Namara Marketplace

2016 QHP Landscape OR Individual Market Dental

State Code

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County Name

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Metal Level

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Issuer Name

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Plan Id (Standard Component)

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Plan Marketing Name

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Plan Type

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Rating Area

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Child Only Offering

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Source

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Customer Service Phone Number Local

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Customer Service Phone Number Toll Free

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Customer Service Phone Number Tty

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Network Url

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Plan Brochure Url

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Summary Of Benefits Url

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Drug Formulary Url

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Routine Dental Services Adult 1

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Basic Dental Care Adult 1

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Major Dental Care Adult 1

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Orthodontia Adult 1

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Dental Check-Up For Children

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Basic Dental Care Child 1

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Major Dental Care Child 1

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Orthodontia Child 1

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Premium Rates

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Premium Child

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Premium Adult Individual Age 21

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Premium Adult Individual Age 27

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Premium Adult Individual Age 30

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Premium Adult Individual Age 40

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Premium Adult Individual Age 50

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Premium Adult Individual Age 60

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Premium Couple 21

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Premium Couple 30

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Premium Couple 40

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Premium Couple 50

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Premium Couple 60

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Couple+1 Child, Age 21

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Couple+1 Child, Age 30

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Couple+1 Child, Age 40

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Couple+1 Child, Age 50

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Couple+2 Children, Age 21

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Couple+2 Children, Age 30

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Couple+2 Children, Age 40

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Couple+2 Children, Age 50

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Couple+3 Or More Children, Age 21

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Couple+3 Or More Children, Age 30

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Couple+3 Or More Children, Age 40

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Couple+3 Or More Children, Age 50

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Individual+1 Child, Age 21

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Individual+1 Child, Age 30

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Individual+1 Child, Age 40

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Individual+1 Child, Age 50

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Individual+2 Children, Age 21

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Individual+2 Children, Age 30

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Individual+2 Children, Age 40

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Individual+2 Children, Age 50

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Individual+3 Or More Children, Age 21

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Individual+3 Or More Children, Age 30

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Individual+3 Or More Children, Age 40

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Individual+3 Or More Children, Age 50

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Standard On Exchange

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Dental Deductible - Individual - Standard

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Dental Deductible - Family - Standard

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Dental Deductible - Family (Per Person) - Standard

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Dental Maximum Out Of Pocket - Individual - Standard

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Dental Maximum Out Of Pocket - Family - Standard

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Dental Maximum Out Of Pocket - Family (Per Person) - Standard

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Routine Dental Services Adult

