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60488412_NW_716All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest
500 NE Multnomah St Suite 100 Portland OR 97232
WASHINGTON
2017
kporgdentalnw
Dental plans for businesses in Washington with 1ndash50 eligible employees
GREAT DENTAL PLANS TO KEEP YOUR EMPLOYEES SMILING
_
SOME TERMS YOU SHOULD KNOW DISCLAIMER Annual benefit maximum the maximum amount that we will pay per member per calendar year for allcovered services
Annual deductible the amount a member must pay ina calendar year for certain services before we will coverthose services at the copayment or coinsurance in thatcalendar year
Coinsurance a percentage of charges a member pays forcovered services
Copayment a specific dollar amount a member pays forcovered services
Pediatric dental services covered on all medical plans
bull All of our medical plans include federally compliantpediatric coverage as pediatric dental coverage isrequired by law for all members
This brochure provides summaries of various plans and isnot a contract These plans are subject to exclusions andlimitations Plan details including all benefits exclusionsand limitations are provided in the Evidence of Coverage (EOC) For specific information about the plans referred toin this brochure see the following forms
bull EWSGOMADULTDNT0117
Usual and customary charge with respect to any oneservice or supply a charge for treatment that is the lesserof the following
bull EWSGOMADULTDNTDEDPPO0117
bull EWSGOMADULTDNTDED0117
bull The usual charge made by the provider forthat treatment
To obtain an EOC for a particular plan contact the ClientServices Unit at 1-866-246-3613 (toll free)
bull The customary charge made by a provider of similarprofessional standing within the same or similargeographic area for that treatment
Kaiser Foundation Health Plan of the Northwest (KFHPNW) determines such charges at the 90thpercentile of the standard fees for that area where theservice was received
6600448888441212 NNWW_ _716 22
PREVENTAMAX PLANS Traditional Dental and Dental Choice
All our dental plans offer preventive care withoutsacrificing coverage for other dental needs
With PreventaMax costs for preventive care donot count toward a planrsquos annual benefit maximum PreventaMax promotes preventive care which leadsto better dental health Preventive care includes oral exams X-rays routine cleanings fluoride treatmentsand space maintainers Get better overall care withoutgiving up coverage for fillings crowns and otherdental procedures
With other dental carriersrsquo maximum rollover planspreventive care may be delayed to ldquosave uprdquo benefitsfor major dental expenses like crowns As a resultcheckups cleanings and other restorative care may beput off for a year or more That can lead to poorer overalldental health mdash and higher costs mdash over the long run
PreventaMax plans are offered as Traditional Dentalplans and Dental Choice (PPO) plans All dental plans areavailable to groups with as few as two employees
TRADITIONAL DENTAL Our Traditional Dental plan emphasizes evidence-basedpreventive care With a copayment members can geta routine exam with X-rays a cleaning and fluoridetreatment Care is provided by our own staff of dentistshygienists and specialists
DENTAL CHOICE
Dental Choice features a preferred provider organization(PPO) with more than 6000 dentists in Oregon andWashington and more than 295000 preferred dentistsnationwide It also covers care by nonparticipating providers
Dental Choice gives employees additional provider choicesand different out-of-pocket costs based on their use of PPOvs non-PPO dentists and no referrals are required
In the example below PreventaMax members have an extra $519 to use on other services like fillings PreventaMax isavailable on our Traditional Dental plans and Dental Choice (PPO) plans
ANNUAL PREVENTIVE CARE MEMBER PAYS WE PAY
ANNUAL MAX REMAINING
WITHOUT PREVENTAMAX
ANNUAL MAX REMAINING WITH
PREVENTAMAX Two cleanings $0 $178 $1322 $1500
Two exams $0 $114 $1208 $1500
One set of X-rays $0 $120 $1088 $1500
One panoramic X-ray $0 $107 $981 $1500
TOTAL $0 $519 $981 $1500
This scenario is based on a $1500 annual benefit maximum It is an example and may not reflect a memberrsquos actual plan maximum or available benefit
VISIT US ONLINE For more information about our dental plans and services visit kporgdentalnw
60488412_NW_716 3
TRADITIONAL DENTAL (ADULT ONLY)What do you get when you combine quality andaffordability Our Traditional Dental plan
We use our dental group which includes dentistsspecialists and hygienists to care for members Formore than two decades wersquove earned the highest levelof accreditation from the Accreditation Association for Ambulatory Health Care (AAAHC) In fact KaiserPermanente is one of only four dental practices in thenation accredited as a dental home by the AAAHC Weare the first and only in the Northwest to achieve thisdistinctiondagger With a dental home your employees havea personal dentist who directs all their care referralsand follow-up visits
But the real measure of quality is customer satisfaction96 percent of our members would recommend us tofamily and friendsDagger
PERSONALIZED CARE Members are encouraged to choose a personal dentistand hygienist These personal care teams get to knowpatients and their specific needs That helps membersget the care thatrsquos right for them Members can changedentists or hygienists anytime they wish
Every member gets a dental health assessment and apersonal treatment plan
COORDINATED CARE Our dental plan and medical plan work together tooMembers of our dental plan receive health screeningsincluding head and neck cancer screenings and bloodpressure checks If members need immunizations orhave health concerns we help them get the carethey need
A CHOICE OF PREVENTAMAX PLAN DESIGNS Most levels of Traditional Dental are available with three different annual deductibles You can choose a plan withno annual deductible a $50 annual deductible ($150 perfamily) or a $100 annual deductible ($300 per family)Annual deductibles are based on the calendar year
Adult orthodontia care options Each plan when purchased with a $100 annual deductible may be purchased with (or without) adult cosmetic orthodontia
No matter which level of coverage you choose Traditional Dental covers regular dental exams for a flat fee or low coinsurance amount That includes the examination teeth cleaning X-rays and fluoride treatment Members pay this fee for routine preventive appointments regardless of whether they have met their annual deductible
EASY ACCESS TO CARE We have 18 dental offices to choose from so youremployees can easily find a dentist near home or workWe have offices in Portland Salem Oregon City TigardBeaverton Hillsboro Gresham Clackamas Vancouver Longview and Eugene
Offices are open Monday through Friday Many officesare also open on Saturdays for hygienist services and emergencies
Our online dental directory allows members to viewbiographies of our more than 150 dentists and specialiststhroughout the area Visit kporgdentalnwdirectory to search by location specialty or name
Members can make an appointment simply by calling ourAppointment Center at 1-800-813-2000 For TTY call 711For language interpretation services call 1-800-324-8010
For more information about our dental plans and services visit kporgdentalnw
Includes contracted community dentists daggerwwwaaahcorg DaggerAccording to the Press Ganey survey for July 2015ndashJune 2016
60488412_NW_716 4
TRADITIONAL PREVENTAMAX PLANS (ADULT ONLY)
ADULT PLANS PLAN NAMES1 KP WA Adult
Traditional 100 ndash$50 Ded$2500 Max
KP WA AdultTraditional 100 ndash$100 Ded$2500 Max
KP WA AdultTraditional 100 ndash$2000 Max
KP WA AdultTraditional 100 ndash$50 Ded$2000 Max
KP WA AdultTraditional 100 ndash$100 Ded$2000 Max
KP WA AdultTraditional 100 ndash$1500 Max
KP WA AdultTraditional 100 ndash$50 Ded$1500 Max
KP WA AdultTraditional 100 ndash$100 Ded$1500 Max
KP WA AdultTraditional 100 ndash$1000 Max
KP WA AdultTraditional 100 ndash$50 Ded$1000 Max
KP WA AdultTraditional 100 ndash$100 Ded$1000 Max
KP WA AdultTraditional 80 ndash$1000 Max
KP WA AdultTraditional 80 ndash$50 Ded$1000 Max
KP WA AdultTraditional 80 ndash$100 Ded$1000 Max
BENEFITS Plan pays
ANNUAL BENEFIT MAXIMUM $2500 $2000 $1500 $1000 $1000
BENEFITS Member pays
OFFICE VISIT COPAYMENT bull For plans with no deductible the officevisit charge applies to all visits
bull For plans with a deductible the officevisit charge applies only to preventive anddiagnostic visits
$10 $10 $10 $10 $10
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gumsand prescribed space maintainers
$0 $0 $0 $0 20
BASIC RESTORATIVE SERVICES Routine fillings and plastic and stainlesssteel crowns
20 20 20 20 20
SIMPLE EXTRACTIONS Simple tooth extractions 20 20 20 20 20
ORAL SURGERY Surgical tooth extractions includingdiagnosis and evaluation
20 20 20 50 20
PERIODONTICS Diagnosis evaluation and treatment of gumdisease including scaling and root planing
20 20 20 50 20
ENDODONTICS Root canal and related therapy includingdiagnosis and evaluation
20 20 20 50 20
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlays bridgeabutments and pontics
50 50 50 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relines and rebases 50 50 50 50 50
NIGHTGUARDS Guards that protect teeth from nighttimegrinding or clenching
10 10 10 10 10
NITROUS OXIDE For adults 19 and older $25 $25 $25 $25 $25
EMERGENCY TREATMENT At facilities listed on the back page
Member pays copayments or coinsurance that normally apply
EMERGENCY TREATMENT From other providers
Any charges that normally apply plus amounts that exceed usual and customary charges forqualifying claims
OPTIONAL DENTAL COVERAGE OPTION The lifetime benefit maximum is $1500 The member pays 50 percent of charges up to the orthodontic benefit maximum and then pays 100 percent thereafter
ORTHODONTIC COVERAGE CAN BE ADDED TO ANY OF THESE PLANS
KP WA Adult Traditional 100 ndash $2500 Max + ortho KP WA Adult Traditional 100 ndash $2000 Max + ortho KP WA Adult Traditional 100 ndash $1500 Max + ortho KP WA Adult Traditional 100 ndash $1000 Max + ortho KP WA Adult Traditional 80 ndash $1000 Max + ortho
For specific plan information see EOC form EWSGOMADULTDNTDED0117 (for plans with a deductible) or EWSGOMADULTDNT0117 (for plans without a deductible)1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits nitrous and nightguards do not count toward the annual benefit maximumThese plans cover members age 19 and older
DENTAL CHOICE (PPO)The choice employees want at a price you can affordEverybody wins
You can offer Dental Choice if you have at least twoemployees The plan gives your employees access toa nationwide PPO of more than 295000 dentists It includes more than 6000 dentists in Washington andOregon including those in our dental facilities
Dental Choice members never need a referral Theycan see both PPO and non-participating dentists
PPO PURCHASING POWER PPO dentists have agreed to charge fees that are up to20 to 50 percent less than usual and customarydental fees
Dental Choice covers a percentage of these alreadylow fees
bull For regular checkups the plan covers 80 to100 percent
bull Coverage for other types of work ranges from 50 to100 percent
bull Members pay their portion of the charges
When members see a non-participating dentist
bull The plan covers up to the 90th percentile ofusual and customary fees for the service (less anyapplicable coinsurance and copayments)
bull Members pay the balance of the charges
bull Non-participating dentists may charge more thanusual and customary rates Membersrsquo out-of-pocketcosts may be higher if they see a non-participatingdentist Any charges in excess of usual and customaryfees may apply
A CHOICE OF PREVENTAMAX PLAN DESIGNS Adult-only plans With Dental Choice small businesses with at least two employees have a choice of twoannual deductibles You can choose plans with a $50annual deductible ($150 per family) or a $100 annualdeductible ($300 per family) Annual deductibles arebased on the calendar year
Adult orthodontia care options Each plan whenpurchased with a $100 annual deductible may bepurchased with (or without) adult cosmetic orthodontia
Pediatric plans Our stand-alone pediatric plans havea $50 deductible The deductible amount appliesonly to the individual child enrolled in the plan themaximum family deductible is $150 Additionallyall of our pediatric dental plans have a $350 out-of-pocket maximum per child with a $700 maximum perfamily The out-of-pocket maximum applies to most in-network services
Pediatric dental coverage As part of the AffordableCare Act pediatric dental coverage for membersis required by law All of our medical plans includefederally compliant pediatric dental coverage Pleaserefer to our medical plan summaries for detailedbenefit information For employer groups that do nothave medical plans with us we now offer stand-alonepediatric coverage including a cosmeticorthodontia option
New hybrid plan We offer a unique plan design thatcovers the preventive basic and major services foradults but also includes cosmetic orthodontia for pediatric members as it may not be covered under theembedded pediatric coverage on the medical plan
FAST ACCURATE ADMINISTRATION Participating providers have agreed to file claims formembers Non-participating dentists may requestpayment up front Members would then need to file aclaim form which the dental office can help themfill out
60488412_NW_716 6
_ _
CLAIMS MAILING ADDRESS
Kaiser Permanente Dental Choice PO Box 714 Milwaukee WI 53201
ONLINE ACCESS Dental Choice members can get answers to claimsquestions at kporgdentalnw They can getinformation on the status of a claim and claim paymentsonce they register on the site
The site also lets members search for providers byname specialty and location Members can getinformation about ID cards online too
Members can also call Dental Choice Customer Care from 630 am to 5 pm Monday through Friday at1-866-498-7912 (toll free) For more information aboutour dental plans and services visit kporgdentalnw
60488412 NW 716
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT ONLY PLANS PLAN NAMES1 KP WA Adult
Choice 100 ndash$50 Ded$2500 Max
KP WA AdultChoice 100 ndash $100 Ded$2500 Max
KP WA AdultChoice 100 ndash$50 Ded$2000 Max
KP WA AdultChoice 100 ndash $100 Ded$2000 Max
KP WA AdultChoice 100 ndash$50 Ded$1500 Max
KP WA AdultChoice 100 ndash $100 Ded$1500 Max
KP WA AdultChoice 100 ndash$50 Ded$1000 Max
KP WA AdultChoice 100 ndash $100 Ded$1000 Max
