Emergencies outside the PPO service area are paid as any other treatment received outside the service area. Confirmation of Treatment and Cost If your dental care will be extensive, you may ask your dentist to complete and submit a request for an estimate, sometimes called a “Confirmation of Treatment and Cost.” This will allow you to know in advance what procedures may be covered, the amount DDWA may pay and your expected financial responsibility. A Confirmation of Treatment and Cost is not an authorization for services but a notification of Covered Dental Benefits available at the time the request is made and is not a guarantee of payment. A Confirmation of Treatment and Cost is valid for 6 months but in the event your benefits are terminated and you are no longer eligible, the Confirmation of Treatment and Cost is voided. DDWA will make payments based on your available benefits (maximum, deductible and other limitations as described in your benefits booklet) and the current plan provisions when the treatment is provided. Second Opinion To determine covered benefits for certain treatments, the Uniform Dental Plan may require a patient to obtain a second opinion from a DDWA-appointed consultant. The Uniform Dental Plan will pay 100% of the charges incurred for the second opinion. Covered Dental Benefits, Limitations and Exclusions The following covered dental benefits are subject to the limitations and exclusions contained in this booklet. Such benefits (as defined) are available only when rendered by a licensed dentist or other DDWA-approved licensed professional when appropriate and necessary as determined by the standards of generally accepted dental practice and DDWA. Claims for services must be submitted within 12 months of the completion of treatment. Note: Please be sure to consult your provider before treatment begins regarding any charges that may be your responsibility. The amounts payable by DDWA for covered dental benefits are described in the Benefit Levels for Uniform Dental Plan section of this benefit booklet. Class I Benefits Class I Diagnostic Services Covered Dental Benefits — Comprehensive, or detailed and extensive oral evaluation — Diagnostic evaluation for routine or emergency purposes — X-rays Limitations — Comprehensive or detailed and extensive oral evaluation is covered once in the patient’s lifetime by the same dentist. Subsequent comprehensive or detailed and extensive oral evaluations from the same dentist is paid as a periodic oral evaluation. — Routine evaluation is covered twice in a benefit period. Routine evaluation includes all evaluations except limited, problem-focused evaluations. — Limited problem-focused evaluations are covered twice in a benefit period. 2024-01-03000-BB 9 LG PPOL 20240101