Summary Plan Description
TMJ and MPDS Treatment
50% Network and Non-Network
The TMJ and MPDS Benefit Is Not Available Under Retiree Coverage
Benefits are provided for services and supplies for the treatment of temporomandibular joint dysfunction or disease (TMJ) and myofascial pain dysfunction syndrome (MPDS). Covered services include treatment to diagnose, prevent or correct malfunction, degeneration, disease, injury, and all other ailments or defects (congenital or hereditary) related to the joints, muscles and tissues that connect the jaw to the skull, with a lifetime maximum of $2,500. 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. Benefits are provided for:
- Examination and x-rays.
- Hospital services and supplies, and the services of a physician or dentist, including the administration of general anesthesia.
- Behavior modification including counseling, bruxism appliances and biofeedback.
- Repair and regeneration including:
- Physical therapy in the form of heat, ultrasound, electrical muscle stimulation, exercises/muscle retraining, and anesthetic injections.
- Restorative dentistry for TMJ/MPDS purposes.
- Mandibular repositioning appliances including splint therapy, bite planes and orthopedic stabilizing appliances.
- Prosthodontic dentistry.
- Surgical procedures including related hospitalization.
- Braces or retainers for tooth movement to stabilize the occlusion.
Benefits are not provided for services or supplies that are educational or experimental in nature, provided primarily for the purpose of medical or research purposes, or include treatment for restorations of the dentition, supporting tissues and bone. Procedures and instrumentation must be approved by the American Dental Association.
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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