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:

  1. The patient's or physician's convenience or for fear anxiety states.
  2. General anesthesia or IV sedation for surgical procedures commonly and primarily performed in a clinic or physician's office.
  3. General anesthesia or IV sedation for dental procedures except as provided and paid for under Dental Benefits as administered by Delta Dental of Washington.