| In-network | Out-of-network | |
|---|---|---|
| Deductible* | $50 | $150 |
| Annual Benefit Maximum | $1,000 每个日历年 | $1,000 每个日历年 |
| 诊断和预防性护理* | You pay 0% | You pay 20% |
| 简单摘取 * | You pay 50% | You pay 60% |
| 基本补牙 | You pay 30% | You pay 60% |
| Major Restorative Care* | You pay 50% | You pay 60% |
Plan details
Providence Dental Basic
Overview
|
Monthly premium |
$39.00 |
|
Medical Deductible |
$50 In-network |
有关这些福利的重要说明
以下是您在满足日历年免赔额后为网络内和网络外服务支付的金额。
Benefits include: Preventive Dental and comprehensive dental
-
Benefits
*适用限制和除外责任。有关承保牙科服务的完整清单，请参阅您的承保范围说明。我们鼓励会员使用网络内的牙科服务提供者。网络外牙医的收费可能超过 Providence Medicare Advantage 计划允许的金额。
请注意：您必须在Medicare B部分保费之外，每月为这些福利支付额外保费。 此外虽然您可以去任何牙医处就诊，但我们的网络内医疗服务提供者已同意接受他们所提供服务的合同费率。 这意味着，如果您在网络内医疗服务提供者处就诊，分担费用会更低。
Portland Metro – Clackamas, Multnomah, Washington, and Yamhill Counties in Oregon
Prime + Rx (HMO), and Extra + Rx (HMO)
Washington Counties – Snohomish, Spokane, Walla Walla, Benton, and Franklin Counties in Washington
Pine + Rx (HMO)
Western OR & SW WA – Hood River, Lane Counties in Oregon, and Clark County in Washington
Timber + Rx (HMO) and Extra + Rx (HMO)
Medical only/No Rx – Clackamas, Multnomah, Washington, Yamhill, Hood River, and Lane Counties in Oregon and Clark, Benton, Franklin, Snohomish, Spokane, and Walla Walla Counties in Washington
Focus Medical (HMO) is available in Clackamas, Multnomah, Washington, Yamhill, Hood River, and Lane Counties in Oregon and Clark County in Washington
Reverence (HMO-POS) is available in Clackamas, Multnomah, Washington, Yamhill, Hood River, and Lane Counties in Oregon and Clark, Benton, Franklin, Snohomish, Spokane, and Walla Walla Counties in Washington
Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.
You must continue to pay your Medicare Part B premium.