KP WA AdultChoice 80 ndash$50 Ded$1000 Max
KP WA AdultChoice 80 ndash $100 Ded$1000 Max
BENEFITS Plan pays
NETWORK IN OUT IN OUT IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $2500 $2000 $1500 $1000 $1000
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 $0 $0 $0 $0 $0 $0 $0 20 20
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 20 20 20 20 20 20 20 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 20 20 20 20 20 20 20 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 20 20 20 20 20 20 20 20 20
ENDODONTICS Root canal and related therapy including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 50 50 50 50 50 50 50 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 50 50 50 50 50 50 50 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 10 10 10 10 10 10 10 10 10
NITROUS OXIDE For adults 19 and older $25 $25 $25 $25 $25 $25 $25 $25 $25 $25
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees foremergency services based on that dental officersquos policy
OPTIONAL DENTAL COVERAGE OPTION The lifetime benefit maximum is $1500 The member pays 50 percent of charges up to the orthodontic benefit maximum and then pays 100 percent thereafter
ORTHODONTIC COVERAGE CAN BE ADDED TO ANY OF THESE PLANS
KP WA Adult Choice 100 - $2500 Max + ortho KP WA Adult Choice 100 - $2000 Max + ortho KP WA Adult Choice 100 - $1500 Max + ortho KP WA Adult Choice 100 - $1000 Max + ortho KP WA Adult Choice 80 - $1000 Max + ortho
For specific plan information see EOC form EWSGOMADULTPLUSDNTDEDPPO0117 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits do not count toward the annual benefit maximumAll adult PPO plans cover members 19 and older
60488412_NW_716 8
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT PLAN (WITH PEDIATRICCOSMETIC ORTHODONTIA)
PEDIATRIC PLANS
PLAN NAMES1 KP WA Adult Choice 100+ Child Ortho
KP WA Choice 100 + OrthoPediatric Dental Plan
($50 individual$150 family)
KP WA Choice 100 Pediatric Dental Plan
($50 individual$150 family)
BENEFITS Plan pays Member pays Member pays
NETWORK IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $1500 NA NA
OUT-OF-POCKET MAXIMUM NA NA $350 per child$700 per family
NA $350 per child$700 per family
NA
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 (adult only) $0 (adult only) $0 $0
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 (adult only) 20 (adult only) 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 (adult only) 20 (adult only) 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 (adult only) 20 (adult only) 20 20
ENDODONTICS Root canal and related therapyincluding diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
ORTHODONTICS 50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary only
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 (adult only) 50 (adult only) 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 (adult only) 50 (adult only) 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 (adult only) 10 (adult only) 10 10
NITROUS OXIDE For adults 19 and older $25 (adult only) $25 (adult only) $25 13 and older
$0 12 and under $25 13 and older $0 12 and under
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees for emergency services based on that dental officersquos policy
For specific plan information see EOC form EWSGPEDDNTDEDPPOYU0117 AND EWSGPEDDNTDEDPPOYW0167 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits nitrous and nightguards do not count toward the annual benefit maximum
60488412_NW_716 9
OUR DENTAL FACILITIES
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
205 26
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
50 49
48
4765
59Lane
Please note Facility locations are approximate Facility location numbers on this map correspond with our larger location map for Kaiser Permanente Northwest
FOR MORE INFORMATION Wersquoll be happy to answer any questions you have about Traditional Dental or Dental Choice Just contactyour producer or Kaiser Foundation Health Plan of the Northwest representative
60488412_NW_716 10
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
ancouver-area enta o ces60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office65 Valley River Dental Office1011 Valley River WayEugene OR 97401
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
DENTAL FACILITIESPortland-area dental offices47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SWWestern AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
DENTAL FACILITIES Portland-area dental offices 47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SW Western AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
V d l ffi
Vancouver-area dental offices 60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices 62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office 64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office 65 Valley River Dental Office1011 Valley River WayEugene OR 97401
60488412_NW_716 11
copy2016 Kaiser Foundation Health Plan of the Northwest
kporgdentalnw
60488412_NW_716
t~ KAISER PERMANENTEreg kporgdentalnw
_
SOME TERMS YOU SHOULD KNOW DISCLAIMER Annual benefit maximum the maximum amount that we will pay per member per calendar year for allcovered services
Annual deductible the amount a member must pay ina calendar year for certain services before we will coverthose services at the copayment or coinsurance in thatcalendar year
Coinsurance a percentage of charges a member pays forcovered services
Copayment a specific dollar amount a member pays forcovered services
Pediatric dental services covered on all medical plans
bull All of our medical plans include federally compliantpediatric coverage as pediatric dental coverage isrequired by law for all members
This brochure provides summaries of various plans and isnot a contract These plans are subject to exclusions andlimitations Plan details including all benefits exclusionsand limitations are provided in the Evidence of Coverage (EOC) For specific information about the plans referred toin this brochure see the following forms
bull EWSGOMADULTDNT0117
Usual and customary charge with respect to any oneservice or supply a charge for treatment that is the lesserof the following
bull EWSGOMADULTDNTDEDPPO0117
bull EWSGOMADULTDNTDED0117
bull The usual charge made by the provider forthat treatment
To obtain an EOC for a particular plan contact the ClientServices Unit at 1-866-246-3613 (toll free)
bull The customary charge made by a provider of similarprofessional standing within the same or similargeographic area for that treatment
Kaiser Foundation Health Plan of the Northwest (KFHPNW) determines such charges at the 90thpercentile of the standard fees for that area where theservice was received
6600448888441212 NNWW_ _716 22
PREVENTAMAX PLANS Traditional Dental and Dental Choice
All our dental plans offer preventive care withoutsacrificing coverage for other dental needs
With PreventaMax costs for preventive care donot count toward a planrsquos annual benefit maximum PreventaMax promotes preventive care which leadsto better dental health Preventive care includes oral exams X-rays routine cleanings fluoride treatmentsand space maintainers Get better overall care withoutgiving up coverage for fillings crowns and otherdental procedures
With other dental carriersrsquo maximum rollover planspreventive care may be delayed to ldquosave uprdquo benefitsfor major dental expenses like crowns As a resultcheckups cleanings and other restorative care may beput off for a year or more That can lead to poorer overalldental health mdash and higher costs mdash over the long run
PreventaMax plans are offered as Traditional Dentalplans and Dental Choice (PPO) plans All dental plans areavailable to groups with as few as two employees
TRADITIONAL DENTAL Our Traditional Dental plan emphasizes evidence-basedpreventive care With a copayment members can geta routine exam with X-rays a cleaning and fluoridetreatment Care is provided by our own staff of dentistshygienists and specialists
DENTAL CHOICE
Dental Choice features a preferred provider organization(PPO) with more than 6000 dentists in Oregon andWashington and more than 295000 preferred dentistsnationwide It also covers care by nonparticipating providers
Dental Choice gives employees additional provider choicesand different out-of-pocket costs based on their use of PPOvs non-PPO dentists and no referrals are required
In the example below PreventaMax members have an extra $519 to use on other services like fillings PreventaMax isavailable on our Traditional Dental plans and Dental Choice (PPO) plans
ANNUAL PREVENTIVE CARE MEMBER PAYS WE PAY
ANNUAL MAX REMAINING
WITHOUT PREVENTAMAX
ANNUAL MAX REMAINING WITH
PREVENTAMAX Two cleanings $0 $178 $1322 $1500
Two exams $0 $114 $1208 $1500
One set of X-rays $0 $120 $1088 $1500
One panoramic X-ray $0 $107 $981 $1500
TOTAL $0 $519 $981 $1500
This scenario is based on a $1500 annual benefit maximum It is an example and may not reflect a memberrsquos actual plan maximum or available benefit
VISIT US ONLINE For more information about our dental plans and services visit kporgdentalnw
60488412_NW_716 3
TRADITIONAL DENTAL (ADULT ONLY)What do you get when you combine quality andaffordability Our Traditional Dental plan
We use our dental group which includes dentistsspecialists and hygienists to care for members Formore than two decades wersquove earned the highest levelof accreditation from the Accreditation Association for Ambulatory Health Care (AAAHC) In fact KaiserPermanente is one of only four dental practices in thenation accredited as a dental home by the AAAHC Weare the first and only in the Northwest to achieve thisdistinctiondagger With a dental home your employees havea personal dentist who directs all their care referralsand follow-up visits
But the real measure of quality is customer satisfaction96 percent of our members would recommend us tofamily and friendsDagger
PERSONALIZED CARE Members are encouraged to choose a personal dentistand hygienist These personal care teams get to knowpatients and their specific needs That helps membersget the care thatrsquos right for them Members can changedentists or hygienists anytime they wish
Every member gets a dental health assessment and apersonal treatment plan
COORDINATED CARE Our dental plan and medical plan work together tooMembers of our dental plan receive health screeningsincluding head and neck cancer screenings and bloodpressure checks If members need immunizations orhave health concerns we help them get the carethey need
A CHOICE OF PREVENTAMAX PLAN DESIGNS Most levels of Traditional Dental are available with three different annual deductibles You can choose a plan withno annual deductible a $50 annual deductible ($150 perfamily) or a $100 annual deductible ($300 per family)Annual deductibles are based on the calendar year
Adult orthodontia care options Each plan when purchased with a $100 annual deductible may be purchased with (or without) adult cosmetic orthodontia
No matter which level of coverage you choose Traditional Dental covers regular dental exams for a flat fee or low coinsurance amount That includes the examination teeth cleaning X-rays and fluoride treatment Members pay this fee for routine preventive appointments regardless of whether they have met their annual deductible
EASY ACCESS TO CARE We have 18 dental offices to choose from so youremployees can easily find a dentist near home or workWe have offices in Portland Salem Oregon City TigardBeaverton Hillsboro Gresham Clackamas Vancouver Longview and Eugene
Offices are open Monday through Friday Many officesare also open on Saturdays for hygienist services and emergencies
Our online dental directory allows members to viewbiographies of our more than 150 dentists and specialiststhroughout the area Visit kporgdentalnwdirectory to search by location specialty or name
Members can make an appointment simply by calling ourAppointment Center at 1-800-813-2000 For TTY call 711For language interpretation services call 1-800-324-8010
For more information about our dental plans and services visit kporgdentalnw
Includes contracted community dentists daggerwwwaaahcorg DaggerAccording to the Press Ganey survey for July 2015ndashJune 2016
60488412_NW_716 4
TRADITIONAL PREVENTAMAX PLANS (ADULT ONLY)
ADULT PLANS PLAN NAMES1 KP WA Adult
Traditional 100 ndash$50 Ded$2500 Max
KP WA AdultTraditional 100 ndash$100 Ded$2500 Max
KP WA AdultTraditional 100 ndash$2000 Max
KP WA AdultTraditional 100 ndash$50 Ded$2000 Max
KP WA AdultTraditional 100 ndash$100 Ded$2000 Max
KP WA AdultTraditional 100 ndash$1500 Max
KP WA AdultTraditional 100 ndash$50 Ded$1500 Max
KP WA AdultTraditional 100 ndash$100 Ded$1500 Max
KP WA AdultTraditional 100 ndash$1000 Max
KP WA AdultTraditional 100 ndash$50 Ded$1000 Max
KP WA AdultTraditional 100 ndash$100 Ded$1000 Max
KP WA AdultTraditional 80 ndash$1000 Max
KP WA AdultTraditional 80 ndash$50 Ded$1000 Max
KP WA AdultTraditional 80 ndash$100 Ded$1000 Max
BENEFITS Plan pays
ANNUAL BENEFIT MAXIMUM $2500 $2000 $1500 $1000 $1000
BENEFITS Member pays
OFFICE VISIT COPAYMENT bull For plans with no deductible the officevisit charge applies to all visits
bull For plans with a deductible the officevisit charge applies only to preventive anddiagnostic visits
$10 $10 $10 $10 $10
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gumsand prescribed space maintainers
$0 $0 $0 $0 20
BASIC RESTORATIVE SERVICES Routine fillings and plastic and stainlesssteel crowns
20 20 20 20 20
SIMPLE EXTRACTIONS Simple tooth extractions 20 20 20 20 20
ORAL SURGERY Surgical tooth extractions includingdiagnosis and evaluation
20 20 20 50 20
PERIODONTICS Diagnosis evaluation and treatment of gumdisease including scaling and root planing
20 20 20 50 20
ENDODONTICS Root canal and related therapy includingdiagnosis and evaluation
20 20 20 50 20
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlays bridgeabutments and pontics
50 50 50 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relines and rebases 50 50 50 50 50
NIGHTGUARDS Guards that protect teeth from nighttimegrinding or clenching
10 10 10 10 10
NITROUS OXIDE For adults 19 and older $25 $25 $25 $25 $25
EMERGENCY TREATMENT At facilities listed on the back page
Member pays copayments or coinsurance that normally apply
EMERGENCY TREATMENT From other providers
Any charges that normally apply plus amounts that exceed usual and customary charges forqualifying claims
OPTIONAL DENTAL COVERAGE OPTION The lifetime benefit maximum is $1500 The member pays 50 percent of charges up to the orthodontic benefit maximum and then pays 100 percent thereafter