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Basic Dental Care Adult

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Major Dental Care Adult

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Orthodontia Adult

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Dental Checkup For Children

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Basic Dental Care Child

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Major Dental Care Child

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Orthodontia Child

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OR
Baker
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 6
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
26.98
25.2
25.2
25.2
25.2
25.2
25.2
50.4
50.4
50.4
50.4
50.4
77.38
77.38
77.38
77.38
104.36
104.36
104.36
104.36
131.34
131.34
131.34
131.34
52.18
52.18
52.18
52.18
79.16
79.16
79.16
79.16
106.14
106.14
106.14
106.14
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Benton
Low
Dental Health Services, Inc.
25486OR0020001
SmartSmile
EPO
Rating Area 2
Allows Adult and Child-Only
SERFF
1-855-495-0907
1-855-495-0907
http://www.dentalhealthservices.com/members/provider-search/index.cfm?state=OR&plan=idp&popup=&fa=search
http://www.dentalhealthservices.com/OR/
http://www.dentalhealthservices.com/OR/
X
X
X
X
X
X
X
X
24.25
14.75
17.25
17.25
17.25
17.25
17.25
29.5
34.5
34.5
34.5
34.5
53.75
58.75
58.75
58.75
78
83
83
83
102.25
107.25
107.25
107.25
39
41.5
41.5
41.5
63.25
65.75
65.75
65.75
87.5
90
90
90
Not Applicable
Not Applicable
Not Applicable
350
700
Not Applicable
$25
$52
$625
$3,495
$45
$50
$350
$350
OR
Benton
Low
Dental Health Services, Inc.
25486OR0020002
Super SmartSmile
EPO
Rating Area 2
Allows Adult and Child-Only
SERFF
1-855-495-0907
1-855-495-0907
http://www.dentalhealthservices.com/members/provider-search/index.cfm?state=OR&plan=idp&popup=&fa=search
http://www.dentalhealthservices.com/OR/
http://www.dentalhealthservices.com/OR/
X
X
X
X
X
X
X
X
24.25
23.5
26
26
26
26
26
47
52
52
52
52
71.25
76.25
76.25
76.25
95.5
100.5
100.5
100.5
119.75
124.75
124.75
124.75
47.75
50.25
50.25
50.25
72
74.5
74.5
74.5
96.25
98.75
98.75
98.75
Not Applicable
Not Applicable
Not Applicable
350
700
Not Applicable
$10
$35
$625
$3,495
$45
$50
$350
$350
OR
Benton
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 2
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
27.81
25.98
25.98
25.98
25.98
25.98
25.98
51.96
51.96
51.96
51.96
51.96
79.77
79.77
79.77
79.77
107.58
107.58
107.58
107.58
135.39
135.39
135.39
135.39
53.79
53.79
53.79
53.79
81.6
81.6
81.6
81.6
109.41
109.41
109.41
109.41
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Benton
Low
Trillium Community Health Plan
95417OR0140001
Trillium Bright Family Dental - Low
PPO
Rating Area 2
Allows Adult and Child-Only
SERFF
1-541-431-1950
http://www.trilliumchp.com/Marketplace/prov-search.php
http://www.trilliumchp.com/Marketplace/PDFS/2016/ExchDen/EXCH_SB23V4-2016-Trillium-Bright-Family-Low-SOB.pdf
X
X
X
X
X
28.61
15.06
16.57
16.82
19.12
22.84
24.84
30.12
33.64
38.24
45.68
49.68
58.73
62.25
66.85
74.29
87.34
90.86
95.46
102.9
115.95
119.47
124.07
131.51
43.67
45.43
47.73
51.45
72.28
74.04
76.34
80.06
100.89
102.65
104.95
108.67
$75
$225
$75
350
700
$350
No Charge
30% Coinsurance after deductible
Not Covered
Not Covered
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
OR
Benton
Low
Willamette Dental Insurance, Inc.
60013OR0020002
Willamette Dental ProCare Oregon Plan 1
EPO
Rating Area 2
Allows Adult and Child-Only
SERFF
1-855-433-6825
1-855-433-6825
http://www.willamettedental.com/locations-oregon.htm
https://www.willamettedental.com/procare-oregon
http://willamettedental.gelfuzion.net/_literature_225953/2016_ProCare_Oregon_Plan_1_Benefit_Summary
X
X
X
X
X
X
X
X
30.4
41.32
41.32
41.32
41.32
41.32
41.32
82.64
82.64
82.64
82.64
82.64
113.04
113.04
113.04
113.04
143.44
143.44
143.44
143.44
173.84
173.84
173.84
173.84
71.72
71.72
71.72
71.72
102.12
102.12
102.12
102.12
132.52
132.52
132.52
132.52
$0
$0
$0
350
700
Not Applicable
$45
$45
$600
$3,000
$35
$45
$600
$3,000
OR
Clackamas
Low
Dental Health Services, Inc.
25486OR0020001
SmartSmile
EPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-855-495-0907
