Under the Uniform Dental Plan, enrollees have the option of seeking care from any licensed dentist, whether or not the dentist is a member of Delta Dental. However, their benefits may be paid at a higher level and their out-of- pocket costs will likely be lower if they see Delta Dental participating PPO dentists. This is because participating PPO dentists agree to provide care based on a lower average fee schedule. Participating dentists submit claim forms to DDWA and receive payments directly from DDWA. Enrollees are responsible only for stated deductibles, copayments and/or amounts in excess of the program maximum. More than 60% of Delta Dental participating dentists participate in the Uniform Dental Plan/Delta Dental PPO network. Enrollees are not required to choose a dentist at enrollment and are free to choose a different dentist each time they seek treatment. If enrollees need assistance locating PPO dentists in their areas, or have questions about benefits or payment of claims, they should call the Uniform Dental Plan customer service team at (800) 537-3406. Customer service representatives are available weekdays from 8 a.m. to 5 p.m., Monday through Friday. In addition you can obtain a current list of Delta Dental dentists by going to our website at www.DeltaDentalWa.com. This will bring up the DDWA Find a Dentist directory. Be sure to click on the Delta Dental PPO plan and follow the prompts. ® Enrollees may also seek treatment from Delta Dental Premier dentists, who are members of Delta Dental’s traditional fee-for-service plan. Their payments, however, are likely to be higher than if they see PPO dentists. ® Delta Dental Premier dentists also submit claims forms and receive payments directly from DDWA. Enrollees are responsible only for stated deductibles, copayments and/or amounts in excess of the program maximum. Nonparticipating dentists have not contracted with Delta Dental. Payment for services performed by a nonparticipating dentist is based upon enrollees’ dentist's actual charges or Delta Dental’s maximum allowable fees for nonparticipating dentists, whichever is less. If the enrollee sees a nonparticipating dentist, they will be responsible for having the dentist complete and sign claim forms. It will also be up to the enrollee to ensure that the claims are sent to DDWA. Deductible Your program has a $50 deductible per eligible person each benefit period. This means that from the first payment or payments DDWA makes for covered dental benefits, a deduction of $50 is made. This deduction is owed to the provider by you. Once each eligible person has satisfied the deductible during the benefit period, no further deduction will be taken for that eligible person until the next benefit period. The maximum deductible for all members of a family (Enrolled Subscriber and one or more Enrolled Dependents) each benefit period is three times the individual deductible, or $150. This means that the maximum amount that will be deducted for all members of a family during a benefit period, regardless of the number of eligible persons, will not exceed $150. Once a family has satisfied the maximum deductible amount during the benefit period, no further deduction will apply to any member of that family until the next benefit period. The deductible does not apply to Class I covered dental benefits or Orthodontic Benefits. Maximum Annual Plan Payment For your program, the maximum amount payable by DDWA/Delta Dental for Class I, II and III covered dental benefits per eligible person is $1,750 each benefit period. Charges for dental procedures requiring multiple treatment dates are considered incurred on the date the services are completed. Amounts paid for such procedures will be applied to the program maximum based on the incurred date. Lifetime Benefit Maximums The lifetime maximum amounts payable per eligible person for covered dental benefits are: 1. Orthodontia: $1,750 2. Temporomandibular joint (TMJ) treatment: $500 3. Orthognathic surgery: $5,000 2024-01-03000-BB 7 LG PPOL 20240101