WAC Periodontal scaling and root planning once per quadrant in a period for ages thirteen and older; WAC Periodontal maintenance once per quadrant in a twelve-month period for ages thirteen and older; Periodontics Required Benchmark plan Complex periodontal procedures (osseous surgery including flap Periodontic entry and closure and mucogingivoplastic surgery) limited to once Services per Member per quadrant in a five-year period; (Cont’d) Benchmark plan Debridement limited to once per Member in a period; and Benchmark plan Gingivectomy and gingivoplasty limited to once per Member per quadrant in a three-year period. Pharmacy This section applies only to plans that cover prescription drugs. If the plan does not cover prescription drugs, you can skip this section and go on to the next section, Preventive Services. No RCW 48.44.465 An HCSC may not retract an authorization issued by any means on a Retracting pharmacy claim. Authorization “Your Statement WAC Contract must include Right to Safe and Effective Pharmacy Required Services” statement. WAC Prescription benefit may include cost control measures, including requiring preferred drug substitution in a therapeutic class, if
Periodontics Required Periodontic Services (Cont’d) WAC Periodontal scaling and root planning once per quadrant in a period for ages thirteen and older; WAC Periodontal maintenance once per quadrant in a twelve-month period for ages thirteen and older; Benchmark plan Complex periodontal procedures (osseous surgery including flap entry and closure and mucogingivoplastic surgery) limited to once per Member per quadrant in a five-year period; Benchmark plan Debridement limited to once per Member in a period; and Benchmark plan Gingivectomy and gingivoplasty limited to once per Member per quadrant in a three-year period. Pharmacy This section applies only to plans that cover prescription drugs. If the plan does not cover prescription drugs, you can skip this section and go on to the next section, Preventive Services. No Retracting Authorization RCW 48.44.465 An HCSC may not retract an authorization issued by any means on a pharmacy claim. Statement Required WAC Contract must include “Your Right to Safe and Effective Pharmacy Services” statement. WAC Prescription benefit may include cost control measures, including requiring preferred drug substitution in a therapeutic class, if
cklist-forms-18-hcsc-ind-stand-alone-dental-w-pediatric-ehbs.docx