1-855-495-0907
http://www.dentalhealthservices.com/members/provider-search/index.cfm?state=OR&plan=idp&popup=&fa=search
http://www.dentalhealthservices.com/OR/
http://www.dentalhealthservices.com/OR/
X
X
X
X
X
X
X
X
24.25
14.75
17.25
17.25
17.25
17.25
17.25
29.5
34.5
34.5
34.5
34.5
53.75
58.75
58.75
58.75
78
83
83
83
102.25
107.25
107.25
107.25
39
41.5
41.5
41.5
63.25
65.75
65.75
65.75
87.5
90
90
90
Not Applicable
Not Applicable
Not Applicable
350
700
Not Applicable
$25
$52
$625
$3,495
$45
$50
$350
$350
OR
Clackamas
Low
Dental Health Services, Inc.
25486OR0020002
Super SmartSmile
EPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-855-495-0907
1-855-495-0907
http://www.dentalhealthservices.com/members/provider-search/index.cfm?state=OR&plan=idp&popup=&fa=search
http://www.dentalhealthservices.com/OR/
http://www.dentalhealthservices.com/OR/
X
X
X
X
X
X
X
X
24.25
23.5
26
26
26
26
26
47
52
52
52
52
71.25
76.25
76.25
76.25
95.5
100.5
100.5
100.5
119.75
124.75
124.75
124.75
47.75
50.25
50.25
50.25
72
74.5
74.5
74.5
96.25
98.75
98.75
98.75
Not Applicable
Not Applicable
Not Applicable
350
700
Not Applicable
$10
$35
$625
$3,495
$45
$50
$350
$350
OR
Clackamas
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
27.96
26.12
26.12
26.12
26.12
26.12
26.12
52.24
52.24
52.24
52.24
52.24
80.2
80.2
80.2
80.2
108.16
108.16
108.16
108.16
136.12
136.12
136.12
136.12
54.08
54.08
54.08
54.08
82.04
82.04
82.04
82.04
110
110
110
110
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Clackamas
Low
Trillium Community Health Plan
95417OR0140001
Trillium Bright Family Dental - Low
PPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-541-431-1950
http://www.trilliumchp.com/Marketplace/prov-search.php
http://www.trilliumchp.com/Marketplace/PDFS/2016/ExchDen/EXCH_SB23V4-2016-Trillium-Bright-Family-Low-SOB.pdf
X
X
X
X
X
30.38
15.99
17.6
17.86
20.31
24.26
26.38
31.98
35.72
40.62
48.52
52.76
62.36
66.1
71
78.9
92.74
96.48
101.38
109.28
123.12
126.86
131.76
139.66
46.37
48.24
50.69
54.64
76.75
78.62
81.07
85.02
107.13
109
111.45
115.4
$75
$225
$75
350
700
$350
No Charge
30% Coinsurance after deductible
Not Covered
Not Covered
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
OR
Clackamas
Low
Willamette Dental Insurance, Inc.
60013OR0020002
Willamette Dental ProCare Oregon Plan 1
EPO
Rating Area 1
Allows Adult and Child-Only
SERFF
1-855-433-6825
1-855-433-6825
http://www.willamettedental.com/locations-oregon.htm
https://www.willamettedental.com/procare-oregon
http://willamettedental.gelfuzion.net/_literature_225953/2016_ProCare_Oregon_Plan_1_Benefit_Summary
X
X
X
X
X
X
X
X
30.4
41.32
41.32
41.32
41.32
41.32
41.32
82.64
82.64
82.64
82.64
82.64
113.04
113.04
113.04
113.04
143.44
143.44
143.44
143.44
173.84
173.84
173.84
173.84
71.72
71.72
71.72
71.72
102.12
102.12
102.12
102.12
132.52
132.52
132.52
132.52
$0
$0
$0
350
700
Not Applicable
$45
$45
$600
$3,000
$35
$45
$600
$3,000
OR
Clatsop
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 5
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
27.8
25.97
25.97
25.97
25.97
25.97
25.97
51.94
51.94
51.94
51.94
51.94
79.74
79.74
79.74
79.74
107.54
107.54
107.54
107.54
135.34
135.34
135.34
135.34
53.77
53.77
53.77
53.77
81.57
81.57
81.57
81.57
109.37
109.37
109.37
109.37
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Clatsop
Low
Trillium Community Health Plan
95417OR0140001
Trillium Bright Family Dental - Low
PPO
Rating Area 5
Allows Adult and Child-Only
SERFF
1-541-431-1950
http://www.trilliumchp.com/Marketplace/prov-search.php
http://www.trilliumchp.com/Marketplace/PDFS/2016/ExchDen/EXCH_SB23V4-2016-Trillium-Bright-Family-Low-SOB.pdf
X
X
X
X
X
27.95
14.71
16.19
16.43
18.68
22.31
24.27
29.42
32.86
37.36
44.62
48.54
57.37
60.81
65.31
72.57
85.32
88.76
93.26
100.52
113.27
116.71
121.21
128.47
42.66
44.38
46.63
50.26
70.61
72.33
74.58
78.21
98.56
100.28
102.53
106.16
$75
$225
$75
350
700
$350
No Charge
30% Coinsurance after deductible
Not Covered
Not Covered
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
OR
Columbia
Low
Dental Health Services, Inc.
25486OR0020001
SmartSmile
EPO
Rating Area 5
Allows Adult and Child-Only
SERFF
1-855-495-0907
1-855-495-0907
