Beaverton School District 2018 Purple Dental Plan

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1 Beaverton School District 2018 Purple Dental Plan In-Network Out-of-Network Dentist Dentist Members Pay Members Pay Annual Costs Deductible Per Member $25 Per Plan Year Deductible Per Family Per Plan Year Benefit Maximum Per Member Per Plan Year Preventive Dental Services Cleanings and Examinations X-rays Other Preventive Dental Services Basic Dental Services Periodontal Services Endodontic Services (Fillings, Extractions) Emergency and Other Basic Dental Services $75 $1,500 35% / 25% / 15% / 5% coinsurance Your coinsurance starts at 35% and decreases by 10% each successive plan year only if you receive covered preventive care services. If you fail to receive any covered dental services in the previous year, your coinsurance remains at the same percentage level as the previous year. Your coinsurance will increase by 10% each successive plan year if you do not receive any covered dental service but will not go over the base of 35%. Deductible does not apply. 35% / 25% / 15% / 5% coinsurance Your coinsurance starts at 35% and decreases by 10% each successive plan year only if you receive covered preventive care services. If you fail to receive any covered dental services in the previous year, your coinsurance remains at the same percentage level as the previous year. Your coinsurance will increase by 10% each successive plan year if you do not receive any covered dental service but will not go over the base of 35%. Deductible does not apply. Benefit and Age Limitations Limited to individuals under age 23 for sealants (permanent bicuspids and molars only) Limited to individuals under age 23 for topical fluoride application. Fillings benefit pays to the least costly amalgam fees. Coverage includes space maintainers for any individual. Major Dental Services Bridges 55% coinsurance 55% coinsurance Limited to replacement bridges Crowns, Inlays, and Onlays once per 5 years after placement. 55% coinsurance 55% coinsurance Limited to replacement crowns, inlays or onlays once per tooth, 5 years after placement. Dentures (Full and Partial) 55% coinsurance 55% coinsurance Limited to replacement dentures 5 years after placement OR Fully Insured L Expressions Dental SBS

2 Limited to 1 denture reline every 24 months. Implants (endosteal) 55% coinsurance 55% coinsurance Orthodontia Orthodontia Services 50% coinsurance, deductible does not apply 50% coinsurance, deductible does not apply Limited to $1,000 per individual / lifetime maximum benefit. General Exclusions - For additional detail please refer to your benefit booklet Aesthetic Dental Procedures Cosmetic/Reconstructive Services and Supplies, except for congenital anomalies Duplicate X-Rays Facility Charges Gold-foil restorations Implants (non-endosteal) Nitrous Oxide Occlusal treatment Orthognathic surgery Temporomandibular joint (TMJ) Dysfunction Treatment Tooth transplantation Veneers Please note: This document is provided for informational purposes only, and is intended as a quick reference of Regence Plan Benefits. It is not considered a Summary of Benefits and Coverage (SBC), and should not be regarded as a replacement for the SBC. For cost and further details of the coverage, including exclusions, any reduction or limitations and the terms under which the policy may be continued in force, contact your producer or Regence. Regence makes no warranties or representations regarding compliance with applicable federal, state, or local laws, or the accuracy of the benefit summary. P.O. Box 1271, M/S C7A Portland, OR Or contact Customer Service: 1(888) Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association 2018 OR Fully Insured L Expressions Dental SBS

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