Cascade Mountains
CITIES: Brightwood, Camp Sherman, Cascade Locks, Cascadia, Chemult, Chiloquin, Crescent, Crescent Lake, Detroit, Diamond Lake, Drew, Estacada, Fort Klamath, Gates, Gilchrist, Government Camp, Idanha, Klamath Agency, La Pine, Lakeview, McKenzie Bridge, Mill City, North Umpqua, Oakridge, Prospect, Rhododendron, Sandy, Sisters, Sunriver, Warm Springs, Welches, Westfir, Zigzag
AREAS: Crater Lake National Park, Deshutes National Forest, Fremont National Forest, Mount Hood National Forest, Rogue River National Forest, The Three Sisters, Umpqua National Forest, Willamette National Forest, Winema National Forest

Central Oregon
CITIES: Antelope, Arlington, Bend, Brothers, Condon, Culver, Dufur, Fossil, Grass Valley, Hampton, Lonerock, Madras, Maupin, Metolius, Mitchell, Moro, Mosier, Paulina, Post, Prineville, Redmond, Rowena, Rufus, Shaniko, Spray, The Dalles, Wasco

Northeast Oregon
CITIES: Adams, Arlington, Athena, Baker City, Boardman, Canyon City, Condon, Cove, Dayville, Echo, Elgin, Enterprise, Fossil, Greenhorn, Haines, Halfway, Heppner, Hermiston, Huntington, Imbler, Imnaha, Irrigon, Island City, John Day, Joseph, La Grande, Lexington, Long Creek, Lostine, Medical Springs, Milton-Freewater, Monument, Mt Vernon, North Powder, Oxbow, Pendleton, Pilot Rock, Prairie City, Richland, Seneca, Summerville, Sumpter, Ukiah, Umatilla, Union, Unity, Wallowa, Weston
AREAS: Hell's Canyon

Oregon Coast
North Coast
Astoria, Bay City, Beaver, Cannon Beach, Garibaldi, Gearhart, Hebo, Nehalem, Manzanita, Neahkahnie, Oceanside, Pacific City, Rockaway Beach, Seaside, Tillamook, Warrenton, Wheeler
Central Coast
Depoe Bay, Dunes City, Florence, Gleneden Beach, Lincoln City, Mapleton, Newport, Otter Rock, Reedsport, Seal Rock, Siletz, Toledo, Waldport, Winchester Bay, Yachats
South Coast
Agness, Bandon, Brookings, Charleston, Coos Bay, Coquille, Gold Beach, Lakeside, Myrtle Point, North Bend, Port Orford, Powers, Wedderburn

Portland and Vicinity
Banks, Barlow, Beaverton, Camas, Canby, Clackamas, Clatskanie, Columbia City, Cornelius, Forest Grove, Gaston, Gresham, Happy Valley, Hillsboro, Lake Oswego, Marquam, Milwaukie, Molalla, North Plains, Oregon City, Portland, Rainier, Sandy, Scappoose, St. Helens, Tigard, Troutdale, Tualatin, Vernonia, West Linn, Wilsonville

Southeast Oregon
Adel, Adrian, Burns, Diamond, Drewsey, Frenchglen, Hines, Jordan Valley, Juntura, Lakeview, Nyssa, Ontario, Plush, Vale

Southern Oregon
CITIES: Ashland, Butte Falls, Cave Junction, Canyonville, Central Point, Dillard, Drain, Eagle Point, Elkton, Glendale, Glide, Gold Hill, Grants Pass, Jacksonville, Klamath Falls, Malin, Medford, Merlin, Myrtle Creek, Oakland, Phoenix, Prospect, Riddle, Rouge River, Roseburg, Shady Cove, Sutherlin, Talent, Umpqua, White City, Winchester, Winston, Wolf Creek, Yoncalla
AREAS: Applegate Valley, Illinois Valley

