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| SPECIALIST SERVICES |
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Treatment for covered procedures which requires a Dentist to provide Specialist Services for oral surgery, endodontics or periodontics must be (1) referred by the assigned Contract Dentist, and (2) preauthorized in writing by us. You pay the specified Copayment. (Refer to Schedule A.)
IF YOU REQUIRE SPECIALIST SERVICES AND THERE IS NO CONTRACT DENTIST TO PROVIDE THESE SERVICES WITHIN 35 MILES OF YOUR HOME ADDRESS, YOUR ASSIGNED CONTRACT DENTIST MUST RECEIVE WRITTEN PRE-AUTHORIZATION FROM DELTA DENTAL TO REFER YOU TO AN OUT-OF-NETWORK DENTIST TO PROVIDE THE SPECIALIST SERVICES. SPECIALIST SERVICES PERFORMED BY AN OUT-OF-NETWORK DENTIST THAT ARE NOT PREAUTHORIZED BY DELTA DENTAL MAY NOT BE COVERED.
If you are referred to a dental school clinic for Specialist Services, those services may be provided by a Dentist, a dental student, a clinician or a dental instructor. Services provided by a health care professional not listed within this section are not covered.
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