Optional Dental

Those who are members of Group Health's* individual and family plans are eligible to enroll in the Washington Dental Service (WDS) PPO program. This WDS dental plan gives you the freedom to use any dentist with slightly better benefits if you see a PPO provider. Check with your dentist to see if they are part of the PPO or Premier Network. The plan will pay a maximum of $1,000 in covered benefits for each person in any calendar year. Other benefits, limitations, and exclusions apply to this plan. This is a brief summary of coverage, not a contract.

If you seek treatment from a WDS dentist, your dentist will submit claim forms, and WDS's payment will be made directly to your dentist based on the dentist's preapproved fees. You are only responsible for ensuring that your dentist completes and mails claim forms to WDS. More than 90 percent of the dentists in Washington state are WDS participants.

If you receive treatment from a dentist who is not a participant of WDS, you will be responsible for submitting the claim form. Payment will be based on actual charges or maximum allowable fees for nonparticipating dentists, whichever is less. If you have any questions, please call WDS Customer Service at 1-800-554-1907, or visit www.DeltaDentalWA.com.

GroupHealth Optional Dental Benefits
Class I: Preventive and diagnostic care
Following is a list of your covered services according to type of service and your cost share. Note: Your plan includes the services in Class I, Class II, and Class III listed below.
Routine exams and cleanings (twice in a benefit period) Fluoride treatment for adults and children (twice in a benefit period) Sealants (once per tooth every two years) Dental X-rays	You are covered at 100% with no deductible.
Class II: Basic dental expenses
Fillings Oral surgery Endodontics (i.e., root canal therapy) Periodontics	You are covered at 50% with a $50 per person per calendar year deductible if you see a Premier or non-Member dentist † or no deductible if you see a PPO dentist.
Class III: Major expenses
Crowns, implants, and onlays Dentures, bridges, and partials Repair and adjustment to prosthetic devices Nightguards - under certain conditions of oral health (must be approved)	You are covered at 30% with a $50 per person per calendar year deductible if you see a Premier or non-Member dentist † or no deductible if you see a PPO dentist.
† $150 per family calendar year deductible. * Group Health refers to Group Health Cooperative or Group Health Options, Inc. + Children under 3 are not required to enroll.
MONTHLY RATES
Subscriber	$50.96
Subscriber and child(ren) +	$89.96
Subscriber and spouse	$96.20
Subscriber and family +	$135.19
GENERAL EXCLUSIONS
Dentistry for cosmetic reasons. Restorations or appliances necessary to correct vertical dimension or to restore the occlusion. Such procedures include restoration of tooth structure lost from attrition, abrasion, or erosion, and restorations for malalignment of teeth. Application of desensitizing agents. Experimental services or supplies. General anesthesia/intravenous (deep) sedation, except as specified by WDS for certain oral, periodontal, or endodontic surgical procedures. Analgesics such as nitrous oxide, conscious sedation, euphoric drugs, injections, or prescriptions drugs. In the event an eligible person fails to obtain a required examination from a WDS-appointed consultant dentist for certain treatments, no benefits shall be provided for such treatment. Hospitalization charges and any additional fees charged by the dentist for hospital treatment. Broken appointments Patient management problems Completing insurance forms Habit-breaking appliances or orthodontic services or supplies. TMJ services or supplies WDS shall have the discretionary authority to determine whether services are covered benefits in accordance with the general limitations and exclusions shown in this contract, but it shall not exercise this authority arbitrarily or capriciously or in violation of the provisions of the contract. This program does not provide benefits for services or supplies to the extent that benefits are payable for them under any motor vehicle medical, motor vehicle no-fault, uninsured motorist, underinsured motorist, personal injury protection (PIP), commercial liability, homeowner's policy, or other similar type of coverage. All other services not specifically included in the Contract as Covered Dental Benefits.