Summary Plan Description
- Analgesics such as nitrous oxide, conscious sedation and euphoric drugs or injections.
- Prescription drugs.
- Consultations, office visits and study models.
- Caries susceptibility/risk tests.
- Plaque control program (oral hygiene instructions, dietary instruction and home fluoride kits).
- Overhang removal or re-contouring of restoration.
- Bone replacement graft for ridge preservation; bone grafts of any kind to the upper or lower jaws not associated with periodontal treatment of teeth; tooth transplants; or materials placed in tooth extraction sockets for the purpose of generating osseous filling.
- Duplicate dentures; personalized dentures; maintenance or cleaning of a prosthetic appliance, except for implant maintenance; temporary crowns, or copings.
- Hospitalization charges or any additional fees charged by the dentist for hospital treatment.
- Broken appointments.
- Behavior management.
- TMJ services or supplies.
- Dentistry for cosmetic reasons or bleaching of teeth.
- Crowns or restorations for anything other than decay or fracture.
- Charges for intravenous sedation or general anesthesia when billed in conjunction with any services other than covered oral surgery procedures. General anesthesia is not a covered benefit except when medically necessary for children through age six, or for a physically or developmentally disabled person and only when in conjunction with covered dental procedures.
- Charges for the replacement of a lost, missing or stolen prosthetic device, unless time limitations have been met.
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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