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Effective Date:
Approval Date: 88
The Iowa hawk-i Dental Plan
If you are enrolled in this Plan, you are entitled to the benefits described below.
Cost Sharing: There are no copayments, deductibles or other cost sharing for this plan.
Annual Benefit Limit: There is a $1,000 benefit maximum per calendar year.
Exceptions to the $1,000 annual benefit maximum will be based on medical necessity and a prior authorization is required. For dental services to be paid above the $1,000 annual benefit maximum must allow a plan member to return to normal, pain and infection-free oral functioning. Typically this includes: Services related to the relief of significant pain or to eliminate acute infection; Services related to treat traumatic clinical conditions; Services that allow a patient to attain the basic human functions (e.g. eating, speech, etc.) Services that prevent a condition from seriously jeopardizing one‟s health/functioning or deteriorating in an imminent time frame to a more serious and costly dental problem.
Orthodontia Payment: Payment for medically necessary orthodontia services will be paid based on an approved treatment plan by the dental carrier and does not apply to the $1.000 benefit maximum.
Dental Providers: Please contact the dental carrier for information for a listing of approved dental providers. Delta Dental of Iowa: 1-866-544-0178 or http://www.deltadentalia.com/
hawk-i Program: For information on eligibility for the hawk-i program, call hawk-i customer services at 1-800-257-8563 or at www.hawk-i.org