Willamette Valley
Albany, Alsea, Amity, Aumsville, Aurora, Brooks, Brownsville, Canby, Canyonville, Carlton, Corvallis, Coburg, Cottage Grove, Creswell, Culp Creek, Dallas, Dayton, Detroit, Donald, Dundee, Eugene, Falls City, Gates, Gervais, Halsey, Harrisburg, Independence, Jefferson, Junction City, Keizer, Lebanon, Lowell, Lyons, McMinnville, Mill City, Millersburg, Mt.Angel, Molalla, Monmouth, Newberg, Oakridge, Oregon City, Philomath, Salem, Scio, Scott Mills, Sheridan, Silverton, Sodaville, Springfield, Stayton, St. Paul, Sublimity, Sweet Home, Tangerit, Turner, Veneta, Walterville, Waterloo, Willamina, Woodburn, Yamhill

Dental Plans

Affordable, Low Cost Dental Plans

Talk with a real person 9:00 am to 9:00 pm 503-922-2903 877-786-8347

This product is currently only available to residents in Oregon.

Incentive and Dollar-Based Dental Insurance
for Individuals and Families in Oregon

Individual Dental Insurance
Indivdual Dental insurance for individuals or families. Pay by credit card, or print your pre-filled application and mail it in with your check. To begin, please enter your zip code and click on the Get More Info button.	Zip Code:

Incentive Plan Description and Enrollment Form (PDF)

Individual Incentive Dental offers immediate access to quality, affordable dental care. The plan is procedure-based, but unlike traditional dental plans you are rewarded for receiving routine preventive care. Each year that you visit the dentist for a checkup and cleaning, means greater benefits and less out-of-pocket expenses the next year.

Dollar-Based Plan Description and Enrollment Form (PDF)

Individual Dollar-Based Dental puts you in control of your dental health dollars. The plan is dollar-based -- a unique departure from traditional procedure-based coverage. Imagine spending your benefit dollars almost any way you choose, on care that's important to you and your family. Each year you decide to include an exam and cleaning, you are rewarded with a benefit increase the following year.

Individual Dental Insurance

Careington Affordable, Low Cost Dental

Find a Provider Near You

$11.95 Dental Vision Plan

Fee Schedule 505

"Recommended Dentist"

Dr. Dan Thompson 971-236-9356

17704 SW Jean Way, Ste 105, Lake Oswego, OR 97035

Additional Information on Companies: Return to Top

Careington

Receive quality dental and vision at affordable rates

Dental work and eye exams are an important – and often expensive – part of taking care of your health. With the Dental and Vision program, you can reduce your overall health care costs by taking advantage of deep discounts on dental and vision care.

Dental Care - CAREINGTON International

Save 20% to 60% on most dental procedures including routine oral exams, unlimited cleanings, and major work such as dentures, root canals, and crowns at over 54,000 participating dentists.

No limits on use, everyone is accepted
No waiting or adminstrative forms to file
Cosmetic dentistry included such as bleaching, bonding, and veneers

Vision care- EyeMed Vision

Members save 15% to 45% off the retail price of eyewear, exams, eyeglasses and contact lenses from more than 40,000 providers nationwide including access to independent Optometrists, Ophthalmologists, and Opticians and leading optical retailers such as Pearle Vision®, LensCrafters®, Sears Optical® and Target Optical®.

Replacement contact Lenses by mail
15% off the retail price or 5% off the promotional price of LASIK or PRK procedures



	Dental

	Vision Care

	Pharmacy

	Chiropractic

	Alternative Health

	Vitamins

	Hearing Aids

	Physicians

	Hospitals

	24-Hour Nurse line

	LASIK Vision Correction

	Teeth Whitening

	Hydrabrush^® Coupon

	Mail Order Pharmacy

	Online Drug Store

	Diabetic Supplies

	Member's Healthy Habits Web Site

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CAREINGTON is one of the largest, most comprehensive, privately held discount health care companies in America. Through esteemed networks of providers, ancillary products and specialty services covering the full continuum of care, CAREINGTON offers innovative programs to compliment traditional health insurance and provide substantial savings for under insured and uninsured individuals.

