These services do not include and do not cover: 1. Personalized restoration, precision attachments and special techniques. 2. Replacement of an existing denture, crown or bridge less than five years after the date of the most recent placement. 3. Denture replacements made necessary by loss, theft or breakage. Implant Services Dental implant Services are available to PEBB Members enrolled in the DeltaCare Dental Plan offered by Delta Dental of Washington. Implant Services will be available at select dental offices experienced in providing dental implants. Implant Services will not be available at every participating DeltaCare dental office location. Enrollees who have been determined by their Primary Care Provider to be candidates for dental implants will be referred to the nearest select dental office trained in the surgical placement of implants. Delta Dental of Washington strongly suggests that any implant services be submitted to Delta Dental of Washington for Confirmation of Treatment and Cost prior to commencement of treatment. Initial Implant Exam or Consultation is subject to a copayment by the subscriber. However, should the enrollee or an enrolled dependent initiate implant services at the office performing the initial Implant Exam or Consultation, the copayment for the Initial Implant Exam or Consultation will be deducted from the copayment of the implant service provided. Orthodontic Services Delta Dental of Washington strongly suggests that orthodontic treatment be submitted to, and confirmed by, DDWA prior to commencement of treatment. Initial orthodontic diagnostic work-up and X-rays are subject to a copayment. However, should the enrollee or an enrolled dependent undergo orthodontic treatment, the initial orthodontia copayment will be deducted from either the partial or full orthodontia copayment. The copayment for limited orthodontic treatment will be prorated according to the extent of orthodontia services provided. The length of treatment of full orthodontic treatment is not limited. Orthodontic treatment must be provided by a DeltaCare orthodontist. Temporomandibular Joint Treatment All treatments of temporomandibular joint disorders (TMJ) must be confirmed before treatment begins. Benefits will be denied if treatment is not confirmed. Services covered shall include but are not limited to: TMJ examination, X-rays (including TMJ film and arthrogram), temporary repositioning splint, occlusal orthotic device (occlusal guard), removable metal overlay stabilizing appliance, fixed stabilizing appliance, occlusal equilibration, arthrocentesis and manipulation under anesthesia. Benefits for surgical and nonsurgical treatment of TMJ are paid at 70% to a lifetime maximum of $5,000. Annual maximum of $1,000. Covered services must be: 1) appropriate for the treatment of a disorder of the temporomandibular joint; 2) effective for the control or elimination of one or more of the following, caused by a disorder of the temporomandibular joint: pain, infection, disease, difficulty in speaking, or difficulty in chewing or swallowing food; 3) recognized as effective, according to the professional standards of good dental practice; 4) not investigational; and 5) not primarily for cosmetic purposes. All services must be provided or ordered by the enrollee’s dentist. Any procedures that are performed in conjunction with TMJ services, and are covered benefits under another portion of the dental plan, are not covered under this portion. 2024-01-03100-BB 16 DCL 20240101