share | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Individual Deductible | $50 | Shared with In Network |
| Family Deductible | $150 | Shared with In Network |
| Preventive Cost Share | Covered in Full | Covered in Full |
| Basic Cost Share | Deductible, then 20% | Deductible, then 20% |
| Major Cost Share | Deductible, then 50% | Deductible, then 50% |
| Dental Annual Maximum | $2,000 PCY applies to basic and major services | Shared with In Network |
| Office Visit | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Routine Comprehensive / Periodic Oral Exams (2 PCY) | Covered in Full | Covered in Full |
| Problem Focused/Emergency Exam (Unlimited) | Covered in Full | Covered in Full |
| Office Visits, Prof Consults, Perio Evals (2 PCY (Shared with Routine)) | Covered in Full | Covered in Full |
| Preventive Services | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Prophylaxis - Cleaning (2 PCY) | Covered in Full | Covered in Full |
| Fluoride Treatments (2 PCY; under the age of 19) | Covered in Full | Covered in Full |
| Sealants (Under age 19 limited to permanent molars only. Replacements limited to once every 24 consecutive months.) | Covered in Full | Covered in Full |
| Space Maintainers (Members under age 19) | Covered in Full | Covered in Full |
| Diagnostic Imaging | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Bitewings X-rays (1 set (up to 4) PCY) | Covered in Full | Covered in Full |
| Panoramic X-ray or comparable Conebeam view (1 complete series, 1 panoramic or 1 comparable cone beam view in any 36 consecutive months) | Covered in Full | Covered in Full |
| Restorative | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Fillings (1 per surface every 24 consecutive months) | Deductible, then 20% | Deductible, then 20% |
| Installation of Inlays, Onlays and Crowns (1 every 5 calendar years | Deductible, then 20% | Deductible, then 20% |
| Re-cement or Rebond Crowns/lnlay/Onlay (When performed 6 or more months after placement | Deductible, then 20% | Deductible, then 20% |
| Repair Crown/lnlay/Onlay (When performed 6 or more months after placement) | Deductible, then 20% | Deductible, then 20% |
| Endodontics | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Endodontic Therapy- Root Canal (Once per tooth every 24 consecutive months) | Deductible, then 20% | Deductible, then 20% |
| Periodontics | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Periodontal Maintenance (4 PCY) | Deductible, then 20% | Deductible, then 20% |
| Full Mouth Debridement (Once every 36 consecutive months) | Deductible, then 20% | Deductible, then 20% |
| Periodontal Scaling and Root Planing (Once per quadrant every 24 consecutive months) | Deductible, then 20% | Deductible, then 20% |
| Periodontal Surgery (Once per quadrant every 36 consecutive months) | Deductible, then 20% | Deductible, then 20% |
| Periodontal Soft Tissue Grafts (Once per quadrant every 36 consecutive months) | Deductible, then 20% | Deductible, then 20% |
| Prosthodontics (Dentures/Bridges) | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Installation or Replacement of Dentures, Partials and Fixed Bridges (1 every 5 calendar years) | Deductible, then 50% | Deductible, then 50% |
| Repair or Re-cement Bridgework and Dentures (When performed 6 or more months after placement) | Deductible, then 50% | Deductible, then 50% |
| Implant Services | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Implant Crowns/Bridge/Denture (1 every 5 calendar years for surgical implants, implant abutments, and/or implant prosthetics) | Deductible, then 50% | Deductible, then 50% |
| Oral Surgery | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Simple Extractions | Deductible, then 20% | Deductible, then 20% |
| Surgical Extractions (Unlimited) | Deductible, then 20% | Deductible, then 20% |
| Oral Surgery (Unlimited) | Deductible, then 20% | Deductible, then 20% |
| General Services | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Anesthesia - Intravenous or General | Deductible, then 20% | Deductible, then 20% |
| Palliative (Emergency) Treatment of Dental Pain | Deductible, then 20% | Deductible, then 20% |
| Orthodontia | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Orthodontia Cost Share | 100% up to lifetime max | 100% up to lifetime max |
| Lifetime Maximum Benefit | $1,500 Lifetime | $1,500 Lifetime |