Our Mission

Core Purpose

To improve the health and well-being of individuals.

Core Value

Everything we do will be driven by:

Systematic improvement in the quality of dental care

Respect for the patient-provider relationship

Commitment to leading-edge innovation

Compassion for people

Honesty and integrity

Business Goal

To be the recognized leader in designing, organizing and managing health care services in communities across the United States. As a company, we will achieve this through a customer-driven focus that emphasizes:

Quality. We will improve the quality of care by helping to identify the most effective treatments, based on scientific evidence, and sharing this information with providers, customers, members and the public.

Value. We will deliver more value for the dollar to our customers than our competitors.

Service. We will strive to deliver unparalleled service to our members.

Efficiency. We will manage dental health care resources efficiently and be disciplined about controlling costs.

Access. We will provide equitable and appropriate access to care and deliver products that provide choice for consumers.

Education. We want members to play an active role in managing their own dental health and will provide them with information and support that will help them lead healthier lives.

Accountability. We will provide objective information that will allow customers, members, and dental care providers to evaluate our performance.

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Guiding Principles

As employees, we will:

Look beyond the horizon. We will not be content with the status quo. We will continue to explore new opportunities, propose new ideas, and search for better ways to meet the needs of our customers.

Work together. No one has all the answers. We will treat each other with respect and solicit advice and assistance from our co-workers. The best work comes from sharing our talents and hard work with each other.

Think like customers. In every decision we make, we will consider the value it provides to our customers. We will treat our members the way we would want to be treated – with compassion, respect, and unsurpassed services.

Act like owners. We will take responsibility for moving business objectives forward. We will continually raise our own expectations of what can be accomplished, and we will hold ourselves accountable for reaching the goals we set.

CAREINGTON POS Dental Network

Provider Network: Over 54,000* available dental practice locations nationwide

Discount Range: Save 20%-50% on everything from general dentistry and cleaning to root canals, crowns and orthodontia, 20% savings for specialists

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Sample Savings

Product/Service	Average Cost *	CI-5 Schedule Price	Total Savings
Adult Cleaning	$82	$52	$30
Child Cleaning	$49	$37	$12
Routine Checkup	$39	$27	$12
Four Bitewing X-rays	$51	$31	$20
Composite (White) Filling	$131	$76	$55
Crown (porcelain fused to noble metal)	$843	$584	$259
Complete Upper Denture	$940	$763	$177
Molar Root Canal	$826	$581	$245
Extraction (single tooth)	$119	$70	$49

* Actual savings may vary

CAREINGTON International Corporation

Limitations. This is a discount program. This is not an insurance plan. CAREINGTON cannot guarantee specialty care in all areas. In cases in which you are referred to a participating specialist, you will generally receive 15% to 20% off their usual and customary fees. Please verify such benefits with each individual provider. Work in progress, after joining the plan, must be completed by the provider who started the work. Any procedures performed by a non-participating provider are not included. CAREINGTON International cannot guarantee the continued participation of any provider. If he or she leaves the plan, you will need to select another provider. Not all types of providers may be available in your area. Some providers may charge for missed or broken appointments if no prior notice is given. It is the member’s responsibility to verify that the provider is a participating provider. This plan does not include all procedures which might be provided. Any procedure delivered which is not listed on the Schedule of Services may cause additional cost to be incurred by the member. The dollar amount specified adjacent to each procedure may not be the only cost incurred for a given treatment because the treatment may require more than one procedure. Note to Utah Residents: This contract is not protected by the Utah Life and Health Guaranty Association. The program and the program administrators have no liability for providing or guaranteeing service and have no liability for the quality of service rendered.

Frequently Asked Questions

Can drinking milk prevent tooth decay?

