SafeGuard HMO Dental Plan

Transcription

1 Summary of Benefi ts Schedule of Benefi ts, Exclusions & Limitations Please refer to your Certifi cate of Insurance for full benefi t information. SafeGuard HMO Dental Plan Dental & Vision Benefi ts provided by SafeGuard Health Plans, Inc. Underwritten by SafeHealth Life Insurance Company

2 SCHEDULE OF BENEFITS DENTAL HMO PLAN SGC1006D This Schedule of Benefits lists the services available to you under your SafeGuard plan, as well as the co-payments associated with each service. There are other factors that impact how your plan works and those are included here in the Exclusions & Limitations. We have also added some dental terminology definitions to help you better understand your plan - these can be found at the back of this Schedule. The following co-payments apply only when services are performed by your selected SafeGuard general dentist. If you choose to receive services from a SafeGuard contracted specialty care provider (periodontics, oral surgery, endodontics, pedodontics, orthodontics), your co-payment will be 75% of that provider's usual fee for those services. A list of these contracted dentists may be found through SafeGuard's online directory at Diagnostic Treatment D0120 Periodic oral evaluation $0 D0140 Limited oral evaluation - problem focused $0 D0150 Comprehensive oral evaluation - new or established patient $0 D0160 Detailed and extensive oral evaluation - problem focused, by report $0 D0170 Benefits provided by SafeGuard Health Plans, Inc. Code Service Co-payment Re-evaluation - limited, problem focused (established patient; not post-operative visit) $0 D0180 Comprehensive periodontal evaluation - new or established patient $0 D0210 X-rays intraoral - complete series - including bitewings (once every 2 years) $0 D0220 X-rays intraoral - periapical - first film $0 D0230 X-rays intraoral - periapical - each additional film $0 D0240 X-rays intraoral - occlusal film $0 D0270 X-rays bitewing - single film $0 D0272 X-rays bitewings - two films $0 D0274 X-rays bitewings - four films (once every 6 months) $0 D0330 X-rays panoramic film $0 D0350 Oral/facial photographic images $0 D0460 Pulp vitality tests $0 D0470 Diagnostic casts $0 D0472 Accession of tissue, gross examination, preparation and transmission of written report $0 D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report $0 D0999 Unspecified diagnostic procedure, by report $0 Preventive Services Cleanings (prophylaxis) and fluoride treatments are limited to 1 every 6 months. Child prophylaxis and fluoride treatments are limited to children under age 19. Sealants are limited to permanent molars through age 15. D1110 Prophylaxis - adult $0 D1120 Prophylaxis - child $0 D1201 Topical application of fluoride (including prophylaxis) - child $0 D1203 Topical application of fluoride (excluding prophylaxis) - child $0

3 Code Service Co-payment D1330 Oral hygiene instructions $0 D1351 Sealant - per tooth $10 D1510 Space maintainer - fixed - unilateral $40 D1515 Space maintainer - fixed - bilateral $40 D1520 Space maintainer - removable - unilateral $40 D1525 Space maintainer - removable - bilateral $40 D1550 Recementation of space maintainer $10 Restorative Treatment D2140 Amalgam - one surface, primary or permanent $0 D2150 Amalgam - two surfaces, primary or permanent $0 D2160 Amalgam - three surfaces, primary or permanent $0 D2161 Amalgam - four or more surfaces, primary or permanent $0 D2330 Resin-based composite - one surface, anterior $0 D2331 Resin-based composite - two surfaces, anterior $0 D2332 Resin-based composite - three surfaces, anterior $0 D2335 Resin-based composite - four or more surfaces or involving incisal angle, anterior $0 D2390 Resin-based composite crown, anterior $0 D2391 Resin-based composite, one surface, posterior $65 D2392 Resin-based composite, two surfaces, posterior $75 D2393 Resin-based composite, three surfaces, posterior $80 D2394 Resin-based composite, four or more surfaces, posterior $80 Crowns Replacement limit 1 every 5 years. Crowns using noble or high noble metal will have additional fees. Cases involving 7 or more crowns in the same treatment plan require additional $125 member fee per unit in addition to co-pay. $75 fee per crown unit above co-pay for porcelain on molars. D2510 Inlay - metallic - one surface $130 D2520 Inlay - metallic - two surfaces $140 D2530 Inlay - metallic - three or more surfaces $150 D2542 Onlay - metallic-two surfaces $146 D2543 Onlay - metallic - three surfaces $156 D2544 Onlay - metallic - four or more surfaces $162 D2610 Inlay - porcelain/ceramic - one surface $496 D2620 Inlay - porcelain/ceramic - two surfaces $524 D2630 Inlay - porcelain/ceramic - three or more surfaces $558 D2642 Onlay - porcelain/ceramic - two surfaces $542 D2643 Onlay - porcelain/ceramic - three surfaces $585 D2644 Onlay - porcelain/ceramic - four or more surfaces $620 D2650 Inlay - resin-based composite - one surface $326 D2651 Inlay - resin-based composite - two surfaces $388 D2652 Inlay - resin-based composite - three or more surfaces $408 D2662 Onlay - resin-based composite - two surfaces $354 D2663 Onlay - resin-based composite - three surfaces $417 D2664 Onlay - - resin-based composite - four or more surfaces $446 D2710 Crown - resin-based composite (indirect) $110 D2712 Crown - 3/4 resin-based composite (indirect) $195 D2720 Crown - resin with high noble metal $195 D2721 Crown - resin with predominantly base metal $195

