Washington Dental Insurance

• Initial exams, child or adult preentie oral hygiene kits
• Children's cleanings (through age 12)
• Children's fluoride (thorugh age 12)
• Periodic examinations
• X-rays (up to four bitewings)
• Custom sports mouth guards
• Orthodontic evaluation

• Sealants to permanent teeth (per quadrant)
• After-hours visits
• Initial orthodontic exam
• Panoramic x-rays

• Restorative fillings (up to four surfaces per tooth)
• Adult cleanings
• Simple extractions
• Simple denture repairs

The following is only a summary of the limitations and exclusions. Please refer to the contract for a complete list of benefits, limitations and exclusions.

• Alevoloplasty
• Analgesia; intravenous sedation; aneshesia, except as specified in the Schedule of Covered Services and Copays.
• Bleaching of a tooth
• Charges by any person other than a Licensed Dentist or Licensed Denturist.
• Cosmetic dentistry or surgery or unnecessary treatment
• Coverage that is available under any federal, state, or other governmental program if application is duly made therefore, except where required by law, such as for cases of emergency or for coverage provided by Medicaid.
• Dental implants, including attachment devices and their maintenance; crowns over implants.
• Dental services started prior to the date the Member became eligible for services under this Contract.
• Excision of a tumor; biopsy of soft or hard tissue; removal of a cyst, nonodontogenic or exostosis.
• Extraction of permanent teeth for tooth guidance procedures; procedures for tooth movement, regardless of purpose; correction of malocclusion; preventive orthodontic procedures; craniomandibular orhopedic treatment; and other orthodontic treatment, unless specified.
• Full-mouth reconstruction
• Habit-breaking or stress-breaking appliances including, but not limited to, occlusal guards.
• Hospitalization for dentistry
• Insuries sustained while practicing for or competing in a professional or Semiprofessional Athletics contest. "Semiprofessional Athletics" contest means an athletic activity for gain or pay, that requires an unusually high level of skill and a substantial time comitment from the participants, who are nevertheless not engaged in the activity as a full-time occupation.
• Investigational Services or Supplies
• Materials not approved by the American Dental Association
• Occupational injury or disease (including and arising out of self-employment).
• Personalized restorations, precision attachments, and special techniques.
• Prescription drugs, medications, or supplies
• Repair or replacement of lost, stolen, or broken items
• Replacement of an exiting denture, crown, or bridge less than seven years from the date of the most recent placement.
• Replacement of sound restorations
• Services and supplies for which Benefits are or would have been payable to a Member eligible and enrolled under Medicare Parts A and B regardless of whether the Member actually enrolled.
• Services for accidental injury to natural teeth that are provided more than 12 months after the date of the accident.
• Services to the extent that they are not necessary for treatment of a dental injury or disease or are not recommended and approved by the Licensed Dentist or Licensed Denturist attending the Member.
• Transseptal fiberotomy
• Treatment of any condition caused by or resulting from a Member's active participation in the armed forces in a war or insurrection.
• Treatment of any Member's condition that the Secretary of Veterans Affairs determines to have been incurred in, or aggravated during, performance of service in the uniformed services of the United States.
• Veneers; composite surfaces on posterior teeth
• Visits or consultations that are not in person, including but not limited to any telephone, Internet, or other electronic communication, whether initiatied by the Member or the Member's provider.