My six-year-old son has a cavity in one of his baby molars. Should I bother to have it fixed since he's going to lose it anyway?

Is there any relationship between teeth and sinus problems?

What is a crown?

Why do some teeth need fillings while others need crowns?

Is it always necessary to crown a tooth after a root canal?

If a tooth needs a crown, do I have to have a root canal?

Are yellow teeth a sign of bad oral hygiene?

Are dental whiteners and polishers good for teeth?

How much toothpaste per brushing is recommended?

What is the difference between fluoride rinse and fluoride tablets?

What is a tooth abscess?

Why are "sealants" sometimes recommended for children's teeth
and how do they work?

Dental Health During Pregnancy

Mouth Injuries

Dental Do's - Birth to 3 Years

Glossary

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A B C D E F G H I L M N P Q R S T U V W

Abutment
A tooth or implant used to support a prosthesis. A crown unit used as part of a fixed bridge.

Abscess
A localized inflammation due to a collection of pus in the bone or soft tissue, usually caused by an infection.

Abutment
A tooth or implant used to support a prosthesis. A crown unit used as part of a fixed bridge.

Accident
An event or occurrence which is unforeseen and unintended.

Accident Insurance
A form of insurance against loss by accidental bodily injury.

Adverse Selection
The tendency of persons who present a poorer-than-average risk to apply for, or continue, insurance to a greater extent than do persons with average or better-than-average expectations of loss.

Agent
An insurance company representative licensed by the state who solicits, negotiates or effects contracts of insurance, and provides service to the policyholder for the insurer.

Agent-brokers
Career agents who place business with companies other than their primary companies. Also known as agents of other companies, surplus brokers, or simply brokers.

Alveoloplasty
A surgical procedure used to recontour the supporting bone structures in preparation of a complete or partial denture.

Amalgam
A dental filling material, composed of mercury and other minerals, used to fill decayed teeth.

Anesthetic
A class of drugs that eliminates or reduces pain. See local anesthetic.

Anterior
Refers to the teeth and tissues located towards the front of the mouth (upper or lower incisors and canines).

Apex
The tip or end of the root of the tooth.

Apicoectomy
The amputation of the apex of a tooth.

Applicant
The party applying for an insurance policy.

Application
A form that must be completed by an individual or other party who is seeking insurance coverage. This form provides the insurance company with much of the information it will need to decide whether to accept or reject the risk.

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INDIVIDUAL DOLLAR-BASED DENTAL INSURANCE

PREMIUM RATES

MONTHLY PREMIUM

QUARTERLY PREMIUM

PER MEMBER

Dental Only

Dental & Vision

Dental Only

Dental & Vision

Under Age 18

$24.66

$27.27

$73.98

$81.81

18 through 64

$44.99

$49.61

$134.97

$148.83

65 and over

$56.98

$62.89

$170.94

$188.67

You may enroll for Dental Only Coverage or Dental with Vision Coverage.

All members must be enrolled for the same coverage and premium payment schedule.

HOW TO APPLY

Please refer to the eligibility section of this brochure to be sure you meet the eligibility requirements.

•	Complete the application in full. Missing information may cause your effective date to be delayed. If you have more than four children, please attach a separate list.

•	Calculate the premium. Indicate if you are enrolling for the Optional Vision coverage. Be sure to select a monthly or quarterly payment schedule. Include the applicable payment for the first month or quarter of coverage, according to the payment schedule you have selected.

•	You may enroll for Child Only coverage. If you are enrolling children only, a separate application must be completed and submitted for each child.

•	If you have any questions, please call 503-721-7161 or toll-free 1-800-794-5390.

•	Send the application and your check or money order made payable to Regence Life and Health

Insurance Company to:

Regence Life and Health Insurance Company

P0 Box 1271, MS E-3A

Portland, OR 97207-127 1

•	Keep this brochure for your records.

REFUNDS Return to Top

If you are not satisfied with this Policy, you may return the policy within 10 days of delivery for a full refund of premium.