ORTHODONTIC COVERAGE CAN BE ADDED TO ANY OF THESE PLANS
KP WA Adult Traditional 100 ndash $2500 Max + ortho KP WA Adult Traditional 100 ndash $2000 Max + ortho KP WA Adult Traditional 100 ndash $1500 Max + ortho KP WA Adult Traditional 100 ndash $1000 Max + ortho KP WA Adult Traditional 80 ndash $1000 Max + ortho
For specific plan information see EOC form EWSGOMADULTDNTDED0117 (for plans with a deductible) or EWSGOMADULTDNT0117 (for plans without a deductible)1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits nitrous and nightguards do not count toward the annual benefit maximumThese plans cover members age 19 and older
DENTAL CHOICE (PPO)The choice employees want at a price you can affordEverybody wins
You can offer Dental Choice if you have at least twoemployees The plan gives your employees access toa nationwide PPO of more than 295000 dentists It includes more than 6000 dentists in Washington andOregon including those in our dental facilities
Dental Choice members never need a referral Theycan see both PPO and non-participating dentists
PPO PURCHASING POWER PPO dentists have agreed to charge fees that are up to20 to 50 percent less than usual and customarydental fees
Dental Choice covers a percentage of these alreadylow fees
bull For regular checkups the plan covers 80 to100 percent
bull Coverage for other types of work ranges from 50 to100 percent
bull Members pay their portion of the charges
When members see a non-participating dentist
bull The plan covers up to the 90th percentile ofusual and customary fees for the service (less anyapplicable coinsurance and copayments)
bull Members pay the balance of the charges
bull Non-participating dentists may charge more thanusual and customary rates Membersrsquo out-of-pocketcosts may be higher if they see a non-participatingdentist Any charges in excess of usual and customaryfees may apply
A CHOICE OF PREVENTAMAX PLAN DESIGNS Adult-only plans With Dental Choice small businesses with at least two employees have a choice of twoannual deductibles You can choose plans with a $50annual deductible ($150 per family) or a $100 annualdeductible ($300 per family) Annual deductibles arebased on the calendar year
Adult orthodontia care options Each plan whenpurchased with a $100 annual deductible may bepurchased with (or without) adult cosmetic orthodontia
Pediatric plans Our stand-alone pediatric plans havea $50 deductible The deductible amount appliesonly to the individual child enrolled in the plan themaximum family deductible is $150 Additionallyall of our pediatric dental plans have a $350 out-of-pocket maximum per child with a $700 maximum perfamily The out-of-pocket maximum applies to most in-network services
Pediatric dental coverage As part of the AffordableCare Act pediatric dental coverage for membersis required by law All of our medical plans includefederally compliant pediatric dental coverage Pleaserefer to our medical plan summaries for detailedbenefit information For employer groups that do nothave medical plans with us we now offer stand-alonepediatric coverage including a cosmeticorthodontia option
New hybrid plan We offer a unique plan design thatcovers the preventive basic and major services foradults but also includes cosmetic orthodontia for pediatric members as it may not be covered under theembedded pediatric coverage on the medical plan
FAST ACCURATE ADMINISTRATION Participating providers have agreed to file claims formembers Non-participating dentists may requestpayment up front Members would then need to file aclaim form which the dental office can help themfill out
60488412_NW_716 6
_ _
CLAIMS MAILING ADDRESS
Kaiser Permanente Dental Choice PO Box 714 Milwaukee WI 53201
ONLINE ACCESS Dental Choice members can get answers to claimsquestions at kporgdentalnw They can getinformation on the status of a claim and claim paymentsonce they register on the site
The site also lets members search for providers byname specialty and location Members can getinformation about ID cards online too
Members can also call Dental Choice Customer Care from 630 am to 5 pm Monday through Friday at1-866-498-7912 (toll free) For more information aboutour dental plans and services visit kporgdentalnw
60488412 NW 716
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT ONLY PLANS PLAN NAMES1 KP WA Adult
Choice 100 ndash$50 Ded$2500 Max
KP WA AdultChoice 100 ndash $100 Ded$2500 Max
KP WA AdultChoice 100 ndash$50 Ded$2000 Max
KP WA AdultChoice 100 ndash $100 Ded$2000 Max
KP WA AdultChoice 100 ndash$50 Ded$1500 Max
KP WA AdultChoice 100 ndash $100 Ded$1500 Max
KP WA AdultChoice 100 ndash$50 Ded$1000 Max
KP WA AdultChoice 100 ndash $100 Ded$1000 Max
KP WA AdultChoice 80 ndash$50 Ded$1000 Max
KP WA AdultChoice 80 ndash $100 Ded$1000 Max
BENEFITS Plan pays
NETWORK IN OUT IN OUT IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $2500 $2000 $1500 $1000 $1000
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 $0 $0 $0 $0 $0 $0 $0 20 20
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 20 20 20 20 20 20 20 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 20 20 20 20 20 20 20 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 20 20 20 20 20 20 20 20 20
ENDODONTICS Root canal and related therapy including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 50 50 50 50 50 50 50 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 50 50 50 50 50 50 50 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 10 10 10 10 10 10 10 10 10
NITROUS OXIDE For adults 19 and older $25 $25 $25 $25 $25 $25 $25 $25 $25 $25
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees foremergency services based on that dental officersquos policy
OPTIONAL DENTAL COVERAGE OPTION The lifetime benefit maximum is $1500 The member pays 50 percent of charges up to the orthodontic benefit maximum and then pays 100 percent thereafter
ORTHODONTIC COVERAGE CAN BE ADDED TO ANY OF THESE PLANS
KP WA Adult Choice 100 - $2500 Max + ortho KP WA Adult Choice 100 - $2000 Max + ortho KP WA Adult Choice 100 - $1500 Max + ortho KP WA Adult Choice 100 - $1000 Max + ortho KP WA Adult Choice 80 - $1000 Max + ortho
For specific plan information see EOC form EWSGOMADULTPLUSDNTDEDPPO0117 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits do not count toward the annual benefit maximumAll adult PPO plans cover members 19 and older
60488412_NW_716 8
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT PLAN (WITH PEDIATRICCOSMETIC ORTHODONTIA)
PEDIATRIC PLANS
PLAN NAMES1 KP WA Adult Choice 100+ Child Ortho
KP WA Choice 100 + OrthoPediatric Dental Plan
($50 individual$150 family)
KP WA Choice 100 Pediatric Dental Plan
($50 individual$150 family)
BENEFITS Plan pays Member pays Member pays
NETWORK IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $1500 NA NA
OUT-OF-POCKET MAXIMUM NA NA $350 per child$700 per family
NA $350 per child$700 per family
NA
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 (adult only) $0 (adult only) $0 $0
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 (adult only) 20 (adult only) 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 (adult only) 20 (adult only) 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 (adult only) 20 (adult only) 20 20
ENDODONTICS Root canal and related therapyincluding diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
ORTHODONTICS 50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary only
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 (adult only) 50 (adult only) 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 (adult only) 50 (adult only) 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 (adult only) 10 (adult only) 10 10
NITROUS OXIDE For adults 19 and older $25 (adult only) $25 (adult only) $25 13 and older
$0 12 and under $25 13 and older $0 12 and under
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees for emergency services based on that dental officersquos policy
For specific plan information see EOC form EWSGPEDDNTDEDPPOYU0117 AND EWSGPEDDNTDEDPPOYW0167 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits nitrous and nightguards do not count toward the annual benefit maximum
60488412_NW_716 9
OUR DENTAL FACILITIES
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
205 26
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
50 49
48
4765
59Lane
Please note Facility locations are approximate Facility location numbers on this map correspond with our larger location map for Kaiser Permanente Northwest
FOR MORE INFORMATION Wersquoll be happy to answer any questions you have about Traditional Dental or Dental Choice Just contactyour producer or Kaiser Foundation Health Plan of the Northwest representative
60488412_NW_716 10
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
ancouver-area enta o ces60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office65 Valley River Dental Office1011 Valley River WayEugene OR 97401
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
DENTAL FACILITIESPortland-area dental offices47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SWWestern AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
DENTAL FACILITIES Portland-area dental offices 47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SW Western AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
V d l ffi
Vancouver-area dental offices 60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices 62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office 64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office 65 Valley River Dental Office1011 Valley River WayEugene OR 97401
60488412_NW_716 11
copy2016 Kaiser Foundation Health Plan of the Northwest
kporgdentalnw
60488412_NW_716
t~ KAISER PERMANENTEreg kporgdentalnw
PREVENTAMAX PLANS Traditional Dental and Dental Choice
All our dental plans offer preventive care withoutsacrificing coverage for other dental needs
With PreventaMax costs for preventive care donot count toward a planrsquos annual benefit maximum PreventaMax promotes preventive care which leadsto better dental health Preventive care includes oral exams X-rays routine cleanings fluoride treatmentsand space maintainers Get better overall care withoutgiving up coverage for fillings crowns and otherdental procedures
With other dental carriersrsquo maximum rollover planspreventive care may be delayed to ldquosave uprdquo benefitsfor major dental expenses like crowns As a resultcheckups cleanings and other restorative care may beput off for a year or more That can lead to poorer overalldental health mdash and higher costs mdash over the long run
PreventaMax plans are offered as Traditional Dentalplans and Dental Choice (PPO) plans All dental plans areavailable to groups with as few as two employees
TRADITIONAL DENTAL Our Traditional Dental plan emphasizes evidence-basedpreventive care With a copayment members can geta routine exam with X-rays a cleaning and fluoridetreatment Care is provided by our own staff of dentistshygienists and specialists
DENTAL CHOICE
Dental Choice features a preferred provider organization(PPO) with more than 6000 dentists in Oregon andWashington and more than 295000 preferred dentistsnationwide It also covers care by nonparticipating providers
Dental Choice gives employees additional provider choicesand different out-of-pocket costs based on their use of PPOvs non-PPO dentists and no referrals are required
In the example below PreventaMax members have an extra $519 to use on other services like fillings PreventaMax isavailable on our Traditional Dental plans and Dental Choice (PPO) plans
ANNUAL PREVENTIVE CARE MEMBER PAYS WE PAY
ANNUAL MAX REMAINING
WITHOUT PREVENTAMAX
ANNUAL MAX REMAINING WITH
PREVENTAMAX Two cleanings $0 $178 $1322 $1500
Two exams $0 $114 $1208 $1500
One set of X-rays $0 $120 $1088 $1500
One panoramic X-ray $0 $107 $981 $1500
TOTAL $0 $519 $981 $1500
This scenario is based on a $1500 annual benefit maximum It is an example and may not reflect a memberrsquos actual plan maximum or available benefit
VISIT US ONLINE For more information about our dental plans and services visit kporgdentalnw
60488412_NW_716 3
TRADITIONAL DENTAL (ADULT ONLY)What do you get when you combine quality andaffordability Our Traditional Dental plan
We use our dental group which includes dentistsspecialists and hygienists to care for members Formore than two decades wersquove earned the highest levelof accreditation from the Accreditation Association for Ambulatory Health Care (AAAHC) In fact KaiserPermanente is one of only four dental practices in thenation accredited as a dental home by the AAAHC Weare the first and only in the Northwest to achieve thisdistinctiondagger With a dental home your employees havea personal dentist who directs all their care referralsand follow-up visits
But the real measure of quality is customer satisfaction96 percent of our members would recommend us tofamily and friendsDagger
PERSONALIZED CARE Members are encouraged to choose a personal dentistand hygienist These personal care teams get to knowpatients and their specific needs That helps membersget the care thatrsquos right for them Members can changedentists or hygienists anytime they wish
Every member gets a dental health assessment and apersonal treatment plan
COORDINATED CARE Our dental plan and medical plan work together tooMembers of our dental plan receive health screeningsincluding head and neck cancer screenings and bloodpressure checks If members need immunizations orhave health concerns we help them get the carethey need
A CHOICE OF PREVENTAMAX PLAN DESIGNS Most levels of Traditional Dental are available with three different annual deductibles You can choose a plan withno annual deductible a $50 annual deductible ($150 perfamily) or a $100 annual deductible ($300 per family)Annual deductibles are based on the calendar year
Adult orthodontia care options Each plan when purchased with a $100 annual deductible may be purchased with (or without) adult cosmetic orthodontia
No matter which level of coverage you choose Traditional Dental covers regular dental exams for a flat fee or low coinsurance amount That includes the examination teeth cleaning X-rays and fluoride treatment Members pay this fee for routine preventive appointments regardless of whether they have met their annual deductible
EASY ACCESS TO CARE We have 18 dental offices to choose from so youremployees can easily find a dentist near home or workWe have offices in Portland Salem Oregon City TigardBeaverton Hillsboro Gresham Clackamas Vancouver Longview and Eugene
