www.DeltaDentalWA.com Certificate of Coverage Table of Contents Welcome to the Uniform Dental Plan and Delta Dental of Washington (DDWA). ........................1 Retiree Participation........................................................................................................................1 Terms Used in This Booklet ...........................................................................................................1 Service Area ....................................................................................................................................6 Uniform Dental Plan Providers .......................................................................................................6 Deductible .......................................................................................................................................7 Maximum Annual Plan Payment ....................................................................................................7 Lifetime Benefit Maximums ............................................................................................................7 Specialty Services ...........................................................................................................................8 Benefit Levels for Uniform Dental Plan ..........................................................................................8 Emergency Care .............................................................................................................................8 Confirmation of Treatment and Cost ..............................................................................................9 Second Opinion...............................................................................................................................9 Covered Dental Benefits, Limitations and Exclusions ...................................................................9 Class I Benefits ........................................................................................................................9 Class II Benefits .....................................................................................................................11 Class III Benefits ....................................................................................................................14 Orthodontic Benefits ..............................................................................................................16 General Exclusions .......................................................................................................................17 Eligibility for subscribers and dependents....................................................................................18 Enrollment for subscribers and dependents ................................................................................20 Medicare eligibility and enrollment ...............................................................................................22 When dental coverage begins ......................................................................................................22 Making changes ............................................................................................................................24 When dental coverage ends .........................................................................................................27 General provisions for eligibility and enrollment ..........................................................................29 Third Party Liability .......................................................................................................................30 (Subrogation/Reimbursement) .....................................................................................................30 Coordination/Non-Duplication of Benefits ....................................................................................30 Claim Review and Appeal ............................................................................................................35 Appeals of Denied Claims ............................................................................................................36 Authorized Representative ...........................................................................................................37 Your Rights and Responsibilities..................................................................................................37 HIPAA Disclosure Policy...............................................................................................................38 2024-01-03000-BB ii LG PPOL 20240101