http://www.dentalhealthservices.com/members/provider-search/index.cfm?state=OR&plan=idp&popup=&fa=search
http://www.dentalhealthservices.com/OR/
http://www.dentalhealthservices.com/OR/
X
X
X
X
X
X
X
X
24.25
14.75
17.25
17.25
17.25
17.25
17.25
29.5
34.5
34.5
34.5
34.5
53.75
58.75
58.75
58.75
78
83
83
83
102.25
107.25
107.25
107.25
39
41.5
41.5
41.5
63.25
65.75
65.75
65.75
87.5
90
90
90
Not Applicable
Not Applicable
Not Applicable
350
700
Not Applicable
$25
$52
$625
$3,495
$45
$50
$350
$350
OR
Columbia
Low
Dental Health Services, Inc.
25486OR0020002
Super SmartSmile
EPO
Rating Area 5
Allows Adult and Child-Only
SERFF
1-855-495-0907
1-855-495-0907
http://www.dentalhealthservices.com/members/provider-search/index.cfm?state=OR&plan=idp&popup=&fa=search
http://www.dentalhealthservices.com/OR/
http://www.dentalhealthservices.com/OR/
X
X
X
X
X
X
X
X
24.25
23.5
26
26
26
26
26
47
52
52
52
52
71.25
76.25
76.25
76.25
95.5
100.5
100.5
100.5
119.75
124.75
124.75
124.75
47.75
50.25
50.25
50.25
72
74.5
74.5
74.5
96.25
98.75
98.75
98.75
Not Applicable
Not Applicable
Not Applicable
350
700
Not Applicable
$10
$35
$625
$3,495
$45
$50
$350
$350
OR
Columbia
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 5
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
27.8
25.97
25.97
25.97
25.97
25.97
25.97
51.94
51.94
51.94
51.94
51.94
79.74
79.74
79.74
79.74
107.54
107.54
107.54
107.54
135.34
135.34
135.34
135.34
53.77
53.77
53.77
53.77
81.57
81.57
81.57
81.57
109.37
109.37
109.37
109.37
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Columbia
Low
Willamette Dental Insurance, Inc.
60013OR0020002
Willamette Dental ProCare Oregon Plan 1
EPO
Rating Area 5
Allows Adult and Child-Only
SERFF
1-855-433-6825
1-855-433-6825
http://www.willamettedental.com/locations-oregon.htm
https://www.willamettedental.com/procare-oregon
http://willamettedental.gelfuzion.net/_literature_225953/2016_ProCare_Oregon_Plan_1_Benefit_Summary
X
X
X
X
X
X
X
X
30.4
41.32
41.32
41.32
41.32
41.32
41.32
82.64
82.64
82.64
82.64
82.64
113.04
113.04
113.04
113.04
143.44
143.44
143.44
143.44
173.84
173.84
173.84
173.84
71.72
71.72
71.72
71.72
102.12
102.12
102.12
102.12
132.52
132.52
132.52
132.52
$0
$0
$0
350
700
Not Applicable
$45
$45
$600
$3,000
$35
$45
$600
$3,000
OR
Coos
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 5
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
27.8
25.97
25.97
25.97
25.97
25.97
25.97
51.94
51.94
51.94
51.94
51.94
79.74
79.74
79.74
79.74
107.54
107.54
107.54
107.54
135.34
135.34
135.34
135.34
53.77
53.77
53.77
53.77
81.57
81.57
81.57
81.57
109.37
109.37
109.37
109.37
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Crook
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 6
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
26.98
25.2
25.2
25.2
25.2
25.2
25.2
50.4
50.4
50.4
50.4
50.4
77.38
77.38
77.38
77.38
104.36
104.36
104.36
104.36
131.34
131.34
131.34
131.34
52.18
52.18
52.18
52.18
79.16
79.16
79.16
79.16
106.14
106.14
106.14
106.14
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Curry
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 5
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
27.8
25.97
25.97
25.97
25.97
25.97
25.97
51.94
51.94
51.94
51.94
51.94
79.74
79.74
79.74
79.74
107.54
107.54
107.54
107.54
135.34
135.34
135.34
135.34
53.77
53.77
53.77
53.77
81.57
81.57
81.57
81.57
109.37
109.37
109.37
109.37
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Deschutes
Low
Dental Health Services, Inc.
25486OR0020001
SmartSmile
EPO
Rating Area 4
Allows Adult and Child-Only
SERFF
1-855-495-0907
1-855-495-0907
http://www.dentalhealthservices.com/members/provider-search/index.cfm?state=OR&plan=idp&popup=&fa=search
http://www.dentalhealthservices.com/OR/
http://www.dentalhealthservices.com/OR/
X
X
X
X
X
X
X
X
24.25
14.75
17.25
17.25
17.25
17.25
17.25
29.5
34.5
34.5
34.5
34.5
53.75
58.75
58.75
58.75
78
83
83
83
102.25
107.25
107.25
107.25
39
41.5
41.5
41.5
63.25
65.75
65.75
65.75
87.5
90
90
90
Not Applicable
Not Applicable
Not Applicable
350
700
Not Applicable
$25
$52
$625
$3,495
$45
$50
$350
$350
OR
Deschutes
Low
Dental Health Services, Inc.
25486OR0020002
Super SmartSmile
EPO
Rating Area 4
Allows Adult and Child-Only
SERFF
1-855-495-0907
1-855-495-0907
