Dental

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Other Benefit Summaries:

MEDICAL DENTAL VISION LIFE LTD FLEX

Washington Dental Service Plan October 1, 2003 - September 30, 2004
Information provided is in summary format. Any difference between the summary provided and actual contract will be settled in favor of the contract.
Plan Number	195
Plan Type	Incentive Dental Plan
Deductible	$0
	In Network	Out-of-Network	Out-of-State
PPO Providers	DeltaPreferred Network	DeltaPremier Network	National Delta Directory
Class I: Diagnostic & Preventive*	70% - 100%	70% - 100%	70% - 100%
Class II: Restorative*	70% - 100%	70% - 100%	70% - 100%
Crowns & Onlays	70% - 100%	50%	70% - 100%
Class III: Major	50%	50%	50%
Annual Maximum	$2,000
Dependent Age Limit	Up to age 23
Predetermination Recommended For:	Extensive procedures
Orthodontia	Not covered
Check Your Benefits	Click here to check your plan coverage and eligible benefits, by entering your WDS subscriber identification number (usually the member's Social Security number) and last name at this site.

*This plan promotes preventive care by increasing payments for covered Class I and Class II procedures by 10 percent from one benefit period to the next as long as the program is used at least once during the benefit period. This can go up to 100 percent. Crowns and onlays are covered as Class II benefits (i.e., with changing levels of coverage) as long as you see a WDS PPO provider; otherwise, crowns and onlays are covered at 50%. Class III covered procedures are paid at a constant 50 percent.