— Orthodontic records: exams (initial, periodic, comprehensive, detailed and extensive), X-rays (intraoral, extraoral, diagnostic radiographs, panoramic), diagnostic photographs, diagnostic casts (study models) or cephalometric films. Limitations — Payment is limited to: o Completion of the treatment plan, or any treatment that is completed through the plan’s limiting age for Orthodontics (refer to “Dependent Eligibility and Termination”), whichever occur first. o Treatment received after coverage begins (claims must be submitted to DDWA within the time limitation stated in the Claim Forms Section of the start of coverage). For orthodontia claims, the initial banding date, which is the date the treatment date considered in the timely filing. — Treatment that began prior to the start of coverage will be prorated. Allowable payment will be calculated based on the balance of treatment costs remaining on the date of eligibility. — In the event of termination of the treatment Plan prior to completion of the case or termination of this plan, no subsequent payments will be made for treatment incurred after such termination date. Exclusions — Charges for replacement or repair of an appliance — Direct-to-consumer Orthodontics — No benefits shall be provided for services considered inappropriate and unnecessary, as determined by DDWA. ***Refer Also To General Limitations and Exclusions*** General Exclusions In addition to the specific exclusions and limitations stated elsewhere in this booklet, Uniform Dental Plan (UDP) does not provide benefits for: 1. Dentistry for cosmetic reasons. 2. Restorations or appliances necessary to correct vertical dimension or to restore the occlusion, which include restoration of tooth structure lost from attrition, abrasion or erosion, and restorations for malalignment of teeth. 3. Services or supplies that the Uniform Dental Plan determines are experimental or investigative. Experimental services or supplies are those whose use and acceptance as a course of dental treatment for a specific condition is still under investigation/observation. 4. Any drugs or medicines, even if they are prescribed. This includes analgesics (medications to relieve pain) and patient management drugs, such as premedication and nitrous oxide. 5. Laboratory tests and laboratory exams. 6. Hospital or other facility care for dental procedures, including physician services and additional fees charged by the dentist for hospital treatment. However, this exclusion will not apply and benefits will be provided for services rendered during such hospital care, including outpatient charges, if all these requirements are met: a. A hospital setting for the dental care must be medically necessary. b. Expenses for such care are not covered under the enrollee’s employer-sponsored medical plan. c. Prior to hospitalization, a request for a Confirmation of Treatment and Cost of dental treatment performed at a hospital is submitted to and approved by DDWA. Such request for Confirmation of Treatment and Costs must be accompanied by a physician’s statement of medical necessity. If hospital or facility care is approved, available benefits will be provided at the same percentage rate as those performed by a participating dental provider, up to the available benefit maximum. 7. Dental services started prior to the date the person became eligible for services under this plan, except as provided for orthodontic benefits. 2024-01-03000-BB 17 LG PPOL 20240101