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SCHEDULE B
ORTHODONTIC LIMITATIONS |
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The DeltaCare USA program provides coverage for orthodontic treatment plans provided through Contract Orthodontists. Start-up fees, retention fees, and the cost to the Enrollee for the treatment plan are listed in Schedule A, and are subject to the following:
- Orthodontic treatment must be provided by the selected Contract Orthodontist.
- Orthodontic Copayments are listed on Schedule A, for both interceptive and comprehensive orthodontic treatment. Additional fees will be charged for start-up and retention.
- Benefits cover 24 months of active comprehensive orthodontic treatment, including initial banding, de-banding and any commonly used appliances such as headgear.
- Following benefited interceptive or comprehensive orthodontic treatment, retention is covered up to a maximum of 24 months. Retention includes the initial construction, placement and adjustment to removable retainers and office visits.
- Treatment plans extending beyond 24 months of active interceptive or comprehensive orthodontic treatment, or 24 months of retention, will be subject to a monthly office visit fee to the Enrollee not to exceed $125.00 per month.
- Should an Enrollee's coverage be cancelled or terminated for any reason, and at the time of cancellation or termination the Enrollee is receiving orthodontic treatment, the Enrollee will be solely responsible for payment for treatment provided after cancellation or termination. In this event the Enrollee's obligation shall be based o f 100 percent of the Contract Orthodontist's "filed fee." The Contract Orthodontist will prorate the amount over the number of months remaining in the initial 24 months of treatment. The Enrollee will make payments based on an arrangement with the Contract Orthodontist.
- If treatment is not required or the Enrollee chooses not to start treatment after the diagnosis and consultation has been completed by the Contract Orthodontist, the Enrollee will be charged a consultation fee of $85.00 in addition to diagnostic record fees.
- Three recementations or replacements of a bracket/band on the same tooth or a total of five rebracketings/rebandings on different teeth during the covered course of treatment are Benefits. If any additional recementations or replacements of brackets/bands are performed, the Enrollee is responsible for the cost at the Contract Orthodontist's usual fee.
- The Copayment is payable to the Contract Orthodontist who initiates banding in a course of orthodontic treatment. If, after banding has been initiated, the Enrollee changes to another Contract Orthodontist to continue orthodontic treatment, the Enrollee:
- will not be entitled to a refund of any amounts previously paid, and
- will be responsible for all payments, up to and including the full Copayment, that are required by the new Contract Orthodontist for completion of the orthodontic treatment.
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