— Fixed partial dentures (fixed bridges) — Removable partial dentures — Inlays when used as a retainer for a fixed partial denture (fixed bridge) — Adjustment or repair of an existing prosthetic appliance — Surgical placement or removal of implants or attachments to implants Limitations — Replacement of an existing fixed or removable partial denture is covered once every five years from the delivery date and only then if it is unserviceable and cannot be made serviceable. — Payment for dentures, fixed partial dentures (fixed bridges); inlays (only when used as a retainer for a fixed bridge) and removable partial dentures shall be paid upon the delivery date. — Implants and superstructures are covered once every five years. — Temporary dentures — DDWA will allow the amount of a reline toward the cost of an interim partial or full denture. After placement of the permanent prosthesis, an initial reline will be a benefit after six months. — Denture adjustments and relines — Denture adjustments and relines, done more than six months after the initial placement are covered. o Subsequent relines or rebases (but not both) will be covered once in a 12-month period from the date of service. Exclusions — Duplicate dentures — Personalized dentures — Maintenance or cleaning of a prosthetic appliance — Copings — Crowns in conjunction with overdentures Orthodontic Benefits It is strongly suggested that orthodontic treatment plan be submitted to, and a Confirmation of Treatment and Cost request be made by, DDWA prior to commencement of treatment. This will allow you to know in advance what procedures may be covered, the amount DDWA may pay toward the treatment and your expected financial responsibility. A Confirmation of Treatment and Cost is not a guarantee of payment. See the “Confirmation of Treatment and Cost” section for additional information. Additionally, payment for orthodontia is based upon eligibility. If individuals terminate coverage prior to the subsequent payment of benefits, subsequent payment is not covered. Orthodontic treatment is the appliance therapy necessary for the correction of teeth or jaws that are positioned improperly. The lifetime maximum amount payable for orthodontic benefits rendered to an eligible person is $1,750. Not more than $875 of the maximum, or one-half of the plan's total responsibility, shall be payable for treatment during the “construction phase.” The remaining plan payments shall be made in monthly increments until completion, up to the plan maximum, providing the employee is eligible and the dependent meets eligibility requirements. The plan will not pay for treatment if claim forms are submitted more than 12 months after banding date. The amount payable for orthodontic treatment shall be 50 percent of the lesser of the maximum allowable fees or the fees actually charged. Covered Dental Benefits — Fixed or removable appliance therapy for the treatment of teeth or jaws. 2024-01-03000-BB 16 LG PPOL 20240101