http://www.dentalhealthservices.com/members/provider-search/index.cfm?state=OR&plan=idp&popup=&fa=search
http://www.dentalhealthservices.com/OR/
http://www.dentalhealthservices.com/OR/
X
X
X
X
X
X
X
X
24.25
23.5
26
26
26
26
26
47
52
52
52
52
71.25
76.25
76.25
76.25
95.5
100.5
100.5
100.5
119.75
124.75
124.75
124.75
47.75
50.25
50.25
50.25
72
74.5
74.5
74.5
96.25
98.75
98.75
98.75
Not Applicable
Not Applicable
Not Applicable
350
700
Not Applicable
$10
$35
$625
$3,495
$45
$50
$350
$350
OR
Deschutes
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 4
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
26.45
24.71
24.71
24.71
24.71
24.71
24.71
49.42
49.42
49.42
49.42
49.42
75.87
75.87
75.87
75.87
102.32
102.32
102.32
102.32
128.77
128.77
128.77
128.77
51.16
51.16
51.16
51.16
77.61
77.61
77.61
77.61
104.06
104.06
104.06
104.06
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Deschutes
Low
Trillium Community Health Plan
95417OR0140001
Trillium Bright Family Dental - Low
PPO
Rating Area 4
Allows Adult and Child-Only
SERFF
1-541-431-1950
http://www.trilliumchp.com/Marketplace/prov-search.php
http://www.trilliumchp.com/Marketplace/PDFS/2016/ExchDen/EXCH_SB23V4-2016-Trillium-Bright-Family-Low-SOB.pdf
X
X
X
X
X
28.5
15
16.5
16.75
19.04
22.75
24.74
30
33.5
38.08
45.5
49.48
58.5
62
66.58
74
87
90.5
95.08
102.5
115.5
119
123.58
131
43.5
45.25
47.54
51.25
72
73.75
76.04
79.75
100.5
102.25
104.54
108.25
$75
$225
$75
350
700
$350
No Charge
30% Coinsurance after deductible
Not Covered
Not Covered
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
OR
Deschutes
Low
Willamette Dental Insurance, Inc.
60013OR0020002
Willamette Dental ProCare Oregon Plan 1
EPO
Rating Area 4
Allows Adult and Child-Only
SERFF
1-855-433-6825
1-855-433-6825
http://www.willamettedental.com/locations-oregon.htm
https://www.willamettedental.com/procare-oregon
http://willamettedental.gelfuzion.net/_literature_225953/2016_ProCare_Oregon_Plan_1_Benefit_Summary
X
X
X
X
X
X
X
X
30.4
41.32
41.32
41.32
41.32
41.32
41.32
82.64
82.64
82.64
82.64
82.64
113.04
113.04
113.04
113.04
143.44
143.44
143.44
143.44
173.84
173.84
173.84
173.84
71.72
71.72
71.72
71.72
102.12
102.12
102.12
102.12
132.52
132.52
132.52
132.52
$0
$0
$0
350
700
Not Applicable
$45
$45
$600
$3,000
$35
$45
$600
$3,000
OR
Douglas
Low
Dental Health Services, Inc.
25486OR0020001
SmartSmile
EPO
Rating Area 7
Allows Adult and Child-Only
SERFF
1-855-495-0907
1-855-495-0907
http://www.dentalhealthservices.com/members/provider-search/index.cfm?state=OR&plan=idp&popup=&fa=search
http://www.dentalhealthservices.com/OR/
http://www.dentalhealthservices.com/OR/
X
X
X
X
X
X
X
X
24.25
14.75
17.25
17.25
17.25
17.25
17.25
29.5
34.5
34.5
34.5
34.5
53.75
58.75
58.75
58.75
78
83
83
83
102.25
107.25
107.25
107.25
39
41.5
41.5
41.5
63.25
65.75
65.75
65.75
87.5
90
90
90
Not Applicable
Not Applicable
Not Applicable
350
700
Not Applicable
$25
$52
$625
$3,495
$45
$50
$350
$350
OR
Douglas
Low
Dental Health Services, Inc.
25486OR0020002
Super SmartSmile
EPO
Rating Area 7
Allows Adult and Child-Only
SERFF
1-855-495-0907
1-855-495-0907
http://www.dentalhealthservices.com/members/provider-search/index.cfm?state=OR&plan=idp&popup=&fa=search
http://www.dentalhealthservices.com/OR/
http://www.dentalhealthservices.com/OR/
X
X
X
X
X
X
X
X
24.25
23.5
26
26
26
26
26
47
52
52
52
52
71.25
76.25
76.25
76.25
95.5
100.5
100.5
100.5
119.75
124.75
124.75
124.75
47.75
50.25
50.25
50.25
72
74.5
74.5
74.5
96.25
98.75
98.75
98.75
Not Applicable
Not Applicable
Not Applicable
350
700
Not Applicable
$10
$35
$625
$3,495
$45
$50
$350
$350
OR
Douglas
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 7
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
26.69
24.93
24.93
24.93
24.93
24.93
24.93
49.86
49.86
49.86
49.86
49.86
76.55
76.55
76.55
76.55
103.24
103.24
103.24
103.24
129.93
129.93
129.93
129.93
51.62
51.62
51.62
51.62
78.31
78.31
78.31
78.31
105
105
105
105
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Douglas
Low
Trillium Community Health Plan
95417OR0140001
Trillium Bright Family Dental - Low
PPO
Rating Area 7
Allows Adult and Child-Only
SERFF
1-541-431-1950
http://www.trilliumchp.com/Marketplace/prov-search.php