Offices are open Monday through Friday Many officesare also open on Saturdays for hygienist services and emergencies
Our online dental directory allows members to viewbiographies of our more than 150 dentists and specialiststhroughout the area Visit kporgdentalnwdirectory to search by location specialty or name
Members can make an appointment simply by calling ourAppointment Center at 1-800-813-2000 For TTY call 711For language interpretation services call 1-800-324-8010
For more information about our dental plans and services visit kporgdentalnw
Includes contracted community dentists daggerwwwaaahcorg DaggerAccording to the Press Ganey survey for July 2015ndashJune 2016
60488412_NW_716 4
TRADITIONAL PREVENTAMAX PLANS (ADULT ONLY)
ADULT PLANS PLAN NAMES1 KP WA Adult
Traditional 100 ndash$50 Ded$2500 Max
KP WA AdultTraditional 100 ndash$100 Ded$2500 Max
KP WA AdultTraditional 100 ndash$2000 Max
KP WA AdultTraditional 100 ndash$50 Ded$2000 Max
KP WA AdultTraditional 100 ndash$100 Ded$2000 Max
KP WA AdultTraditional 100 ndash$1500 Max
KP WA AdultTraditional 100 ndash$50 Ded$1500 Max
KP WA AdultTraditional 100 ndash$100 Ded$1500 Max
KP WA AdultTraditional 100 ndash$1000 Max
KP WA AdultTraditional 100 ndash$50 Ded$1000 Max
KP WA AdultTraditional 100 ndash$100 Ded$1000 Max
KP WA AdultTraditional 80 ndash$1000 Max
KP WA AdultTraditional 80 ndash$50 Ded$1000 Max
KP WA AdultTraditional 80 ndash$100 Ded$1000 Max
BENEFITS Plan pays
ANNUAL BENEFIT MAXIMUM $2500 $2000 $1500 $1000 $1000
BENEFITS Member pays
OFFICE VISIT COPAYMENT bull For plans with no deductible the officevisit charge applies to all visits
bull For plans with a deductible the officevisit charge applies only to preventive anddiagnostic visits
$10 $10 $10 $10 $10
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gumsand prescribed space maintainers
$0 $0 $0 $0 20
BASIC RESTORATIVE SERVICES Routine fillings and plastic and stainlesssteel crowns
20 20 20 20 20
SIMPLE EXTRACTIONS Simple tooth extractions 20 20 20 20 20
ORAL SURGERY Surgical tooth extractions includingdiagnosis and evaluation
20 20 20 50 20
PERIODONTICS Diagnosis evaluation and treatment of gumdisease including scaling and root planing
20 20 20 50 20
ENDODONTICS Root canal and related therapy includingdiagnosis and evaluation
20 20 20 50 20
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlays bridgeabutments and pontics
50 50 50 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relines and rebases 50 50 50 50 50
NIGHTGUARDS Guards that protect teeth from nighttimegrinding or clenching
10 10 10 10 10
NITROUS OXIDE For adults 19 and older $25 $25 $25 $25 $25
EMERGENCY TREATMENT At facilities listed on the back page
Member pays copayments or coinsurance that normally apply
EMERGENCY TREATMENT From other providers
Any charges that normally apply plus amounts that exceed usual and customary charges forqualifying claims
OPTIONAL DENTAL COVERAGE OPTION The lifetime benefit maximum is $1500 The member pays 50 percent of charges up to the orthodontic benefit maximum and then pays 100 percent thereafter
ORTHODONTIC COVERAGE CAN BE ADDED TO ANY OF THESE PLANS
KP WA Adult Traditional 100 ndash $2500 Max + ortho KP WA Adult Traditional 100 ndash $2000 Max + ortho KP WA Adult Traditional 100 ndash $1500 Max + ortho KP WA Adult Traditional 100 ndash $1000 Max + ortho KP WA Adult Traditional 80 ndash $1000 Max + ortho
For specific plan information see EOC form EWSGOMADULTDNTDED0117 (for plans with a deductible) or EWSGOMADULTDNT0117 (for plans without a deductible)1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits nitrous and nightguards do not count toward the annual benefit maximumThese plans cover members age 19 and older
DENTAL CHOICE (PPO)The choice employees want at a price you can affordEverybody wins
You can offer Dental Choice if you have at least twoemployees The plan gives your employees access toa nationwide PPO of more than 295000 dentists It includes more than 6000 dentists in Washington andOregon including those in our dental facilities
Dental Choice members never need a referral Theycan see both PPO and non-participating dentists
PPO PURCHASING POWER PPO dentists have agreed to charge fees that are up to20 to 50 percent less than usual and customarydental fees
Dental Choice covers a percentage of these alreadylow fees
bull For regular checkups the plan covers 80 to100 percent
bull Coverage for other types of work ranges from 50 to100 percent
bull Members pay their portion of the charges
When members see a non-participating dentist
bull The plan covers up to the 90th percentile ofusual and customary fees for the service (less anyapplicable coinsurance and copayments)
bull Members pay the balance of the charges
bull Non-participating dentists may charge more thanusual and customary rates Membersrsquo out-of-pocketcosts may be higher if they see a non-participatingdentist Any charges in excess of usual and customaryfees may apply
A CHOICE OF PREVENTAMAX PLAN DESIGNS Adult-only plans With Dental Choice small businesses with at least two employees have a choice of twoannual deductibles You can choose plans with a $50annual deductible ($150 per family) or a $100 annualdeductible ($300 per family) Annual deductibles arebased on the calendar year
Adult orthodontia care options Each plan whenpurchased with a $100 annual deductible may bepurchased with (or without) adult cosmetic orthodontia
Pediatric plans Our stand-alone pediatric plans havea $50 deductible The deductible amount appliesonly to the individual child enrolled in the plan themaximum family deductible is $150 Additionallyall of our pediatric dental plans have a $350 out-of-pocket maximum per child with a $700 maximum perfamily The out-of-pocket maximum applies to most in-network services
Pediatric dental coverage As part of the AffordableCare Act pediatric dental coverage for membersis required by law All of our medical plans includefederally compliant pediatric dental coverage Pleaserefer to our medical plan summaries for detailedbenefit information For employer groups that do nothave medical plans with us we now offer stand-alonepediatric coverage including a cosmeticorthodontia option
New hybrid plan We offer a unique plan design thatcovers the preventive basic and major services foradults but also includes cosmetic orthodontia for pediatric members as it may not be covered under theembedded pediatric coverage on the medical plan
FAST ACCURATE ADMINISTRATION Participating providers have agreed to file claims formembers Non-participating dentists may requestpayment up front Members would then need to file aclaim form which the dental office can help themfill out
60488412_NW_716 6
_ _
CLAIMS MAILING ADDRESS
Kaiser Permanente Dental Choice PO Box 714 Milwaukee WI 53201
ONLINE ACCESS Dental Choice members can get answers to claimsquestions at kporgdentalnw They can getinformation on the status of a claim and claim paymentsonce they register on the site
The site also lets members search for providers byname specialty and location Members can getinformation about ID cards online too
Members can also call Dental Choice Customer Care from 630 am to 5 pm Monday through Friday at1-866-498-7912 (toll free) For more information aboutour dental plans and services visit kporgdentalnw
60488412 NW 716
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT ONLY PLANS PLAN NAMES1 KP WA Adult
Choice 100 ndash$50 Ded$2500 Max
KP WA AdultChoice 100 ndash $100 Ded$2500 Max
KP WA AdultChoice 100 ndash$50 Ded$2000 Max
KP WA AdultChoice 100 ndash $100 Ded$2000 Max
KP WA AdultChoice 100 ndash$50 Ded$1500 Max
KP WA AdultChoice 100 ndash $100 Ded$1500 Max
KP WA AdultChoice 100 ndash$50 Ded$1000 Max
KP WA AdultChoice 100 ndash $100 Ded$1000 Max
KP WA AdultChoice 80 ndash$50 Ded$1000 Max
KP WA AdultChoice 80 ndash $100 Ded$1000 Max
BENEFITS Plan pays
NETWORK IN OUT IN OUT IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $2500 $2000 $1500 $1000 $1000
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 $0 $0 $0 $0 $0 $0 $0 20 20
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 20 20 20 20 20 20 20 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 20 20 20 20 20 20 20 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 20 20 20 20 20 20 20 20 20
ENDODONTICS Root canal and related therapy including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 50 50 50 50 50 50 50 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 50 50 50 50 50 50 50 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 10 10 10 10 10 10 10 10 10
NITROUS OXIDE For adults 19 and older $25 $25 $25 $25 $25 $25 $25 $25 $25 $25
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees foremergency services based on that dental officersquos policy
OPTIONAL DENTAL COVERAGE OPTION The lifetime benefit maximum is $1500 The member pays 50 percent of charges up to the orthodontic benefit maximum and then pays 100 percent thereafter
ORTHODONTIC COVERAGE CAN BE ADDED TO ANY OF THESE PLANS
KP WA Adult Choice 100 - $2500 Max + ortho KP WA Adult Choice 100 - $2000 Max + ortho KP WA Adult Choice 100 - $1500 Max + ortho KP WA Adult Choice 100 - $1000 Max + ortho KP WA Adult Choice 80 - $1000 Max + ortho
For specific plan information see EOC form EWSGOMADULTPLUSDNTDEDPPO0117 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits do not count toward the annual benefit maximumAll adult PPO plans cover members 19 and older
60488412_NW_716 8
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT PLAN (WITH PEDIATRICCOSMETIC ORTHODONTIA)
PEDIATRIC PLANS
PLAN NAMES1 KP WA Adult Choice 100+ Child Ortho
KP WA Choice 100 + OrthoPediatric Dental Plan
($50 individual$150 family)
KP WA Choice 100 Pediatric Dental Plan
($50 individual$150 family)
BENEFITS Plan pays Member pays Member pays
NETWORK IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $1500 NA NA
OUT-OF-POCKET MAXIMUM NA NA $350 per child$700 per family
NA $350 per child$700 per family
NA
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 (adult only) $0 (adult only) $0 $0
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 (adult only) 20 (adult only) 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 (adult only) 20 (adult only) 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 (adult only) 20 (adult only) 20 20
ENDODONTICS Root canal and related therapyincluding diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
ORTHODONTICS 50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary only
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 (adult only) 50 (adult only) 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 (adult only) 50 (adult only) 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 (adult only) 10 (adult only) 10 10
NITROUS OXIDE For adults 19 and older $25 (adult only) $25 (adult only) $25 13 and older
$0 12 and under $25 13 and older $0 12 and under
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees for emergency services based on that dental officersquos policy
For specific plan information see EOC form EWSGPEDDNTDEDPPOYU0117 AND EWSGPEDDNTDEDPPOYW0167 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits nitrous and nightguards do not count toward the annual benefit maximum
60488412_NW_716 9
OUR DENTAL FACILITIES
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
205 26
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
50 49
48
4765
59Lane
Please note Facility locations are approximate Facility location numbers on this map correspond with our larger location map for Kaiser Permanente Northwest
FOR MORE INFORMATION Wersquoll be happy to answer any questions you have about Traditional Dental or Dental Choice Just contactyour producer or Kaiser Foundation Health Plan of the Northwest representative
60488412_NW_716 10
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
ancouver-area enta o ces60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office65 Valley River Dental Office1011 Valley River WayEugene OR 97401
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
DENTAL FACILITIESPortland-area dental offices47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SWWestern AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
DENTAL FACILITIES Portland-area dental offices 47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SW Western AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
V d l ffi
Vancouver-area dental offices 60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices 62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office 64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office 65 Valley River Dental Office1011 Valley River WayEugene OR 97401
60488412_NW_716 11
copy2016 Kaiser Foundation Health Plan of the Northwest
kporgdentalnw
60488412_NW_716
t~ KAISER PERMANENTEreg kporgdentalnw
TRADITIONAL DENTAL (ADULT ONLY)What do you get when you combine quality andaffordability Our Traditional Dental plan
We use our dental group which includes dentistsspecialists and hygienists to care for members Formore than two decades wersquove earned the highest levelof accreditation from the Accreditation Association for Ambulatory Health Care (AAAHC) In fact KaiserPermanente is one of only four dental practices in thenation accredited as a dental home by the AAAHC Weare the first and only in the Northwest to achieve thisdistinctiondagger With a dental home your employees havea personal dentist who directs all their care referralsand follow-up visits
But the real measure of quality is customer satisfaction96 percent of our members would recommend us tofamily and friendsDagger
PERSONALIZED CARE Members are encouraged to choose a personal dentistand hygienist These personal care teams get to knowpatients and their specific needs That helps membersget the care thatrsquos right for them Members can changedentists or hygienists anytime they wish
Every member gets a dental health assessment and apersonal treatment plan
COORDINATED CARE Our dental plan and medical plan work together tooMembers of our dental plan receive health screeningsincluding head and neck cancer screenings and bloodpressure checks If members need immunizations orhave health concerns we help them get the carethey need
A CHOICE OF PREVENTAMAX PLAN DESIGNS Most levels of Traditional Dental are available with three different annual deductibles You can choose a plan withno annual deductible a $50 annual deductible ($150 perfamily) or a $100 annual deductible ($300 per family)Annual deductibles are based on the calendar year
Adult orthodontia care options Each plan when purchased with a $100 annual deductible may be purchased with (or without) adult cosmetic orthodontia
