Summary Plan Description
90% Network and 80% Non-Network
Benefits are provided for services and supplies performed by a physician or dentist for the treatment of the tissues of the mouth. This includes treatment for the following medical conditions:
- Excision of a tumor or cyst of the jaw, cheek, lips, tongue, or roof or floor of the mouth.
- Excision of exostosis of the jaw and hard palate.
- Incision and drainage of cellulitis.
- Incision of accessory sinuses, salivary glands or ducts.
Benefits are not provided for:
- Services or supplies in connection with the correction of acquired developmental or congenital abnormalities of the jaw, or malocclusion of the jaw by orthognathic surgery with or without bone grafting, or vestibuloplasty performed by a physician or dentist, except as provided for under Orthognathic Surgery and TMJ and MPDS Treatment.
- Extraoral grafts (grafts from tissues outside the mouth or using artificial materials) or tooth transplants.
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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