http://www.trilliumchp.com/Marketplace/PDFS/2016/ExchDen/EXCH_SB23V4-2016-Trillium-Bright-Family-Low-SOB.pdf
X
X
X
X
X
28.38
14.94
16.44
16.69
18.97
22.66
24.64
29.88
33.38
37.94
45.32
49.28
58.26
61.76
66.32
73.7
86.64
90.14
94.7
102.08
115.02
118.52
123.08
130.46
43.32
45.07
47.35
51.04
71.7
73.45
75.73
79.42
100.08
101.83
104.11
107.8
$75
$225
$75
350
700
$350
No Charge
30% Coinsurance after deductible
Not Covered
Not Covered
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
OR
Douglas
Low
Willamette Dental Insurance, Inc.
60013OR0020002
Willamette Dental ProCare Oregon Plan 1
EPO
Rating Area 7
Allows Adult and Child-Only
SERFF
1-855-433-6825
1-855-433-6825
http://www.willamettedental.com/locations-oregon.htm
https://www.willamettedental.com/procare-oregon
http://willamettedental.gelfuzion.net/_literature_225953/2016_ProCare_Oregon_Plan_1_Benefit_Summary
X
X
X
X
X
X
X
X
30.4
41.32
41.32
41.32
41.32
41.32
41.32
82.64
82.64
82.64
82.64
82.64
113.04
113.04
113.04
113.04
143.44
143.44
143.44
143.44
173.84
173.84
173.84
173.84
71.72
71.72
71.72
71.72
102.12
102.12
102.12
102.12
132.52
132.52
132.52
132.52
$0
$0
$0
350
700
Not Applicable
$45
$45
$600
$3,000
$35
$45
$600
$3,000
OR
Gilliam
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 6
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
26.98
25.2
25.2
25.2
25.2
25.2
25.2
50.4
50.4
50.4
50.4
50.4
77.38
77.38
77.38
77.38
104.36
104.36
104.36
104.36
131.34
131.34
131.34
131.34
52.18
52.18
52.18
52.18
79.16
79.16
79.16
79.16
106.14
106.14
106.14
106.14
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Grant
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 6
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
26.98
25.2
25.2
25.2
25.2
25.2
25.2
50.4
50.4
50.4
50.4
50.4
77.38
77.38
77.38
77.38
104.36
104.36
104.36
104.36
131.34
131.34
131.34
131.34
52.18
52.18
52.18
52.18
79.16
79.16
79.16
79.16
106.14
106.14
106.14
106.14
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Harney
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 6
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
26.98
25.2
25.2
25.2
25.2
25.2
25.2
50.4
50.4
50.4
50.4
50.4
77.38
77.38
77.38
77.38
104.36
104.36
104.36
104.36
131.34
131.34
131.34
131.34
52.18
52.18
52.18
52.18
79.16
79.16
79.16
79.16
106.14
106.14
106.14
106.14
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Hood River
Low
Dental Health Services, Inc.
25486OR0020001
SmartSmile
EPO
Rating Area 6
Allows Adult and Child-Only
SERFF
1-855-495-0907
1-855-495-0907
http://www.dentalhealthservices.com/members/provider-search/index.cfm?state=OR&plan=idp&popup=&fa=search
http://www.dentalhealthservices.com/OR/
http://www.dentalhealthservices.com/OR/
X
X
X
X
X
X
X
X
24.25
14.75
17.25
17.25
17.25
17.25
17.25
29.5
34.5
34.5
34.5
34.5
53.75
58.75
58.75
58.75
78
83
83
83
102.25
107.25
107.25
107.25
39
41.5
41.5
41.5
63.25
65.75
65.75
65.75
87.5
90
90
90
Not Applicable
Not Applicable
Not Applicable
350
700
Not Applicable
$25
$52
$625
$3,495
$45
$50
$350
$350
OR
Hood River
Low
Dental Health Services, Inc.
25486OR0020002
Super SmartSmile
EPO
Rating Area 6
Allows Adult and Child-Only
SERFF
1-855-495-0907
1-855-495-0907
http://www.dentalhealthservices.com/members/provider-search/index.cfm?state=OR&plan=idp&popup=&fa=search
http://www.dentalhealthservices.com/OR/
http://www.dentalhealthservices.com/OR/
X
X
X
X
X
X
X
X
24.25
23.5
26
26
26
26
26
47
52
52
52
52
71.25
76.25
76.25
76.25
95.5
100.5
100.5
100.5
119.75
124.75
124.75
124.75
47.75
50.25
50.25
50.25
72
74.5
74.5
74.5
96.25
98.75
98.75
98.75
Not Applicable
Not Applicable
Not Applicable
350
700
Not Applicable
$10
$35
$625
$3,495
$45
$50
$350
$350
OR
Hood River
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 6
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
26.98
25.2
25.2
25.2
25.2
25.2
25.2
50.4
50.4
50.4
50.4
50.4
77.38
77.38
77.38
77.38
104.36
104.36
104.36
104.36
131.34
131.34
131.34
131.34
52.18
52.18
52.18
52.18
79.16
79.16
79.16
79.16
106.14
106.14
106.14
106.14
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Hood River
Low
Trillium Community Health Plan
95417OR0140001
Trillium Bright Family Dental - Low
PPO
Rating Area 6
Allows Adult and Child-Only
SERFF
1-541-431-1950
http://www.trilliumchp.com/Marketplace/prov-search.php
