Summary Plan Description
90% Network and 80% Non-Network
Benefits are provided for services and supplies performed by a physician (MD or DO) or dentist (DDS or DMD) for the prompt repair of sound natural teeth (as defined in number one below) when damaged as a result of an injury. Covered services and supplies include only those dental procedures completed within 270 days following the date of the accident, and only if the individual remains eligible under this plan. Benefits are provided based on the maximum allowable fee.
The following limitations apply to this benefit:
- Any tooth being repaired must have been a sound natural tooth, meaning whole or properly restored, without impairment or periodontal disease, and not in need of treatment for reasons other than the dental injury. Repair or replacement of existing crowns or prosthetic appliances will be covered under this benefit if satisfactory proof is submitted documenting that the need for repair or replacement is a direct result of the injury.
- If crowns, dental implants, dentures, bridgework, or in-mouth appliances are installed as a result of an injury, the plan allows only the first denture or bridgework to replace lost teeth, the first crown or dental implant to repair each damaged tooth, or the in-mouth appliance that is installed as the first course of orthodontic treatment following the injury. A dental implant is considered acceptable treatment when clear clinical evidence shows a conventional fixed or removable prosthesis cannot provide clinically acceptable treatment. If dental implant treatment is elected when a conventional fixed or removable prosthesis provides acceptable clinical treatment, an allowance for the implant will be provided based on the cost of a conventional fixed or removable prosthesis as determined by this plan.
Benefits are not provided for:
- Services or supplies related to the removal, repair, replacement, restoration, or repositioning of teeth lost or damaged in the course of biting or chewing.
- Procedures, appliances or restorations that are primarily for cosmetic purposes, including any direct or indirect complications thereof.
- Services or supplies resulting from illness or disease, or that is in any way related to an illness or disease.
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
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