No matter which level of coverage you choose Traditional Dental covers regular dental exams for a flat fee or low coinsurance amount That includes the examination teeth cleaning X-rays and fluoride treatment Members pay this fee for routine preventive appointments regardless of whether they have met their annual deductible
EASY ACCESS TO CARE We have 18 dental offices to choose from so youremployees can easily find a dentist near home or workWe have offices in Portland Salem Oregon City TigardBeaverton Hillsboro Gresham Clackamas Vancouver Longview and Eugene
Offices are open Monday through Friday Many officesare also open on Saturdays for hygienist services and emergencies
Our online dental directory allows members to viewbiographies of our more than 150 dentists and specialiststhroughout the area Visit kporgdentalnwdirectory to search by location specialty or name
Members can make an appointment simply by calling ourAppointment Center at 1-800-813-2000 For TTY call 711For language interpretation services call 1-800-324-8010
For more information about our dental plans and services visit kporgdentalnw
Includes contracted community dentists daggerwwwaaahcorg DaggerAccording to the Press Ganey survey for July 2015ndashJune 2016
60488412_NW_716 4
TRADITIONAL PREVENTAMAX PLANS (ADULT ONLY)
ADULT PLANS PLAN NAMES1 KP WA Adult
Traditional 100 ndash$50 Ded$2500 Max
KP WA AdultTraditional 100 ndash$100 Ded$2500 Max
KP WA AdultTraditional 100 ndash$2000 Max
KP WA AdultTraditional 100 ndash$50 Ded$2000 Max
KP WA AdultTraditional 100 ndash$100 Ded$2000 Max
KP WA AdultTraditional 100 ndash$1500 Max
KP WA AdultTraditional 100 ndash$50 Ded$1500 Max
KP WA AdultTraditional 100 ndash$100 Ded$1500 Max
KP WA AdultTraditional 100 ndash$1000 Max
KP WA AdultTraditional 100 ndash$50 Ded$1000 Max
KP WA AdultTraditional 100 ndash$100 Ded$1000 Max
KP WA AdultTraditional 80 ndash$1000 Max
KP WA AdultTraditional 80 ndash$50 Ded$1000 Max
KP WA AdultTraditional 80 ndash$100 Ded$1000 Max
BENEFITS Plan pays
ANNUAL BENEFIT MAXIMUM $2500 $2000 $1500 $1000 $1000
BENEFITS Member pays
OFFICE VISIT COPAYMENT bull For plans with no deductible the officevisit charge applies to all visits
bull For plans with a deductible the officevisit charge applies only to preventive anddiagnostic visits
$10 $10 $10 $10 $10
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gumsand prescribed space maintainers
$0 $0 $0 $0 20
BASIC RESTORATIVE SERVICES Routine fillings and plastic and stainlesssteel crowns
20 20 20 20 20
SIMPLE EXTRACTIONS Simple tooth extractions 20 20 20 20 20
ORAL SURGERY Surgical tooth extractions includingdiagnosis and evaluation
20 20 20 50 20
PERIODONTICS Diagnosis evaluation and treatment of gumdisease including scaling and root planing
20 20 20 50 20
ENDODONTICS Root canal and related therapy includingdiagnosis and evaluation
20 20 20 50 20
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlays bridgeabutments and pontics
50 50 50 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relines and rebases 50 50 50 50 50
NIGHTGUARDS Guards that protect teeth from nighttimegrinding or clenching
10 10 10 10 10
NITROUS OXIDE For adults 19 and older $25 $25 $25 $25 $25
EMERGENCY TREATMENT At facilities listed on the back page
Member pays copayments or coinsurance that normally apply
EMERGENCY TREATMENT From other providers
Any charges that normally apply plus amounts that exceed usual and customary charges forqualifying claims
OPTIONAL DENTAL COVERAGE OPTION The lifetime benefit maximum is $1500 The member pays 50 percent of charges up to the orthodontic benefit maximum and then pays 100 percent thereafter
ORTHODONTIC COVERAGE CAN BE ADDED TO ANY OF THESE PLANS
KP WA Adult Traditional 100 ndash $2500 Max + ortho KP WA Adult Traditional 100 ndash $2000 Max + ortho KP WA Adult Traditional 100 ndash $1500 Max + ortho KP WA Adult Traditional 100 ndash $1000 Max + ortho KP WA Adult Traditional 80 ndash $1000 Max + ortho
For specific plan information see EOC form EWSGOMADULTDNTDED0117 (for plans with a deductible) or EWSGOMADULTDNT0117 (for plans without a deductible)1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits nitrous and nightguards do not count toward the annual benefit maximumThese plans cover members age 19 and older
DENTAL CHOICE (PPO)The choice employees want at a price you can affordEverybody wins
You can offer Dental Choice if you have at least twoemployees The plan gives your employees access toa nationwide PPO of more than 295000 dentists It includes more than 6000 dentists in Washington andOregon including those in our dental facilities
Dental Choice members never need a referral Theycan see both PPO and non-participating dentists
PPO PURCHASING POWER PPO dentists have agreed to charge fees that are up to20 to 50 percent less than usual and customarydental fees
Dental Choice covers a percentage of these alreadylow fees
bull For regular checkups the plan covers 80 to100 percent
bull Coverage for other types of work ranges from 50 to100 percent
bull Members pay their portion of the charges
When members see a non-participating dentist
bull The plan covers up to the 90th percentile ofusual and customary fees for the service (less anyapplicable coinsurance and copayments)
bull Members pay the balance of the charges
bull Non-participating dentists may charge more thanusual and customary rates Membersrsquo out-of-pocketcosts may be higher if they see a non-participatingdentist Any charges in excess of usual and customaryfees may apply
A CHOICE OF PREVENTAMAX PLAN DESIGNS Adult-only plans With Dental Choice small businesses with at least two employees have a choice of twoannual deductibles You can choose plans with a $50annual deductible ($150 per family) or a $100 annualdeductible ($300 per family) Annual deductibles arebased on the calendar year
Adult orthodontia care options Each plan whenpurchased with a $100 annual deductible may bepurchased with (or without) adult cosmetic orthodontia
Pediatric plans Our stand-alone pediatric plans havea $50 deductible The deductible amount appliesonly to the individual child enrolled in the plan themaximum family deductible is $150 Additionallyall of our pediatric dental plans have a $350 out-of-pocket maximum per child with a $700 maximum perfamily The out-of-pocket maximum applies to most in-network services
Pediatric dental coverage As part of the AffordableCare Act pediatric dental coverage for membersis required by law All of our medical plans includefederally compliant pediatric dental coverage Pleaserefer to our medical plan summaries for detailedbenefit information For employer groups that do nothave medical plans with us we now offer stand-alonepediatric coverage including a cosmeticorthodontia option
New hybrid plan We offer a unique plan design thatcovers the preventive basic and major services foradults but also includes cosmetic orthodontia for pediatric members as it may not be covered under theembedded pediatric coverage on the medical plan
FAST ACCURATE ADMINISTRATION Participating providers have agreed to file claims formembers Non-participating dentists may requestpayment up front Members would then need to file aclaim form which the dental office can help themfill out
60488412_NW_716 6
_ _
CLAIMS MAILING ADDRESS
Kaiser Permanente Dental Choice PO Box 714 Milwaukee WI 53201
ONLINE ACCESS Dental Choice members can get answers to claimsquestions at kporgdentalnw They can getinformation on the status of a claim and claim paymentsonce they register on the site
The site also lets members search for providers byname specialty and location Members can getinformation about ID cards online too
Members can also call Dental Choice Customer Care from 630 am to 5 pm Monday through Friday at1-866-498-7912 (toll free) For more information aboutour dental plans and services visit kporgdentalnw
60488412 NW 716
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT ONLY PLANS PLAN NAMES1 KP WA Adult
Choice 100 ndash$50 Ded$2500 Max
KP WA AdultChoice 100 ndash $100 Ded$2500 Max
KP WA AdultChoice 100 ndash$50 Ded$2000 Max
KP WA AdultChoice 100 ndash $100 Ded$2000 Max
KP WA AdultChoice 100 ndash$50 Ded$1500 Max
KP WA AdultChoice 100 ndash $100 Ded$1500 Max
KP WA AdultChoice 100 ndash$50 Ded$1000 Max
KP WA AdultChoice 100 ndash $100 Ded$1000 Max
KP WA AdultChoice 80 ndash$50 Ded$1000 Max
KP WA AdultChoice 80 ndash $100 Ded$1000 Max
BENEFITS Plan pays
NETWORK IN OUT IN OUT IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $2500 $2000 $1500 $1000 $1000
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 $0 $0 $0 $0 $0 $0 $0 20 20
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 20 20 20 20 20 20 20 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 20 20 20 20 20 20 20 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 20 20 20 20 20 20 20 20 20
ENDODONTICS Root canal and related therapy including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 50 50 50 50 50 50 50 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 50 50 50 50 50 50 50 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 10 10 10 10 10 10 10 10 10
NITROUS OXIDE For adults 19 and older $25 $25 $25 $25 $25 $25 $25 $25 $25 $25
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees foremergency services based on that dental officersquos policy
OPTIONAL DENTAL COVERAGE OPTION The lifetime benefit maximum is $1500 The member pays 50 percent of charges up to the orthodontic benefit maximum and then pays 100 percent thereafter
ORTHODONTIC COVERAGE CAN BE ADDED TO ANY OF THESE PLANS
KP WA Adult Choice 100 - $2500 Max + ortho KP WA Adult Choice 100 - $2000 Max + ortho KP WA Adult Choice 100 - $1500 Max + ortho KP WA Adult Choice 100 - $1000 Max + ortho KP WA Adult Choice 80 - $1000 Max + ortho
For specific plan information see EOC form EWSGOMADULTPLUSDNTDEDPPO0117 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits do not count toward the annual benefit maximumAll adult PPO plans cover members 19 and older
60488412_NW_716 8
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT PLAN (WITH PEDIATRICCOSMETIC ORTHODONTIA)
PEDIATRIC PLANS
PLAN NAMES1 KP WA Adult Choice 100+ Child Ortho
KP WA Choice 100 + OrthoPediatric Dental Plan
($50 individual$150 family)
KP WA Choice 100 Pediatric Dental Plan
($50 individual$150 family)
BENEFITS Plan pays Member pays Member pays
NETWORK IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $1500 NA NA
OUT-OF-POCKET MAXIMUM NA NA $350 per child$700 per family
NA $350 per child$700 per family
NA
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 (adult only) $0 (adult only) $0 $0
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 (adult only) 20 (adult only) 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 (adult only) 20 (adult only) 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 (adult only) 20 (adult only) 20 20
ENDODONTICS Root canal and related therapyincluding diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
ORTHODONTICS 50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary only
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 (adult only) 50 (adult only) 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 (adult only) 50 (adult only) 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 (adult only) 10 (adult only) 10 10
NITROUS OXIDE For adults 19 and older $25 (adult only) $25 (adult only) $25 13 and older
$0 12 and under $25 13 and older $0 12 and under
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees for emergency services based on that dental officersquos policy
For specific plan information see EOC form EWSGPEDDNTDEDPPOYU0117 AND EWSGPEDDNTDEDPPOYW0167 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits nitrous and nightguards do not count toward the annual benefit maximum
60488412_NW_716 9
OUR DENTAL FACILITIES
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
205 26
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
50 49
48
4765
59Lane
Please note Facility locations are approximate Facility location numbers on this map correspond with our larger location map for Kaiser Permanente Northwest
FOR MORE INFORMATION Wersquoll be happy to answer any questions you have about Traditional Dental or Dental Choice Just contactyour producer or Kaiser Foundation Health Plan of the Northwest representative
60488412_NW_716 10
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
ancouver-area enta o ces60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office65 Valley River Dental Office1011 Valley River WayEugene OR 97401
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
DENTAL FACILITIESPortland-area dental offices47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SWWestern AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
DENTAL FACILITIES Portland-area dental offices 47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SW Western AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
V d l ffi
Vancouver-area dental offices 60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices 62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office 64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office 65 Valley River Dental Office1011 Valley River WayEugene OR 97401
60488412_NW_716 11
copy2016 Kaiser Foundation Health Plan of the Northwest
kporgdentalnw
60488412_NW_716
t~ KAISER PERMANENTEreg kporgdentalnw
TRADITIONAL PREVENTAMAX PLANS (ADULT ONLY)
ADULT PLANS PLAN NAMES1 KP WA Adult
Traditional 100 ndash$50 Ded$2500 Max
KP WA AdultTraditional 100 ndash$100 Ded$2500 Max
KP WA AdultTraditional 100 ndash$2000 Max
KP WA AdultTraditional 100 ndash$50 Ded$2000 Max
KP WA AdultTraditional 100 ndash$100 Ded$2000 Max
KP WA AdultTraditional 100 ndash$1500 Max
KP WA AdultTraditional 100 ndash$50 Ded$1500 Max
KP WA AdultTraditional 100 ndash$100 Ded$1500 Max
KP WA AdultTraditional 100 ndash$1000 Max
KP WA AdultTraditional 100 ndash$50 Ded$1000 Max
KP WA AdultTraditional 100 ndash$100 Ded$1000 Max
KP WA AdultTraditional 80 ndash$1000 Max
KP WA AdultTraditional 80 ndash$50 Ded$1000 Max
KP WA AdultTraditional 80 ndash$100 Ded$1000 Max
BENEFITS Plan pays
ANNUAL BENEFIT MAXIMUM $2500 $2000 $1500 $1000 $1000
BENEFITS Member pays
OFFICE VISIT COPAYMENT bull For plans with no deductible the officevisit charge applies to all visits
bull For plans with a deductible the officevisit charge applies only to preventive anddiagnostic visits
$10 $10 $10 $10 $10
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gumsand prescribed space maintainers
$0 $0 $0 $0 20
