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SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS |
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| D8000-D8999 XI. Orthodontics |
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- The listed copayment for orthodontic treatment covers up to 24 months of active treatment and 24 months of retention (includes adjustments and office visits) provided by Contract Orthodontists. Beyond 24 months of orthodontic treatment and/or beyond 24 months of retention, an additional monthly fee, not to exceed $75.00 applies. |
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| Code |
Description |
Enrollee Pays |
| D8010 |
Limited orthodontic treatment of the primary dentition |
$1,400.00 |
| D8020 |
Limited orthodontic treatment of the transitional dentition - child or adolescent to age 19 |
$1,400.00 |
| D8030 |
Limited orthodontic treatment of the adolescent dentition - adolescent to age 19 |
$1,400.00 |
| D8040 |
Limited orthodontic treatment of the adult dentition - adults, including dependent adult children covered as full-time students |
$1,600.00 |
| D8050 |
Interceptive orthodontic treatment of the primary dentition |
$1,650..00 |
| D8060 |
Interceptive orthodontic treatment of the transitional dentition |
$1,650..00 |
| D8070 |
Comprehensive orthodontic treatment of the transitional dentition - child or adolescent to age 19 |
$2,500.00 |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition - adolescent to age 19 |
$2,500.00 |
| D8090 |
Comprehensive orthodontic treatment of the adult dentition - adults, including dependent adult children covered as full-time students |
$2,700.00 |
| D8660 |
Pre-orthodontic treatment visit 3 |
No Cost |
| D8680 |
Orthodontic retention (removal of appliances, construction and placement of removable retainers) |
$250.00 |
| D8999 |
Unspecified orthodontic procedure, by report - includes treatment planning session |
$200.00 |
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