Specialized Services for oral surgery, endodontics, periodontics or pediatric dentistry must be referred by the assigned Contract Dentist. You will pay for all Specialized Services, which are Benefits provided by a Contract Specialty Care Dentist, directly to the Contract Specialty Care Dentist. (Refer to Schedule A.)
IF YOU REQUIRE SPECIALIZED SERVICES AND THERE IS NO CONTRACT SPECIALTY CARE DENTIST TO PROVIDE THESE SERVICES WITHIN 35 MILES OF YOUR HOME ADDRESS, YOUR ASSIGNED CONTRACT DENTIST MUST RECEIVE AUTHORIZATION FROM US TO REFER YOU TO AN OUT-OF-NETWORK DENTIST TO PROVIDE THE SPECIALIZED SERVICES. SPECIALIZED SERVICES PERFORMED BY AN OUT-OF-NETWORK DENTIST THAT ARE NOT AUTHORIZED ARE NOT COVERED.
If the services of a Contract Orthodontist are needed, please refer to Orthodontics in Schedule A, Description of Benefits and Copayments and Schedule B, Limitations and Exclusions to determine Benefits.