BASIC RESTORATIVE SERVICES Routine fillings and plastic and stainlesssteel crowns
20 20 20 20 20
SIMPLE EXTRACTIONS Simple tooth extractions 20 20 20 20 20
ORAL SURGERY Surgical tooth extractions includingdiagnosis and evaluation
20 20 20 50 20
PERIODONTICS Diagnosis evaluation and treatment of gumdisease including scaling and root planing
20 20 20 50 20
ENDODONTICS Root canal and related therapy includingdiagnosis and evaluation
20 20 20 50 20
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlays bridgeabutments and pontics
50 50 50 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relines and rebases 50 50 50 50 50
NIGHTGUARDS Guards that protect teeth from nighttimegrinding or clenching
10 10 10 10 10
NITROUS OXIDE For adults 19 and older $25 $25 $25 $25 $25
EMERGENCY TREATMENT At facilities listed on the back page
Member pays copayments or coinsurance that normally apply
EMERGENCY TREATMENT From other providers
Any charges that normally apply plus amounts that exceed usual and customary charges forqualifying claims
OPTIONAL DENTAL COVERAGE OPTION The lifetime benefit maximum is $1500 The member pays 50 percent of charges up to the orthodontic benefit maximum and then pays 100 percent thereafter
ORTHODONTIC COVERAGE CAN BE ADDED TO ANY OF THESE PLANS
KP WA Adult Traditional 100 ndash $2500 Max + ortho KP WA Adult Traditional 100 ndash $2000 Max + ortho KP WA Adult Traditional 100 ndash $1500 Max + ortho KP WA Adult Traditional 100 ndash $1000 Max + ortho KP WA Adult Traditional 80 ndash $1000 Max + ortho
For specific plan information see EOC form EWSGOMADULTDNTDED0117 (for plans with a deductible) or EWSGOMADULTDNT0117 (for plans without a deductible)1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits nitrous and nightguards do not count toward the annual benefit maximumThese plans cover members age 19 and older
DENTAL CHOICE (PPO)The choice employees want at a price you can affordEverybody wins
You can offer Dental Choice if you have at least twoemployees The plan gives your employees access toa nationwide PPO of more than 295000 dentists It includes more than 6000 dentists in Washington andOregon including those in our dental facilities
Dental Choice members never need a referral Theycan see both PPO and non-participating dentists
PPO PURCHASING POWER PPO dentists have agreed to charge fees that are up to20 to 50 percent less than usual and customarydental fees
Dental Choice covers a percentage of these alreadylow fees
bull For regular checkups the plan covers 80 to100 percent
bull Coverage for other types of work ranges from 50 to100 percent
bull Members pay their portion of the charges
When members see a non-participating dentist
bull The plan covers up to the 90th percentile ofusual and customary fees for the service (less anyapplicable coinsurance and copayments)
bull Members pay the balance of the charges
bull Non-participating dentists may charge more thanusual and customary rates Membersrsquo out-of-pocketcosts may be higher if they see a non-participatingdentist Any charges in excess of usual and customaryfees may apply
A CHOICE OF PREVENTAMAX PLAN DESIGNS Adult-only plans With Dental Choice small businesses with at least two employees have a choice of twoannual deductibles You can choose plans with a $50annual deductible ($150 per family) or a $100 annualdeductible ($300 per family) Annual deductibles arebased on the calendar year
Adult orthodontia care options Each plan whenpurchased with a $100 annual deductible may bepurchased with (or without) adult cosmetic orthodontia
Pediatric plans Our stand-alone pediatric plans havea $50 deductible The deductible amount appliesonly to the individual child enrolled in the plan themaximum family deductible is $150 Additionallyall of our pediatric dental plans have a $350 out-of-pocket maximum per child with a $700 maximum perfamily The out-of-pocket maximum applies to most in-network services
Pediatric dental coverage As part of the AffordableCare Act pediatric dental coverage for membersis required by law All of our medical plans includefederally compliant pediatric dental coverage Pleaserefer to our medical plan summaries for detailedbenefit information For employer groups that do nothave medical plans with us we now offer stand-alonepediatric coverage including a cosmeticorthodontia option
New hybrid plan We offer a unique plan design thatcovers the preventive basic and major services foradults but also includes cosmetic orthodontia for pediatric members as it may not be covered under theembedded pediatric coverage on the medical plan
FAST ACCURATE ADMINISTRATION Participating providers have agreed to file claims formembers Non-participating dentists may requestpayment up front Members would then need to file aclaim form which the dental office can help themfill out
60488412_NW_716 6
_ _
CLAIMS MAILING ADDRESS
Kaiser Permanente Dental Choice PO Box 714 Milwaukee WI 53201
ONLINE ACCESS Dental Choice members can get answers to claimsquestions at kporgdentalnw They can getinformation on the status of a claim and claim paymentsonce they register on the site
The site also lets members search for providers byname specialty and location Members can getinformation about ID cards online too
Members can also call Dental Choice Customer Care from 630 am to 5 pm Monday through Friday at1-866-498-7912 (toll free) For more information aboutour dental plans and services visit kporgdentalnw
60488412 NW 716
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT ONLY PLANS PLAN NAMES1 KP WA Adult
Choice 100 ndash$50 Ded$2500 Max
KP WA AdultChoice 100 ndash $100 Ded$2500 Max
KP WA AdultChoice 100 ndash$50 Ded$2000 Max
KP WA AdultChoice 100 ndash $100 Ded$2000 Max
KP WA AdultChoice 100 ndash$50 Ded$1500 Max
KP WA AdultChoice 100 ndash $100 Ded$1500 Max
KP WA AdultChoice 100 ndash$50 Ded$1000 Max
KP WA AdultChoice 100 ndash $100 Ded$1000 Max
KP WA AdultChoice 80 ndash$50 Ded$1000 Max
KP WA AdultChoice 80 ndash $100 Ded$1000 Max
BENEFITS Plan pays
NETWORK IN OUT IN OUT IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $2500 $2000 $1500 $1000 $1000
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 $0 $0 $0 $0 $0 $0 $0 20 20
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 20 20 20 20 20 20 20 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 20 20 20 20 20 20 20 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 20 20 20 20 20 20 20 20 20
ENDODONTICS Root canal and related therapy including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 50 50 50 50 50 50 50 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 50 50 50 50 50 50 50 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 10 10 10 10 10 10 10 10 10
NITROUS OXIDE For adults 19 and older $25 $25 $25 $25 $25 $25 $25 $25 $25 $25
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees foremergency services based on that dental officersquos policy
OPTIONAL DENTAL COVERAGE OPTION The lifetime benefit maximum is $1500 The member pays 50 percent of charges up to the orthodontic benefit maximum and then pays 100 percent thereafter
ORTHODONTIC COVERAGE CAN BE ADDED TO ANY OF THESE PLANS
KP WA Adult Choice 100 - $2500 Max + ortho KP WA Adult Choice 100 - $2000 Max + ortho KP WA Adult Choice 100 - $1500 Max + ortho KP WA Adult Choice 100 - $1000 Max + ortho KP WA Adult Choice 80 - $1000 Max + ortho
For specific plan information see EOC form EWSGOMADULTPLUSDNTDEDPPO0117 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits do not count toward the annual benefit maximumAll adult PPO plans cover members 19 and older
60488412_NW_716 8
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT PLAN (WITH PEDIATRICCOSMETIC ORTHODONTIA)
PEDIATRIC PLANS
PLAN NAMES1 KP WA Adult Choice 100+ Child Ortho
KP WA Choice 100 + OrthoPediatric Dental Plan
($50 individual$150 family)
KP WA Choice 100 Pediatric Dental Plan
($50 individual$150 family)
BENEFITS Plan pays Member pays Member pays
NETWORK IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $1500 NA NA
OUT-OF-POCKET MAXIMUM NA NA $350 per child$700 per family
NA $350 per child$700 per family
NA
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 (adult only) $0 (adult only) $0 $0
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 (adult only) 20 (adult only) 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 (adult only) 20 (adult only) 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 (adult only) 20 (adult only) 20 20
ENDODONTICS Root canal and related therapyincluding diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
ORTHODONTICS 50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary only
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 (adult only) 50 (adult only) 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 (adult only) 50 (adult only) 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 (adult only) 10 (adult only) 10 10
NITROUS OXIDE For adults 19 and older $25 (adult only) $25 (adult only) $25 13 and older
$0 12 and under $25 13 and older $0 12 and under
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees for emergency services based on that dental officersquos policy
For specific plan information see EOC form EWSGPEDDNTDEDPPOYU0117 AND EWSGPEDDNTDEDPPOYW0167 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits nitrous and nightguards do not count toward the annual benefit maximum
60488412_NW_716 9
OUR DENTAL FACILITIES
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
205 26
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
50 49
48
4765
59Lane
Please note Facility locations are approximate Facility location numbers on this map correspond with our larger location map for Kaiser Permanente Northwest
FOR MORE INFORMATION Wersquoll be happy to answer any questions you have about Traditional Dental or Dental Choice Just contactyour producer or Kaiser Foundation Health Plan of the Northwest representative
60488412_NW_716 10
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
ancouver-area enta o ces60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office65 Valley River Dental Office1011 Valley River WayEugene OR 97401
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
DENTAL FACILITIESPortland-area dental offices47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SWWestern AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
DENTAL FACILITIES Portland-area dental offices 47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SW Western AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
V d l ffi
Vancouver-area dental offices 60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices 62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office 64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office 65 Valley River Dental Office1011 Valley River WayEugene OR 97401
60488412_NW_716 11
copy2016 Kaiser Foundation Health Plan of the Northwest
kporgdentalnw
60488412_NW_716
t~ KAISER PERMANENTEreg kporgdentalnw
DENTAL CHOICE (PPO)The choice employees want at a price you can affordEverybody wins
You can offer Dental Choice if you have at least twoemployees The plan gives your employees access toa nationwide PPO of more than 295000 dentists It includes more than 6000 dentists in Washington andOregon including those in our dental facilities
Dental Choice members never need a referral Theycan see both PPO and non-participating dentists
PPO PURCHASING POWER PPO dentists have agreed to charge fees that are up to20 to 50 percent less than usual and customarydental fees
Dental Choice covers a percentage of these alreadylow fees
bull For regular checkups the plan covers 80 to100 percent
bull Coverage for other types of work ranges from 50 to100 percent
bull Members pay their portion of the charges
When members see a non-participating dentist
bull The plan covers up to the 90th percentile ofusual and customary fees for the service (less anyapplicable coinsurance and copayments)
bull Members pay the balance of the charges
bull Non-participating dentists may charge more thanusual and customary rates Membersrsquo out-of-pocketcosts may be higher if they see a non-participatingdentist Any charges in excess of usual and customaryfees may apply
A CHOICE OF PREVENTAMAX PLAN DESIGNS Adult-only plans With Dental Choice small businesses with at least two employees have a choice of twoannual deductibles You can choose plans with a $50annual deductible ($150 per family) or a $100 annualdeductible ($300 per family) Annual deductibles arebased on the calendar year
Adult orthodontia care options Each plan whenpurchased with a $100 annual deductible may bepurchased with (or without) adult cosmetic orthodontia
Pediatric plans Our stand-alone pediatric plans havea $50 deductible The deductible amount appliesonly to the individual child enrolled in the plan themaximum family deductible is $150 Additionallyall of our pediatric dental plans have a $350 out-of-pocket maximum per child with a $700 maximum perfamily The out-of-pocket maximum applies to most in-network services
Pediatric dental coverage As part of the AffordableCare Act pediatric dental coverage for membersis required by law All of our medical plans includefederally compliant pediatric dental coverage Pleaserefer to our medical plan summaries for detailedbenefit information For employer groups that do nothave medical plans with us we now offer stand-alonepediatric coverage including a cosmeticorthodontia option
New hybrid plan We offer a unique plan design thatcovers the preventive basic and major services foradults but also includes cosmetic orthodontia for pediatric members as it may not be covered under theembedded pediatric coverage on the medical plan
FAST ACCURATE ADMINISTRATION Participating providers have agreed to file claims formembers Non-participating dentists may requestpayment up front Members would then need to file aclaim form which the dental office can help themfill out
60488412_NW_716 6
_ _
CLAIMS MAILING ADDRESS
Kaiser Permanente Dental Choice PO Box 714 Milwaukee WI 53201
ONLINE ACCESS Dental Choice members can get answers to claimsquestions at kporgdentalnw They can getinformation on the status of a claim and claim paymentsonce they register on the site
The site also lets members search for providers byname specialty and location Members can getinformation about ID cards online too
Members can also call Dental Choice Customer Care from 630 am to 5 pm Monday through Friday at1-866-498-7912 (toll free) For more information aboutour dental plans and services visit kporgdentalnw
60488412 NW 716
