Summary Plan Description
50% Network and Non-Network
Services and Supplies Must Be Precertified
The Orthognathic Surgery Benefit Is Not Available Under Retiree Coverage
Benefits are provided for services and supplies provided by a physician or dentist for orthognathic surgery. Services and supplies are covered at 50 percent with a lifetime maximum of $5,000. These services always require 50 percent coinsurance and these coinsurance expenses do not apply toward the $2,300 annual coinsurance maximum or the $4,000 annual out-of-pocket maximum.
For the purpose of this plan, orthognathic surgery or surgical orthodontics refers to those surgical procedures necessary to correct the malposition of the maxilla (upper jaw bone) or the mandible (lower jaw bone). Treatment is covered when necessary to correct the following: a congenital defect or anomaly with severe functional or skeletal discrepancies; or trauma leading to an acquired defect with severe functional or skeletal discrepancies to the maxillofacial complex. Surgical treatment must be in association with conventional orthodontics. Covered services and supplies include:
- Examinations, laboratory services, x-rays, the administration of general anesthesia, the surgical procedure(s), and any complications thereof.
- Hospital or outpatient surgical services and supplies including surgical splints, stents and appliances.
Benefits are not provided for:
- Any service or supply primarily for cosmetic purposes including any direct or indirect complications thereof.
- Any treatment for a relapse of a previous orthognathic surgery.
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- 2016 Summary of Material Modifications
- 2014 Summary of Material Modifications
2017 Summary of Benefits and Coverage
Delta Dental of Washington
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