Please note: The application fee of $25 is non-refundable.

Please read your policy carefully and keep it available for future reference.

Dental care is a vital part of maintaining and improving overall health for both children and adults. It is about more than keeping teeth looking good

Dental disease is chronic, progressive and, at times, painful. It is also highly preventable and maintainable with routine care. Routine dental care is essential for a healthy l~fesiyle which is why Regence Life and Health ‘s Individual Dollar-Based Dental plan is available to you and your family.

HOW THE POLICY WORKS

Individual Dollar-Based Dental puts you and your dentist in control. With this dental plan there are no dental service limitations or treatment exclusions, except orthodontia, teeth bleaching and labial veneers. If you engage in your oral health by receiving a routine exam and cleaning from your dentist during your benefit year, in the following year Regence Life and Health will increase the annual benefit maximum. You are in control.

With the Individual Dollar-Based Dental plan you and your family are free to visit any dentist. As an added bonus, when you visit one of the many Regence Life and Health participating dentists you will be accessing dental providers who have agreed to bill no more than our allowed amounts for covered procedures.

Incentive: You control your benefit increase by ieceiving at least one exam and cleaning in the benefit year.

•	No deductibles

•	No limitations or exclusions for covered services, except orthodontia, teeth

bleaching and veneers

•	Six month waiting period

•	Optional Vision Rider available: $150 in services and/or hardware every 24 months

INDIVIDUAL DOLLAR-BASED DENTAL INSURANCE

OUTLINE OF COVERAGE

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Read the Policy Carefully - This outline of coverage provides a very brief description of the important features of the policy. Please note that this outline is not intended to be a part of the insurance contract. Only the actual policy provisions are final and binding. The policy itself sets forth in detail your rights and obligations as well as those of the insurance company. PLEASE READ THE POLICY CAREFULLY!

ELIGIBILITY

You are eligible for this policy if you and any family members who apply for coverage are

not covered under any other plan that provides dental coverage, including any Medicare or

Medicare supplement plan providing dental coverage.

Important Note: If we receive notice that a member has become covered under any other dental coverage, this policy’s coverage for that member will be terminated as of the last day of the month (or the 14th day of the month if the effective date of the policy is the l5th of the month) in which such notice is received.

Eligible dependents include your spouse and your unmarried dependent children under age 23 who are primarily dependent on you for support. Any other of your unmarried children under age 23 are eligible if you are legally required to contribute to their support (unless a court order requires that someone else provide insurance for them).

Children placed in your custody pending adoption by you and children related to you by blood or marriage for whom you are the legal guardian (court order required) will also be considered eligible dependents.

WAITING PERIOD

This policy has a 6 month benefit waiting period. The benefit waiting period is the continuous length of time a member must be covered under the policy before becoming eligible for benefits.

COVERED SERVICES

Covered Services are those services or supplies that are required to prevent, diagnose, or treat diseases or conditions of the teeth and supporting tissues and are dentally appropriate. These services must be performed by a Dentist or other provider practicing within the scope of his or her license.

COINSURANCE*

We pay a percentage of the allowed amount as shown below.

100% of the First

$150

80% of the Next

$500

50% of the Next	$400 in Year 1
	$900 in Year 2*
	$1,400 in Year3*
	$1,900 in Year 4*

BENEFIT YEAR MAXIMUM*

$750 in Year 1

$1,000 in Year 2*

$1,250 in Year 3*

$1,500 in Year 4*

*The yearly maximum will increase only if the member receives at least one cleaning and exam during the benefit year.

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EXCLUSIONS

Your policy does not cover:

•	Bleaching of teeth

•	Labial veneers

•	Orthodontic services, including craniomandibular orthopedic treatment; procedures for

tooth movement, regardless of purpose; correction of malocclusion; preventive orthodontic procedures; and other orthodontic treatment

•	Expenses payable by motor vehicle insurance or other liability insurance coverage

•	Work-related injuries

OPTIONAL VISION BENEFITS RIDER

You may elect to include Vision Benefits along with your dental coverage. The Vision

Benefit pays $150 per member for services and/or hardware every 24 months.