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT ONLY PLANS PLAN NAMES1 KP WA Adult
Choice 100 ndash$50 Ded$2500 Max
KP WA AdultChoice 100 ndash $100 Ded$2500 Max
KP WA AdultChoice 100 ndash$50 Ded$2000 Max
KP WA AdultChoice 100 ndash $100 Ded$2000 Max
KP WA AdultChoice 100 ndash$50 Ded$1500 Max
KP WA AdultChoice 100 ndash $100 Ded$1500 Max
KP WA AdultChoice 100 ndash$50 Ded$1000 Max
KP WA AdultChoice 100 ndash $100 Ded$1000 Max
KP WA AdultChoice 80 ndash$50 Ded$1000 Max
KP WA AdultChoice 80 ndash $100 Ded$1000 Max
BENEFITS Plan pays
NETWORK IN OUT IN OUT IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $2500 $2000 $1500 $1000 $1000
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 $0 $0 $0 $0 $0 $0 $0 20 20
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 20 20 20 20 20 20 20 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 20 20 20 20 20 20 20 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 20 20 20 20 20 20 20 20 20
ENDODONTICS Root canal and related therapy including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 50 50 50 50 50 50 50 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 50 50 50 50 50 50 50 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 10 10 10 10 10 10 10 10 10
NITROUS OXIDE For adults 19 and older $25 $25 $25 $25 $25 $25 $25 $25 $25 $25
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees foremergency services based on that dental officersquos policy
OPTIONAL DENTAL COVERAGE OPTION The lifetime benefit maximum is $1500 The member pays 50 percent of charges up to the orthodontic benefit maximum and then pays 100 percent thereafter
ORTHODONTIC COVERAGE CAN BE ADDED TO ANY OF THESE PLANS
KP WA Adult Choice 100 - $2500 Max + ortho KP WA Adult Choice 100 - $2000 Max + ortho KP WA Adult Choice 100 - $1500 Max + ortho KP WA Adult Choice 100 - $1000 Max + ortho KP WA Adult Choice 80 - $1000 Max + ortho
For specific plan information see EOC form EWSGOMADULTPLUSDNTDEDPPO0117 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits do not count toward the annual benefit maximumAll adult PPO plans cover members 19 and older
60488412_NW_716 8
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT PLAN (WITH PEDIATRICCOSMETIC ORTHODONTIA)
PEDIATRIC PLANS
PLAN NAMES1 KP WA Adult Choice 100+ Child Ortho
KP WA Choice 100 + OrthoPediatric Dental Plan
($50 individual$150 family)
KP WA Choice 100 Pediatric Dental Plan
($50 individual$150 family)
BENEFITS Plan pays Member pays Member pays
NETWORK IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $1500 NA NA
OUT-OF-POCKET MAXIMUM NA NA $350 per child$700 per family
NA $350 per child$700 per family
NA
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 (adult only) $0 (adult only) $0 $0
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 (adult only) 20 (adult only) 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 (adult only) 20 (adult only) 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 (adult only) 20 (adult only) 20 20
ENDODONTICS Root canal and related therapyincluding diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
ORTHODONTICS 50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary only
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 (adult only) 50 (adult only) 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 (adult only) 50 (adult only) 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 (adult only) 10 (adult only) 10 10
NITROUS OXIDE For adults 19 and older $25 (adult only) $25 (adult only) $25 13 and older
$0 12 and under $25 13 and older $0 12 and under
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees for emergency services based on that dental officersquos policy
For specific plan information see EOC form EWSGPEDDNTDEDPPOYU0117 AND EWSGPEDDNTDEDPPOYW0167 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits nitrous and nightguards do not count toward the annual benefit maximum
60488412_NW_716 9
OUR DENTAL FACILITIES
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
205 26
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
50 49
48
4765
59Lane
Please note Facility locations are approximate Facility location numbers on this map correspond with our larger location map for Kaiser Permanente Northwest
FOR MORE INFORMATION Wersquoll be happy to answer any questions you have about Traditional Dental or Dental Choice Just contactyour producer or Kaiser Foundation Health Plan of the Northwest representative
60488412_NW_716 10
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
ancouver-area enta o ces60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office65 Valley River Dental Office1011 Valley River WayEugene OR 97401
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
DENTAL FACILITIESPortland-area dental offices47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SWWestern AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
DENTAL FACILITIES Portland-area dental offices 47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SW Western AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
V d l ffi
Vancouver-area dental offices 60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices 62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office 64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office 65 Valley River Dental Office1011 Valley River WayEugene OR 97401
60488412_NW_716 11
copy2016 Kaiser Foundation Health Plan of the Northwest
kporgdentalnw
60488412_NW_716
t~ KAISER PERMANENTEreg kporgdentalnw
_ _
CLAIMS MAILING ADDRESS
Kaiser Permanente Dental Choice PO Box 714 Milwaukee WI 53201
ONLINE ACCESS Dental Choice members can get answers to claimsquestions at kporgdentalnw They can getinformation on the status of a claim and claim paymentsonce they register on the site
The site also lets members search for providers byname specialty and location Members can getinformation about ID cards online too
Members can also call Dental Choice Customer Care from 630 am to 5 pm Monday through Friday at1-866-498-7912 (toll free) For more information aboutour dental plans and services visit kporgdentalnw
60488412 NW 716
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT ONLY PLANS PLAN NAMES1 KP WA Adult
Choice 100 ndash$50 Ded$2500 Max
KP WA AdultChoice 100 ndash $100 Ded$2500 Max
KP WA AdultChoice 100 ndash$50 Ded$2000 Max
KP WA AdultChoice 100 ndash $100 Ded$2000 Max
KP WA AdultChoice 100 ndash$50 Ded$1500 Max
KP WA AdultChoice 100 ndash $100 Ded$1500 Max
KP WA AdultChoice 100 ndash$50 Ded$1000 Max
KP WA AdultChoice 100 ndash $100 Ded$1000 Max
KP WA AdultChoice 80 ndash$50 Ded$1000 Max
KP WA AdultChoice 80 ndash $100 Ded$1000 Max
BENEFITS Plan pays
NETWORK IN OUT IN OUT IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $2500 $2000 $1500 $1000 $1000
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 $0 $0 $0 $0 $0 $0 $0 20 20
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 20 20 20 20 20 20 20 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 20 20 20 20 20 20 20 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 20 20 20 20 20 20 20 20 20
ENDODONTICS Root canal and related therapy including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 50 50 50 50 50 50 50 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 50 50 50 50 50 50 50 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 10 10 10 10 10 10 10 10 10
NITROUS OXIDE For adults 19 and older $25 $25 $25 $25 $25 $25 $25 $25 $25 $25
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees foremergency services based on that dental officersquos policy
OPTIONAL DENTAL COVERAGE OPTION The lifetime benefit maximum is $1500 The member pays 50 percent of charges up to the orthodontic benefit maximum and then pays 100 percent thereafter
ORTHODONTIC COVERAGE CAN BE ADDED TO ANY OF THESE PLANS
KP WA Adult Choice 100 - $2500 Max + ortho KP WA Adult Choice 100 - $2000 Max + ortho KP WA Adult Choice 100 - $1500 Max + ortho KP WA Adult Choice 100 - $1000 Max + ortho KP WA Adult Choice 80 - $1000 Max + ortho
For specific plan information see EOC form EWSGOMADULTPLUSDNTDEDPPO0117 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits do not count toward the annual benefit maximumAll adult PPO plans cover members 19 and older
60488412_NW_716 8
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT PLAN (WITH PEDIATRICCOSMETIC ORTHODONTIA)
PEDIATRIC PLANS
PLAN NAMES1 KP WA Adult Choice 100+ Child Ortho
KP WA Choice 100 + OrthoPediatric Dental Plan
($50 individual$150 family)
KP WA Choice 100 Pediatric Dental Plan
($50 individual$150 family)
BENEFITS Plan pays Member pays Member pays
NETWORK IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $1500 NA NA
OUT-OF-POCKET MAXIMUM NA NA $350 per child$700 per family
NA $350 per child$700 per family
NA
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 (adult only) $0 (adult only) $0 $0
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 (adult only) 20 (adult only) 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 (adult only) 20 (adult only) 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 (adult only) 20 (adult only) 20 20
ENDODONTICS Root canal and related therapyincluding diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
ORTHODONTICS 50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary only
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 (adult only) 50 (adult only) 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 (adult only) 50 (adult only) 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 (adult only) 10 (adult only) 10 10
NITROUS OXIDE For adults 19 and older $25 (adult only) $25 (adult only) $25 13 and older
$0 12 and under $25 13 and older $0 12 and under
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees for emergency services based on that dental officersquos policy
For specific plan information see EOC form EWSGPEDDNTDEDPPOYU0117 AND EWSGPEDDNTDEDPPOYW0167 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits nitrous and nightguards do not count toward the annual benefit maximum
60488412_NW_716 9
OUR DENTAL FACILITIES
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
205 26
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
50 49
48
4765
59Lane
Please note Facility locations are approximate Facility location numbers on this map correspond with our larger location map for Kaiser Permanente Northwest
FOR MORE INFORMATION Wersquoll be happy to answer any questions you have about Traditional Dental or Dental Choice Just contactyour producer or Kaiser Foundation Health Plan of the Northwest representative
60488412_NW_716 10
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
ancouver-area enta o ces60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office65 Valley River Dental Office1011 Valley River WayEugene OR 97401
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
DENTAL FACILITIESPortland-area dental offices47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SWWestern AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
DENTAL FACILITIES Portland-area dental offices 47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SW Western AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
V d l ffi
Vancouver-area dental offices 60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices 62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office 64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office 65 Valley River Dental Office1011 Valley River WayEugene OR 97401
60488412_NW_716 11
copy2016 Kaiser Foundation Health Plan of the Northwest
kporgdentalnw
60488412_NW_716
t~ KAISER PERMANENTEreg kporgdentalnw
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT ONLY PLANS PLAN NAMES1 KP WA Adult
Choice 100 ndash$50 Ded$2500 Max
KP WA AdultChoice 100 ndash $100 Ded$2500 Max
KP WA AdultChoice 100 ndash$50 Ded$2000 Max
KP WA AdultChoice 100 ndash $100 Ded$2000 Max
KP WA AdultChoice 100 ndash$50 Ded$1500 Max
KP WA AdultChoice 100 ndash $100 Ded$1500 Max
KP WA AdultChoice 100 ndash$50 Ded$1000 Max
KP WA AdultChoice 100 ndash $100 Ded$1000 Max
KP WA AdultChoice 80 ndash$50 Ded$1000 Max
KP WA AdultChoice 80 ndash $100 Ded$1000 Max
BENEFITS Plan pays
NETWORK IN OUT IN OUT IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $2500 $2000 $1500 $1000 $1000
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 $0 $0 $0 $0 $0 $0 $0 20 20
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 20 20 20 20 20 20 20 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 20 20 20 20 20 20 20 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 20 20 20 20 20 20 20 20 20
ENDODONTICS Root canal and related therapy including diagnosis and evaluation
20 20 20 20 20 20 20 20 20 20
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 50 50 50 50 50 50 50 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 50 50 50 50 50 50 50 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 10 10 10 10 10 10 10 10 10
NITROUS OXIDE For adults 19 and older $25 $25 $25 $25 $25 $25 $25 $25 $25 $25
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees foremergency services based on that dental officersquos policy
OPTIONAL DENTAL COVERAGE OPTION The lifetime benefit maximum is $1500 The member pays 50 percent of charges up to the orthodontic benefit maximum and then pays 100 percent thereafter
ORTHODONTIC COVERAGE CAN BE ADDED TO ANY OF THESE PLANS
KP WA Adult Choice 100 - $2500 Max + ortho KP WA Adult Choice 100 - $2000 Max + ortho KP WA Adult Choice 100 - $1500 Max + ortho KP WA Adult Choice 100 - $1000 Max + ortho KP WA Adult Choice 80 - $1000 Max + ortho
For specific plan information see EOC form EWSGOMADULTPLUSDNTDEDPPO0117 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits do not count toward the annual benefit maximumAll adult PPO plans cover members 19 and older
60488412_NW_716 8
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT PLAN (WITH PEDIATRICCOSMETIC ORTHODONTIA)
PEDIATRIC PLANS
PLAN NAMES1 KP WA Adult Choice 100+ Child Ortho
KP WA Choice 100 + OrthoPediatric Dental Plan
($50 individual$150 family)
KP WA Choice 100 Pediatric Dental Plan
($50 individual$150 family)
BENEFITS Plan pays Member pays Member pays
NETWORK IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $1500 NA NA
OUT-OF-POCKET MAXIMUM NA NA $350 per child$700 per family
NA $350 per child$700 per family
NA
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 (adult only) $0 (adult only) $0 $0
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 (adult only) 20 (adult only) 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 (adult only) 20 (adult only) 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 (adult only) 20 (adult only) 20 20
