Summary Plan Description
90% Network and 80% Non-Network
Benefits are provided for the services of an anesthesiologist required for a covered surgery. If you receive services from a non-network provider, and you had no choice in the selection of the provider or knowledge that the provider was a non-network provider, the plan will pay covered expenses at 90 percent/100 percent of the maximum allowable fee and coinsurance expenses will apply toward the annual coinsurance and out-of-pocket maximums. You must submit proof that you had no choice in provider selection or knowledge of the use of a non-network provider.
Benefits are not provided for:
- The patient's or physician's convenience or for fear anxiety states.
- General anesthesia or IV sedation for surgical procedures commonly and primarily performed in a clinic or physician's office.
- General anesthesia or IV sedation for dental procedures except as provided and paid for under "Dental Benefits" as administered by Delta Dental of Washington.
Related Health & Security Content
- 2017 Summary of Material Modifications (1/31/2017)
- 2017 Summary of Material Modifications (1/1/2017)
- 2016 Summary of Material Modifications
- 2014 Summary of Material Modifications
2017 Summary of Benefits and Coverage
Delta Dental of Washington
VSP Vision Care
Quit For Life
See All the Plan Rules and Forms Related to Events in Your Life