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Index | Dental Plan | Exclusions
& Limitations | Locate
Providers | Application
Plan Benefits:
Diamond 15 | Pearl 25 HMO
| Emerald 40 | Garnet 50 | Topaz | Crystal 80 HDHP | Crystal 100 HDHP
Plan Rates:
Diamond 15 | Pearl 25 HMO | Emerald 40 | Garnet 50 | Topaz | Crystal 80 HDHP | Crystal 100 HDHP
Oregon Dental Insurance > HealthNet of Oregon > Dental Coverage Rates & Benefits
To be eligible, these optional benefits must be purchased along with a HealthNet Health Insurance
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Dental & Vision Rider Rates
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| All Ages |
Subscriber
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Subscriber & Spouse
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Subscriber & Child(ren)
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Subscriber & Family
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$30.00
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$60.00
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$60.00
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$90.00
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| Rates shown below are for residents of all Oregon counties | ||||
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Dental Net Benefit Schedule
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| Deductible per Member |
$50 per Calendar Year
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| Maximum family deductible |
$150 per Calendar Year
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| Maximum Benefit All services combined |
$1,000 per Member per Calendar Year
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| Waiting Periods | ||
| Part A Services |
None
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| Part B Services |
None
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| Part C Services |
12 Months
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| Covered Services |
Plan Pays*
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Benefit Limitations
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Part A Services: Diagnostic and Preventive Services
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| Periodic Oral Examinations |
80%
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2 times per consecutive 12 months
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| Dental Prophylaxis (cleaning) |
80%
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2 times per consecutive 12 months
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| Bitewing X-Rays |
80%
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1 series of films per Calendar Year
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| Full Mouth or Panoramic X-Rays |
80%
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1 time per consecutive 36 months
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| Extraoral X-Rays |
80%
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2 films per Calendar Year
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| Fluoride Treatments |
80%
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Under age 16, 2 times per Calendar Year
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| Sealants |
80%
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Under age 16, once per first or second permanent molar
every 5 years
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Part B Services: Basic Services
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| Space Maintainers |
80%
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Under age 16, once per lifetime
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| Amalgam Restorations (fillings) |
80%
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1 restoration per surface every 3 years
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| Composite Resin Restorations (fillings) |
80%
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1 restoration per surface every 3 years
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| Sedative Filling |
80%
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Covered as a separate benefit only if no services other
than exam and x-rays were performed on the same tooth during the visit.
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| Palliative Treatment (relief of pain) |
80%
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Covered as a separate benefit only if no services other
than exam and x-rays were performed on the same tooth during the visit.
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| General Anesthesia |
80%
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Covered only for patients under age 7 or who are physically
or developmentally disabled
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| Occlusal Guards |
80%
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For habitual grinding, 1 per 60 consecutive months
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| Diagnostic Casts |
80%
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1 time per 24 consecutive months
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| Pin Retention |
80%
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2 pins per tooth, not covered in addition to cast restoration
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Part C Services: Major Services
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| Root Canal Treatment |
50%
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| Post and Core |
50%
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Covered only for a tooth that has had root canal therapy
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| Scaling and Root Planing |
50%
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1 time per quadrant per consecutive 24 months
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| Periodontal Surgery |
50%
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1 time per consecutive 36 months per surgical area
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| Osseous Grafts |
50%
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1 time per consecutive 36 mohths per quadrant or surgical
site
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| Periodontal Maintenance |
50%
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2 times per consecutive 12 months following active and
adjunctive periodontal therapy within the prior 24 months, exclusive of
gross debridement
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| Mouth Debridement |
50%
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1 time per consecutive 36 months
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| Simple Extraction |
50%
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| Surgical Extraction, including impacted wisdom teeth |
50%
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| Crowns, Inlays, Onlays |
50%
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1 time per tooth per consecutive 60 months
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| Fixed Bridges |
50%
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1 time per tooth per consecutive 60 months. Alternate
benefits for a partial denture may be applied
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| Full Dentures |
50%
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1 time per consecutive 60 months. No allowance for overdentures
or customized dentures.
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| Partial Dentures |
50%
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1 time per consecutive 60 months. No allowance for precision
or semi-precision attachments.
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| Recement Crowns, Inlays, Onlays, Bridges |
50%
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1 time per 6 months per restoration
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| Relining and Rebasing Dentures |
50%
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1 time per consecutive 12 months, and more than 6 months
after initial insertions
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| Repairs to Bridges, Full Dentures, Partial Dentures |
50%
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Repairs and adjustments more than 12 months after initial
insertion
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Access: With this Health Net of Oregon Dental Plan, you can see
any licensed dentist and receive Benefits for covered services. You
do not have to go to a specific network of Providers. However, if you
do see a Participating Provider, charges for covered services will be
limited to Health Net’s contracted amount with the Provider. The deductible is the amount you pay before your plan begins paying Benefits
for covered services. This document presents general information only. Refer to the plan contract for complete details, limitations and exclusions. |
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