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1 Frequency limitations do not apply when services are needed more frequently due to medical necessity as determined by the Contract Dentist.
2 Base or noble metal is the benefit if the Contract Dentist determines that it will restore the form and function of the tooth. If an inlay, onlay or cast post and core made of high noble metal is elected by the Enrollee, an additional fee up to $100.00 per tooth will be charged for the upgrade.
3 Replacement is subject to a limitation requiring the existing restoration to be 5+ years old.
4 Porcelain and other tooth-colored materials on molars, if elected by the Enrollee, are considered a material upgrade with a maximum additional charge to the Enrollee of $150.00.
5 A benefit for permanent teeth only.
6 Includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement, if the Enrollee continues to be eligible and the service is provided at the Contract Dentist's facility where the denture was originally delivered.
7 Replacement is subject to a limitation requiring the existing denture to be 5+ years old.
8 Limited to 1 per denture during any 12 consecutive months.
9 Replacement is subject to a limitation requiring the existing bridge to be 5+ years old.
10 Listed Copayment covers up to 24 months of active orthodontic treatment excluding the services listed for D8999 (Start-up fee), and D8680 (Orthodontic retention). Beyond 24 months, an additional monthly fee not to exceed 75 percent of the Contract Orthodontist's "filed fee" applies.
11 In the event orthodontic treatment is not required or is declined by the Enrollee, a fee of $85.00 will apply. The Enrollee is also responsible for any incurred orthodontic diagnostic record fees.
12 Includes adjustments and/or office visits up to 24 months. After 24 months, a monthly fee not to exceed 75 percent of the Contract Orthodontist's "filed fee" applies.
12 Interceptive orthodontics is defined as early treatment including orthodontia prior to the development of late mixed dentition.
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