INDIVIDUAL INCENTIVE DENTAL INSURANCE

OUTLINE OF COVERAGE

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PREMIUM RATES

MONTHLY PREMIUM

QUARTERLY PREMIUM

PER MEMBER

Dental Only

Dental & Vision

Dental Only

Dental & Vision

Under Age 18

$27.94

$30.55

$83.82

$91.65

18 through 64

$33.66

$38.28

$100.98

$114.84

65 and over

$35.88

$41.79

$107.64

$125.37

You may enroll for Dental Only Coverage or Dental with Vision Coverage. All members must be enrolled for the same coverage and premium payment schedule.

•	Keep this brochure for your records.

REFUNDS

If you are not satisfied with this Policy, you may return the policy within 10 days of delivery for a

full refund of premium.

Please note: The application fee of $25 is non-refundable.

Please read your policy carefully and keep it available for future reference.

ELIGIBILITY

You are eligible for this policy if you and any family members who apply for coverage are

not covered under any other plan that provides dental coverage, including any Medicare or

Medicare supplement plan providing dental coverage.

Important Note: If we receive notice that a member has become covered under any other dental coverage, this policy’s coverage for that member will be terminated as of the last day of the month (or the 14th1 day of the month if the effective date of the policy is the 15th of the month) in which such notice is received.

DEDUCTIBLES

An annual $50 deductible applies individually to each member before benefits are paid, except that the deductible is waived for cleanings and exams covered by the policy.

COINSURANCE

After the annual deductible is met, we pay a percentage of the allowed amount as shown below. Please note that the coinsurance benefit will increase only jf the member receives at least one cleaning and exam each benefit year.

YEAR 1

YEAR 2

YEAR 3

Preventive Services

80%

90%

100%

Restorative Services

60%

70%

80%

Major Dental Services

30%

40%

50%

BENEFIT MAXIMUM Return to Top

The maximum benefit payable each year per member is shown below. Please note that the benefit maximum will increase only jf the member receives at least one cleaning and exam each benefit year.

YEAR 1	YEAR 2	YEAR 3	YEAR 4
$750	$1,000	$1,250	$1,500

COVERED SERVICES

Covered Services are those services or supplies that are required to prevent, diagnose, or treat diseases or conditions of the teeth and supporting tissues and are Dentally Appropriate. These services must be performed by a Dentist or other provider practicing within the scope of his or her license.

Subject to the limitations and conditions described in the policy, the following will be considered covered services under your policy:

Preventive and Diagnostic Services

•	Cleanings allowed two per benefit year (includes cleanings and periodontal

maintenance)

•	Oral exams allowed two per benefit year

•	Fluoride Treatment allowed two applications per benefit year for members age 17

and under

•	X-rays bitewings: allowed one set limited to twice per benefit year; panoramic and

full mouth series: limited to once every three years

•	Sealants allowed for permanent bicuspid and molars for members age 17 and under

•	Space Maintainers allowed for members age 11 and under

Restorative Services

•	Fillings composite and amalgam

•	Emergency treatment for pain relief only

•	Oral surgery including surgical extractions, removal of teeth, biopsies and incision and drainage

•	General anesthesia or intravenous sedation allowed for surgical extractions of teeth and for members age 6 and under

•	Direct pulp capping

Major Services Return to Top

•	Crowns or onlays and related services

•	Bridges (fixed partial dentures) limited to one in a 7-year period

•	Dentures (full or partial) and related services

•	Endosteal Implants and related services implants are limited to 4 per lifetime per member

•	Endodontics including root canal treatment, pulpotomy, apicoectomy

•	Periodontal Maintenance allowed two per benefit year (includes cleanings and periodontal maintenance)

