Summary Plan Description
90% Network and 80% Non-Network
Benefits are provided for the following items prescribed by a physician if the patient has an immediate medical need: sterile surgical dressings; casts; splints; surgical and orthopedic appliances; compression support stockings (e.g., Jobst) up to four pair per calendar year; catheters; syringes; and formulas for the treatment of phenylketonuria. The plan may elect to provide benefits for a less costly alternative item.
Benefits are not provided for:
- Supplies purchased or dispensed when a plan benefit is not in effect or when the patient is not covered under this plan.
- Items purchased or used more frequently than considered reasonable by the plan.
- Incontinence supplies, ear plugs, enemas, alcohol swabs, cotton balls, or like supplies.
- Freight, postage or delivery charges.
- Compression support stockings (e.g., Jobst) in excess of four pair per calendar year.
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
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