http://www.trilliumchp.com/Marketplace/PDFS/2016/ExchDen/EXCH_SB23V4-2016-Trillium-Bright-Family-Low-SOB.pdf
X
X
X
X
X
27.95
14.71
16.19
16.43
18.68
22.31
24.27
29.42
32.86
37.36
44.62
48.54
57.37
60.81
65.31
72.57
85.32
88.76
93.26
100.52
113.27
116.71
121.21
128.47
42.66
44.38
46.63
50.26
70.61
72.33
74.58
78.21
98.56
100.28
102.53
106.16
$75
$225
$75
350
700
$350
No Charge
30% Coinsurance after deductible
Not Covered
Not Covered
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
OR
Jackson
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 7
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
26.69
24.93
24.93
24.93
24.93
24.93
24.93
49.86
49.86
49.86
49.86
49.86
76.55
76.55
76.55
76.55
103.24
103.24
103.24
103.24
129.93
129.93
129.93
129.93
51.62
51.62
51.62
51.62
78.31
78.31
78.31
78.31
105
105
105
105
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Jackson
Low
Trillium Community Health Plan
95417OR0140001
Trillium Bright Family Dental - Low
PPO
Rating Area 7
Allows Adult and Child-Only
SERFF
1-541-431-1950
http://www.trilliumchp.com/Marketplace/prov-search.php
http://www.trilliumchp.com/Marketplace/PDFS/2016/ExchDen/EXCH_SB23V4-2016-Trillium-Bright-Family-Low-SOB.pdf
X
X
X
X
X
28.38
14.94
16.44
16.69
18.97
22.66
24.64
29.88
33.38
37.94
45.32
49.28
58.26
61.76
66.32
73.7
86.64
90.14
94.7
102.08
115.02
118.52
123.08
130.46
43.32
45.07
47.35
51.04
71.7
73.45
75.73
79.42
100.08
101.83
104.11
107.8
$75
$225
$75
350
700
$350
No Charge
30% Coinsurance after deductible
Not Covered
Not Covered
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
OR
Jackson
Low
Willamette Dental Insurance, Inc.
60013OR0020002
Willamette Dental ProCare Oregon Plan 1
EPO
Rating Area 7
Allows Adult and Child-Only
SERFF
1-855-433-6825
1-855-433-6825
http://www.willamettedental.com/locations-oregon.htm
https://www.willamettedental.com/procare-oregon
http://willamettedental.gelfuzion.net/_literature_225953/2016_ProCare_Oregon_Plan_1_Benefit_Summary
X
X
X
X
X
X
X
X
30.4
41.32
41.32
41.32
41.32
41.32
41.32
82.64
82.64
82.64
82.64
82.64
113.04
113.04
113.04
113.04
143.44
143.44
143.44
143.44
173.84
173.84
173.84
173.84
71.72
71.72
71.72
71.72
102.12
102.12
102.12
102.12
132.52
132.52
132.52
132.52
$0
$0
$0
350
700
Not Applicable
$45
$45
$600
$3,000
$35
$45
$600
$3,000
OR
Jefferson
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 6
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
26.98
25.2
25.2
25.2
25.2
25.2
25.2
50.4
50.4
50.4
50.4
50.4
77.38
77.38
77.38
77.38
104.36
104.36
104.36
104.36
131.34
131.34
131.34
131.34
52.18
52.18
52.18
52.18
79.16
79.16
79.16
79.16
106.14
106.14
106.14
106.14
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Jefferson
Low
Willamette Dental Insurance, Inc.
60013OR0020002
Willamette Dental ProCare Oregon Plan 1
EPO
Rating Area 6
Allows Adult and Child-Only
SERFF
1-855-433-6825
1-855-433-6825
http://www.willamettedental.com/locations-oregon.htm
https://www.willamettedental.com/procare-oregon
http://willamettedental.gelfuzion.net/_literature_225953/2016_ProCare_Oregon_Plan_1_Benefit_Summary
X
X
X
X
X
X
X
X
30.4
41.32
41.32
41.32
41.32
41.32
41.32
82.64
82.64
82.64
82.64
82.64
113.04
113.04
113.04
113.04
143.44
143.44
143.44
143.44
173.84
173.84
173.84
173.84
71.72
71.72
71.72
71.72
102.12
102.12
102.12
102.12
132.52
132.52
132.52
132.52
$0
$0
$0
350
700
Not Applicable
$45
$45
$600
$3,000
$35
$45
$600
$3,000
OR
Josephine
Low
Dental Health Services, Inc.
25486OR0020001
SmartSmile
EPO
Rating Area 7
Allows Adult and Child-Only
SERFF
1-855-495-0907
1-855-495-0907
http://www.dentalhealthservices.com/members/provider-search/index.cfm?state=OR&plan=idp&popup=&fa=search
http://www.dentalhealthservices.com/OR/
http://www.dentalhealthservices.com/OR/
X
X
X
X
X
X
X
X
24.25
14.75
17.25
17.25
17.25
17.25
17.25
29.5
34.5
34.5
34.5
34.5
53.75
58.75
58.75
58.75
78
83
83
83
102.25
107.25
107.25
107.25
39
41.5
41.5
41.5
63.25
65.75
65.75
65.75
87.5
90
90
90
Not Applicable
Not Applicable
Not Applicable
350
700
Not Applicable
$25
$52
$625
$3,495
$45
$50
$350
$350
OR
Josephine
Low
Dental Health Services, Inc.
25486OR0020002
Super SmartSmile
EPO
Rating Area 7
Allows Adult and Child-Only
SERFF
1-855-495-0907