•	Gingivectomy and gingivoplasty allowed once every three years per quadrant

•	Osseous and mucogingival surgery allowed once every five years per quadrant

•	Debridement allowed once every 3 years

•	Scaling and root planing allowed once every two years per quadrant

Replacement of prosthetics is limited to once in a seven year period from the date of the most recent placement

EXCLUSIONS Return to Top

Your policy does not cover:

•	Additional procedures to construct new crown under existing partial denture framework

•	Application of desensitizing resin for cervical aTnd/or root surface

•	Bleaching of teeth

•	Collection of cultures and specimens

•	Connector bar or stress breaker

•	Cosmetic/Reconstructive Services and Supplies (certain exceptions apply)

•	Diagnostic casts or study models

•	Duplicate x-rays

•	Endodontic endosseous implants

•	Expenses payable by motor vehicle insurance or other liability insurance coverage

•	Exfoliate cytology sample collection or brush biopsy

•	Fees, Taxes, Interest

•	Gold foil restorations

•	Hospitalization for dentistry

•	Implant maintenance procedures, including: removal of prosthesis, cleansing of prosthesis and abutments, reinsertion of prosthesis

•	Incision and drainage of abscess extraoral soft tissue, complicated or non-complicated

•	Indirect pulp c~apping

•	Interim partial or complete dentures

•	Labial veneers

•	Local anesthesia, sterilization, and supplies billed as separate charges (these procedures are considered inclusive of billed procedures)

•	Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue per tooth

•	Maxillofacial prosthetic procedures

•	Military Service Related Conditions: Any condition resulting from military service in the armed forces of any country

•	Modification of removable prosthesis following implant surgery

•	Nitrous oxide

•	Occlusal analysis and adjustments

•	Occiusal guards

•	Oral hygiene instructions

•	Oral/facial photographic images

•	Orthodontic services, including craniomandibular orthopedic treatment; procedures for tooth movement, regardless of purpose; correction of malocclusion; preventive orthodontic procedures; and other orthodontic treatment

•	Pediatric dentures

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•	Pin retention in addition to restoration

•	Precision attachments

•	Prescription drugs, including take home prescription drugs, pre-medications, therapeutic drug injections, or supplies

•	Provisional splinting

•	Pulp vitality tests

•	Radical resection of maxilla or mandible

•	Radiographic/surgical implant index

•	Removal of nonodontogenic cyst, tumor or lesion

•	Replacement of lost, stolen or broken dental appliances

•	Self-Help, Non Dental Self-Care, Training, or Instructional Programs

•	Services and Supplies provided by a Family Member: Services and supplies provided to a member by an immediate family member

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•	Surgical procedures for isolation of a tooth with rubber dam

•	Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)

•	Treatment of simple or compound fractures of the mandible

•	Treatment of Temporomandibular Joint Dysfunction

•	Unspecified implant procedures

•	Work-related injuries

OPTIONAL VISION BENEFITS RIDER

You may elect to include Vision Benefits along with your dental coverage. The Vision

Benefit pays $150 per member for services and/or hardware every 24 months

HOW TO APPLY Return to Top

Please refer to the eligibility section of this brochure to be sure you meet the eligibility requirements.

•	Complete the application in full. Missing information may cause your effective date to be delayed. If you have more than four children, please attach a separate list

•	Calculate the premium. Indicate if you are enrolling for the Optional Vision coverage. Be sure to select a monthly or quarterly payment schedule. Include the applicable payment for the first month or quarter of coverage, according to the payment schedule you have selected.

•	You may enroll for Child Only coverage. If you are enrolling children only, a separate application must be completed and submitted for each child.

•	If you have any questions, please call 503-721-7161 or toll-free 1-800-794-5390.

•	Send the application and your check or money order made payable to Regence Life and Health

Return to Top

Insurance Company to:

Regence Life and Health Insurance Company

P0 Box 1271,MSE-3A

Portland, OR 97207-1271