Regence BlueShield   LifeWise of WA   Group Health   HSA Plans   Individual Dental     Smart Smile     Regence Dental       Incentive 10 Plan       Dollar-Based Plan       Managed Care Plan       Exclusions       Plan Rates       Apply Now!   Group Medical   Group Dental   Grp Life & Disability   About the Plan   Premiums   Application		Exclusions for Individual Incentive 10 Dental Plan These services and supplies are not covered: Additional procedures to construct new crown under existing partial denture framework Application of desensitizing resin for cervical and/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 Exfoliate cytology sample collection or brush biopsy Expenses payable by motor vehicle insurance or other liability insurance coverage Experimental/investigational treatments, procedures, and services and supplies 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 capping 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 Non-direct patient care Occlusal analysis and adjustments Occlusal guards Oral hygiene instructions Oral/facial photographic images Orthodontic services, including craniomandibularorthopedic treatment; procedures for tooth movement, regardless of purpose; correction of malocclusion; preventive orthodontic procedures; and other orthodontic treatment Pediatric dentures 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 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 for an illness or injury caused by a member’s unlawful instigation and/or active participation in a riot, rebellion, war or illegal act Treatment of simple or compound fractures of the mandible Treatment of Temporomandibular Joint Dysfunction Unspecified implant procedures Work-related injuries Exclusions for Individual Dollar-Base Dental Plan This 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 Treatment for an illness or injury caused by a member's unlawful instigation and/or active participation in a riot, rebellion, war or illegal act. Work-related injuries Exclusions for Individual Managed Care Dental Plan These services and supplies are not covered: Aesthetic dental procedures and complications arising out of such services Benefits not stated Charges by any person other than a participating provider except as otherwise indicated in the policy Cosmetic/reconstructive services and supplies (certain exceptions apply) Coverage available under any federal, state, or other governmental program, except where required by law Diagnostic casts or study models Endodontics, bridges, crowns, and other prosthetic devices or services if treatment was started or ordered prior to the member's effective date or delivered more than 60 days after the member’s coverage under this policy has terminated Excision of a tumor; biopsy of soft or hard tissue; removal of a cyst Experimental/investigational treatments, procedures, services and supplies Extraction of permanent teeth for tooth guidance procedures; procedures for tooth movement Full-mouth reconstruction General Anesthesia, except as specified in the Schedule of Covered Services, Copays and Coinsurance Habit-breaking or stress-breaking appliances Hospitalization for dentistry Maxillofacial prosthetic services Medication and supply charges Military service-related conditions Motor vehicle coverage and other insurance liability Non-direct patient care Occlusal treatment including complete occlusal adjustments and occlusal guards Personalized restorations, precision attachments, and special techniques Repair or replacement of lost, stolen, or broken items Replacement of sound restorations Services and supplies for treatment of an illness or injury caused by riot, rebellion, war and illegal acts Services for accidental injury to natural teeth that are provided more than 12 months after the date of the accident Services or supplies and related exams or consultations that are not within the prescribed treatment plan and/or are not recommended and approved a participating provider Temporomandibular Joint (TMJ) dysfunction treatment Transseptal fiberotomy Treatment started prior to the member's effective date under this policy or completed after this policy terminates Work-related injuries E-mail us for more information and a free quote or CALL TOLL FREE 1-800-875-4490 (in the U.S.) or 1-253-854-0199 (outside the U.S.) Fax: 1-253-896-9411 Mailing address: Maddock & Associates, 1407 Willow Road E, Suite C, Tacoma, WA 98424 Serving all of Washington at 800-875-4490, Seattle at 206-682-1628, Bellevue at 425-454-6834, Kent at 253-854-0199 and Tacoma at 253-572-3291. 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