ENDODONTICS Root canal and related therapyincluding diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
ORTHODONTICS 50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary only
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 (adult only) 50 (adult only) 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 (adult only) 50 (adult only) 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 (adult only) 10 (adult only) 10 10
NITROUS OXIDE For adults 19 and older $25 (adult only) $25 (adult only) $25 13 and older
$0 12 and under $25 13 and older $0 12 and under
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees for emergency services based on that dental officersquos policy
For specific plan information see EOC form EWSGPEDDNTDEDPPOYU0117 AND EWSGPEDDNTDEDPPOYW0167 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits nitrous and nightguards do not count toward the annual benefit maximum
60488412_NW_716 9
OUR DENTAL FACILITIES
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
205 26
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
50 49
48
4765
59Lane
Please note Facility locations are approximate Facility location numbers on this map correspond with our larger location map for Kaiser Permanente Northwest
FOR MORE INFORMATION Wersquoll be happy to answer any questions you have about Traditional Dental or Dental Choice Just contactyour producer or Kaiser Foundation Health Plan of the Northwest representative
60488412_NW_716 10
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
ancouver-area enta o ces60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office65 Valley River Dental Office1011 Valley River WayEugene OR 97401
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
DENTAL FACILITIESPortland-area dental offices47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SWWestern AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
DENTAL FACILITIES Portland-area dental offices 47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SW Western AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
V d l ffi
Vancouver-area dental offices 60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices 62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office 64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office 65 Valley River Dental Office1011 Valley River WayEugene OR 97401
60488412_NW_716 11
copy2016 Kaiser Foundation Health Plan of the Northwest
kporgdentalnw
60488412_NW_716
t~ KAISER PERMANENTEreg kporgdentalnw
DENTAL CHOICE PREVENTAMAX DENTAL PLANS (PPO)
ADULT PLAN (WITH PEDIATRICCOSMETIC ORTHODONTIA)
PEDIATRIC PLANS
PLAN NAMES1 KP WA Adult Choice 100+ Child Ortho
KP WA Choice 100 + OrthoPediatric Dental Plan
($50 individual$150 family)
KP WA Choice 100 Pediatric Dental Plan
($50 individual$150 family)
BENEFITS Plan pays Member pays Member pays
NETWORK IN OUT IN OUT IN OUT
ANNUAL BENEFIT MAXIMUM $1500 NA NA
OUT-OF-POCKET MAXIMUM NA NA $350 per child$700 per family
NA $350 per child$700 per family
NA
BENEFITS Member pays
PREVENTIVE AND DIAGNOSTIC SERVICES2
Oral exams and X-rays cleaning(prophylaxis) fluoride treatmentsinstructions in the care of teeth and gums and prescribed spacemaintainers
$0 (adult only) $0 (adult only) $0 $0
BASIC RESTORATIVE SERVICES Routine fillings and plastic andstainless steel crowns
20 (adult only) 20 (adult only) 20 20
SIMPLE EXTRACTIONS Simple tooth extractions
20 (adult only) 20 (adult only) 20 20
ORAL SURGERY Surgical tooth extractions including diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
PERIODONTICS Diagnosis evaluation and treatmentof gum disease including scaling and root planing
20 (adult only) 20 (adult only) 20 20
ENDODONTICS Root canal and related therapyincluding diagnosis and evaluation
20 (adult only) 20 (adult only) 20 20
ORTHODONTICS 50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary ortho50 for traditional ortho
up to $1500 benefit maximum
50 medically necessary only
MAJOR RESTORATIVE SERVICES Gold or porcelain crowns inlaysbridge abutments and pontics
50 (adult only) 50 (adult only) 50 50
REMOVABLE PROSTHETIC SERVICES Full and partial dentures relinesand rebases
50 (adult only) 50 (adult only) 50 50
NIGHTGUARDS Guards that protect teeth fromnighttime grinding or clenching
10 (adult only) 10 (adult only) 10 10
NITROUS OXIDE For adults 19 and older $25 (adult only) $25 (adult only) $25 13 and older
$0 12 and under $25 13 and older $0 12 and under
EMERGENCY TREATMENT Member pays copayments or coinsurance that normally apply Providers may charge additional fees for emergency services based on that dental officersquos policy
For specific plan information see EOC form EWSGPEDDNTDEDPPOYU0117 AND EWSGPEDDNTDEDPPOYW0167 1Deductible does not apply to preventive and diagnostic visits2Preventive and diagnostic visits nitrous and nightguards do not count toward the annual benefit maximum
60488412_NW_716 9
OUR DENTAL FACILITIES
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
205 26
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
50 49
48
4765
59Lane
Please note Facility locations are approximate Facility location numbers on this map correspond with our larger location map for Kaiser Permanente Northwest
FOR MORE INFORMATION Wersquoll be happy to answer any questions you have about Traditional Dental or Dental Choice Just contactyour producer or Kaiser Foundation Health Plan of the Northwest representative
60488412_NW_716 10
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
ancouver-area enta o ces60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office65 Valley River Dental Office1011 Valley River WayEugene OR 97401
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
DENTAL FACILITIESPortland-area dental offices47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SWWestern AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
DENTAL FACILITIES Portland-area dental offices 47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SW Western AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
V d l ffi
Vancouver-area dental offices 60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices 62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office 64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office 65 Valley River Dental Office1011 Valley River WayEugene OR 97401
60488412_NW_716 11
copy2016 Kaiser Foundation Health Plan of the Northwest
kporgdentalnw
60488412_NW_716
t~ KAISER PERMANENTEreg kporgdentalnw
OUR DENTAL FACILITIES
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
205 26
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
50 49
48
4765
59Lane
Please note Facility locations are approximate Facility location numbers on this map correspond with our larger location map for Kaiser Permanente Northwest
FOR MORE INFORMATION Wersquoll be happy to answer any questions you have about Traditional Dental or Dental Choice Just contactyour producer or Kaiser Foundation Health Plan of the Northwest representative
60488412_NW_716 10
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
ancouver-area enta o ces60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office65 Valley River Dental Office1011 Valley River WayEugene OR 97401
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
DENTAL FACILITIESPortland-area dental offices47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SWWestern AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
DENTAL FACILITIES Portland-area dental offices 47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SW Western AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
V d l ffi
Vancouver-area dental offices 60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices 62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office 64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office 65 Valley River Dental Office1011 Valley River WayEugene OR 97401
60488412_NW_716 11
copy2016 Kaiser Foundation Health Plan of the Northwest
kporgdentalnw
60488412_NW_716
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MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
ancouver-area enta o ces60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office65 Valley River Dental Office1011 Valley River WayEugene OR 97401
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
MEDICAL FACILITIESPortland-area medical centers1 Kaiser Permanente SunnysideMedical Center10180 SE Sunnyside RoadClackamas OR 97015
2 Kaiser Permanente WestsideMedical Center2875 NW Stucki AveHillsboro OR 97124
3 OHSU Doernbecher Childrenrsquos Hospital3181 SW Sam Jackson Park RoadPortland OR 97239(For children 17 and younger)
Portland-area medical offices4 Beaverton Medical Office4855 SWWestern AveBeaverton OR 97005
5 Brookside Center10180 SE Sunnyside RoadClackamas OR 97015
6 Care Essentials by Kaiser Permanentemdash opening Fall 20161035 NW Northrup StPortland OR 97209
7 Center for Health Research3800 N Interstate AvePortland OR 97227
8 Clackamas Eye Care12100 SE Stevens Court Suite 106Portland OR 97086
9 Gateway Medical Office1700 NE 102nd AvePortland OR 97220
10 Hillsboro Medical Office5373 W Baseline Road Hillsboro OR 97123
11 Interstate Medical Office Central3600 N Interstate AvePortland OR 97227
12 Interstate Medical Office East3550 N Interstate AvePortland OR 97227
13 Interstate Medical Office South3500 N Interstate AvePortland OR 97227
14 Interstate Medical Office West3325 N Interstate AvePortland OR 97227
15 Interstate Radiation Oncology Center3620 N Interstate AvePortland OR 97227
16 Lake Road Nephrology Center6902 SE Lake Road Suite 100Milwaukie OR 97267
17 Mt Scott Medical Office9800 SE Sunnyside RoadClackamas OR 97015
18 Mt Talbert Medical Office10100 SE Sunnyside RoadClackamas OR 97015
19 Murrayhill Medical Office11200 SW Murray Scholls Place Suite 100Beaverton OR 97007
20 One Town Center10163 SE Sunnyside Road Suite 490Clackamas OR 97015
21 Rockwood Medical Office19500 SE Stark StPortland OR 97233
22 Sunnybrook Medical Office9900 SE Sunnyside RoadClackamas OR 97015
23 Sunnyside Medical Office10180 SE Sunnyside RoadClackamas OR 97015
24 Sunset Medical Office19400 NW Evergreen ParkwayHillsboro OR 97124
25 Tualatin Medical Office19185 SW 90th AveTualatin OR 97062
26 Westside Medical Office2875 NW Stucki AveHillsboro Oregon 97124(located inside Kaiser PermanenteWestside Medical Center)
The Portland Clinic facilities
27 The Portland Clinic mdash Beaverton15950 SW Millikan WayBeaverton OR 97006
28 The Portland Clinic mdash Columbia5847 NE 122nd AvePortland OR 97230
29 The Portland Clinic mdash Downtown800 SW 13th AvePortland OR 97205
30 The Portland Clinic mdash East541 NE 20th Ave Suite 210Portland OR 97232
31 The Portland Clinic mdash Hillsboro256 SE Second AveHillsboro OR 97123
32 The Portland Clinic mdash South6640 SW Redwood LanePortland OR 97224
33 The Portland Clinic mdash Tigard9250 SW Hall BlvdTigard OR 97223
Vancouver-area medical center and offices34 Legacy Salmon Creek Medical Center2211 NE 139th StVancouver WA 98686(24-hour emergency low-risk childbirth and selected services only)
35 Cascade Park Medical Office12607 SE Mill Plain BlvdVancouver WA 98684
36 Mill Plain One Medical Office203 SE Park Plaza Drive Suite 140Vancouver WA 98684
37 Orchards Medical Office7101 NE 137th AveVancouver WA 98682
38 Salmon Creek Medical Office14406 NE 20th AveVancouver WA 98686
Salem-area medical center and offices39 Salem Hospital890 Oak St SESalem OR 97301
40 Keizer Station Medical Office5940 Ulali DriveKeizer OR 97303
41 North Lancaster Medical Office2400 Lancaster Drive NESalem OR 97305
42 Skyline Medical Office5125 Skyline Road SSalem OR 97306
43 West Salem Medical Office1160 Wallace Road NWSalem OR 97304
Longview-area medical office
44 Longview-Kelso Medical Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area medical office
45 Downtown Eugene Medical Office100 W 13th AveEugene OR 97401
Battle Ground-area medical office
46 Battle Ground Medical Office 720 W Main St Suite 15Battle Ground WA 98604
DENTAL FACILITIESPortland-area dental offices47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SWWestern AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
Available to all Kaiser Permanente members except those on Medicaid receiving full financial assistance or visiting from another Kaiser Permanente region
Polk
Washington
Columbia
Yamhill
Clark
Cowlitz
5
30
5
20526
Salem
Vancouver
Longview
Portland
N
84
Multnomah
Clackamas
217
5
5
205
205
84
26
Hillsboro
Tigard
Portland
Vancouver
Milwaukie
Tualatin
Beaverton
Oregon City
64
63
62
61
60
58
57
56
55
54
53
52
51
5049
48
47
44
43
42
4139
38
37
36
35
34
33
32
31
3029
28
2726
25
24
2322
21
2019
181716
15
14131211
10
9
8
7
5
4
32
1
40
65
45
46
6
59
Please note Facility locations are approximate Facility location numbers on this mapcorrespond with our larger location map for Kaiser Permanente Northwest
Lane
DENTAL FACILITIES Portland-area dental offices 47 Aloha Dental Office17675 SW Tualatin Valley HwyBeaverton OR 97003
48 Beaverton Dental Office4855 SW Western AveBeaverton OR 97005
49 Clackamas Dental Office10209 SE Sunnyside RoadClackamas OR 97015
50 Eastmoreland Dental Office5025 SE 28th AvePortland OR 97202
51 Glisan Dental Office10102 NE Glisan StPortland OR 97220
52 Grand Avenue Dental Office1314 NE Grand AvePortland OR 97232
53 Gresham Dental Office360 NW Burnside StGresham OR 97030
54 North Interstate Dental Office7201 N Interstate AvePortland OR 97217
55 Oregon City Dental Office1900 McLoughlin Blvd Suite 68Oregon City OR 97045
56 Rockwood Dental Office822 NE 181st AvePortland OR 97230
57 Sunset Dental Office19075 NW Tanasbourne DriveHillsboro OR 97124
58 Tigard Dental Office7105 SW Hampton StTigard OR 97223
59 Walker Road Dental Office mdash opening Fall 20162606 SW Walker Rd 12450Beaverton OR 97005
V d l ffi
Vancouver-area dental offices 60 Cascade Park Dental Office12711 SE Mill Plain BlvdVancouver WA 98684
61 Salmon Creek Dental Office14406 NE 20th AveVancouver WA 98686
Salem-area dental offices 62 North Lancaster Dental Office2300 Lancaster Drive NESalem OR 97305
63 Skyline Dental Office5135 Skyline Road SSalem OR 97306
Longview-area dental office 64 Longview-Kelso Dental Office1230 Seventh AveLongview WA 98632
Eugene-Springfield-area dental office 65 Valley River Dental Office1011 Valley River WayEugene OR 97401
60488412_NW_716 11
copy2016 Kaiser Foundation Health Plan of the Northwest
kporgdentalnw
60488412_NW_716
t~ KAISER PERMANENTEreg kporgdentalnw
copy2016 Kaiser Foundation Health Plan of the Northwest
kporgdentalnw
60488412_NW_716
t~ KAISER PERMANENTEreg kporgdentalnw
