Specialty Services Specialty treatment is a covered benefit under the Uniform Dental Plan. As with all dental treatment, enrollees will receive a higher level of benefits if they obtain treatment from a PPO dentist. Enrollees may want to ask their dentists to refer them to PPO specialists in the event they need specialty care. PPO specialists are listed in the Uniform Dental Plan provider directory, or enrollees may contact the Uniform Dental Plan customer service team at (800) 537-3406. Benefit Levels for Uniform Dental Plan Services PPO Dentists in Out of Non-PPO Dentist in Washington State State Washington State Diagnostic/preventive 100% 90% 80% Restorative fillings 80% 80% 70% Oral surgery 80% 80% 70% Periodontic services 80% 80% 70% Endodontic services 80% 80% 70% Restorative crowns 50% 50% 40% Prosthodontic (dentures and bridges) 50% 50% 40% Orthodontic (to lifetime maximum plan 50% 50% 50% payment of $1,750) Non-surgical TMJ (to lifetime maximum 70% 70% 70% plan payment of $500) Orthognathic (to lifetime maximum plan 70% 70% 70% payment of $5,000) Emergency Care Emergency care is defined as treatment for relief of pain resulting from an unexpected condition that requires immediate dental treatment. Enrollees should first contact their dentists. If the enrollee’s PPO dentist is not available, they should call the Uniform Dental Plan customer service team at (800) 537-3406. DDWA will find a PPO dentist who can treat the enrollee or will approve treatment from a non-PPO dentist and will pay benefits at the PPO benefit level. If an emergency occurs after regular office hours, enrollees should first contact their PPO dentists. If the enrollee’s dentist is not available, enrollees may seek treatment from any dentist for pain relief. If a PPO dentist is not available, the enrollee’s claim from a non-PPO dentist will be paid at the PPO benefit level. Emergency care treatment involving Restorative Fillings are not subject to the frequency limitations stated in the “Class II Restoration” section of this booklet. Claims for emergency treatment received by a non-PPO dentist when the enrollee’s regular PPO dentist is not available must be sent with a written explanation to: Send your claim to: Delta Dental of Washington Customer Service Post Office Box 75983 Seattle, WA 98175-0983 2024-01-03000-BB 8 LG PPOL 20240101