Periodontics by General Dentist
Fixed Prosthodontics (Bridges/Implants)
Oral Surgery PERFORMED by General Dentist
Specialist Fee Schedule
Orthodontic Exclusions and Limitations
1. No benefits will apply for a treatment program that began BEFORE the Member/Subscriber enrolled in orthodontic plan.
2. No benefits will apply for lost or broken appliances, except provided herein
3. Ortho extractions ARE NOT included as a benefit
4. No benefits will apply for the following:
a. Care required in excess of 24 mo. From the time of banding
b. Gross non-cooperation and compliance
c. Accidents occurring during the period of treatment.
d. Cases involving surgical orthodontics.
e. Cases involving myofunctional therapy or TMJ
5. If the Member and/or Subscriber relocates to an area and is unable to receive treatment from a member orthodontist, coverage under the plan ceases and it becomes the obligation of the Member and/or Subscriber to pay the usual and customary fee of the Orthodontist where the treatment is completed.
6. Choice of Orthodontist is limited to Orthodontists participating who will accept the fees outlined in the Plan.
7. If the Member and/or Subscriber become ineligible for benefits or this Plan ceases, it becomes the obligation of the Member and/or the Subscriber to pay the remaining balance due to the Orthodontist.