1-855-495-0907
http://www.dentalhealthservices.com/members/provider-search/index.cfm?state=OR&plan=idp&popup=&fa=search
http://www.dentalhealthservices.com/OR/
http://www.dentalhealthservices.com/OR/
X
X
X
X
X
X
X
X
24.25
23.5
26
26
26
26
26
47
52
52
52
52
71.25
76.25
76.25
76.25
95.5
100.5
100.5
100.5
119.75
124.75
124.75
124.75
47.75
50.25
50.25
50.25
72
74.5
74.5
74.5
96.25
98.75
98.75
98.75
Not Applicable
Not Applicable
Not Applicable
350
700
Not Applicable
$10
$35
$625
$3,495
$45
$50
$350
$350
OR
Josephine
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 7
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
26.69
24.93
24.93
24.93
24.93
24.93
24.93
49.86
49.86
49.86
49.86
49.86
76.55
76.55
76.55
76.55
103.24
103.24
103.24
103.24
129.93
129.93
129.93
129.93
51.62
51.62
51.62
51.62
78.31
78.31
78.31
78.31
105
105
105
105
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Josephine
Low
Trillium Community Health Plan
95417OR0140001
Trillium Bright Family Dental - Low
PPO
Rating Area 7
Allows Adult and Child-Only
SERFF
1-541-431-1950
http://www.trilliumchp.com/Marketplace/prov-search.php
http://www.trilliumchp.com/Marketplace/PDFS/2016/ExchDen/EXCH_SB23V4-2016-Trillium-Bright-Family-Low-SOB.pdf
X
X
X
X
X
28.38
14.94
16.44
16.69
18.97
22.66
24.64
29.88
33.38
37.94
45.32
49.28
58.26
61.76
66.32
73.7
86.64
90.14
94.7
102.08
115.02
118.52
123.08
130.46
43.32
45.07
47.35
51.04
71.7
73.45
75.73
79.42
100.08
101.83
104.11
107.8
$75
$225
$75
350
700
$350
No Charge
30% Coinsurance after deductible
Not Covered
Not Covered
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
OR
Josephine
Low
Willamette Dental Insurance, Inc.
60013OR0020002
Willamette Dental ProCare Oregon Plan 1
EPO
Rating Area 7
Allows Adult and Child-Only
SERFF
1-855-433-6825
1-855-433-6825
http://www.willamettedental.com/locations-oregon.htm
https://www.willamettedental.com/procare-oregon
http://willamettedental.gelfuzion.net/_literature_225953/2016_ProCare_Oregon_Plan_1_Benefit_Summary
X
X
X
X
X
X
X
X
30.4
41.32
41.32
41.32
41.32
41.32
41.32
82.64
82.64
82.64
82.64
82.64
113.04
113.04
113.04
113.04
143.44
143.44
143.44
143.44
173.84
173.84
173.84
173.84
71.72
71.72
71.72
71.72
102.12
102.12
102.12
102.12
132.52
132.52
132.52
132.52
$0
$0
$0
350
700
Not Applicable
$45
$45
$600
$3,000
$35
$45
$600
$3,000
OR
Klamath
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 4
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
26.45
24.71
24.71
24.71
24.71
24.71
24.71
49.42
49.42
49.42
49.42
49.42
75.87
75.87
75.87
75.87
102.32
102.32
102.32
102.32
128.77
128.77
128.77
128.77
51.16
51.16
51.16
51.16
77.61
77.61
77.61
77.61
104.06
104.06
104.06
104.06
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
OR
Klamath
Low
Trillium Community Health Plan
95417OR0140001
Trillium Bright Family Dental - Low
PPO
Rating Area 4
Allows Adult and Child-Only
SERFF
1-541-431-1950
http://www.trilliumchp.com/Marketplace/prov-search.php
http://www.trilliumchp.com/Marketplace/PDFS/2016/ExchDen/EXCH_SB23V4-2016-Trillium-Bright-Family-Low-SOB.pdf
X
X
X
X
X
28.5
15
16.5
16.75
19.04
22.75
24.74
30
33.5
38.08
45.5
49.48
58.5
62
66.58
74
87
90.5
95.08
102.5
115.5
119
123.58
131
43.5
45.25
47.54
51.25
72
73.75
76.04
79.75
100.5
102.25
104.54
108.25
$75
$225
$75
350
700
$350
No Charge
30% Coinsurance after deductible
Not Covered
Not Covered
No Charge
50% Coinsurance after deductible
50% Coinsurance after deductible
Not Covered
OR
Lake
Low
Dentegra Insurance Company
68420OR0010006
Dentegra Dental PPO Family Basic Plan
PPO
Rating Area 4
Allows Adult and Child-Only
SERFF
http://www.dentegra.com/find-a-dentist
https://dentegra.com/hcx/or/68420or0010006-16
X
X
X
X
X
X
26.45
24.71
24.71
24.71
24.71
24.71
24.71
49.42
49.42
49.42
49.42
49.42
75.87
75.87
75.87
75.87
102.32
102.32
102.32
102.32
128.77
128.77
128.77
128.77
51.16
51.16
51.16
51.16
77.61
77.61
77.61
77.61
104.06
104.06
104.06
104.06
$65
See Plan Brochure
Not Applicable
350
700
$350
No Charge after Deductible
50% Coinsurance after deductible
Not Covered
Not Covered
No Charge after Deductible
50% Coinsurance after deductible
50% Coinsurance after deductible
50% Coinsurance after deductible

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