4 Code Service Co-payment D2722 Crown - resin with noble metal $195 D2740 Crown - porcelain/ceramic substrate $195 D2750 Crown - porcelain fused to high noble metal $195 D2751 Crown - porcelain fused to predominantly base metal $195 D2752 Crown - porcelain fused to noble metal $195 D2780 Crown - 3/4 cast high noble metal $195 D2781 Crown - 3/4 cast predominantly base metal $195 D2782 Crown - 3/4 cast noble metal $195 D2790 Crown - full cast high noble metal $195 D2791 Crown - full cast predominantly base metal $195 D2792 Crown - full cast noble metal $195 D2794 Crown - titanium $195 D2910 Recement inlay, onlay, or partial coverage restoration $10 D2915 Recement cast or prefabricated post and core $10 D2920 Recement crown $10 D2930 Prefabricated stainless steel crown - primary tooth $35 D2931 Prefabricated stainless steel crown - permanent tooth $35 D2932 Prefabricated resin crown $45 D2933 Prefabricated stainless steel crown with resin window $35 D2940 Sedative filling $0 D2950 Core build up, including any pins $15 D2951 Pin retention - per tooth, in addition to restoration $15 D2952 Cast post and core in addition to crown $15 D2953 Each additional cast post - same tooth $15 D2954 Prefabricated post and core in addition to crown $15 D2957 Each additional prefabricated post - same tooth $15 D2980 Crown repair, by report $15 Endodontics All procedures exclude final restoration D3110 Pulp cap - direct $0 D3120 Pulp cap - indirect $0 D3220 Therapeutic pulpotomy $5 D3221 Pulpal debridement, primary and permanent teeth $5 D3230 Pulpal therapy with resorbable filling - primary anterior tooth $5 D3240 Pulpal therapy with resorbable filling - primary posterior tooth $5 D3310 Root canal - anterior, per tooth $75 D3320 Root canal - bicuspid, per tooth $120 D3330 Root canal - molar, per tooth $180 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $75 D3346 Retreatment of root canal - anterior, per tooth $95 D3347 Retreatment of root canal - bicuspid, per tooth $140 D3348 Retreatment of root canal - molar, per tooth $200 D3410 Apicoectomy/periradicular surgery - anterior $85 D3421 Apicoectomy/periradicular surgery - bicuspid, 1st root $85 D3425 Apicoectomy/periradicular surgery - molar, 1st root $85 D3426 Apicoectomy/periradicular surgery - each additional root $50 D3430 Retrograde filling - per root $50 D3450 Root amputation - per root $60

5 Code Service Co-payment Periodontics Periodontal scaling and root planing is limited to 4 quadrants during any 12 consecutive months. D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces - per quadrant $125 D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces - per quadrant $25 D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces - per quadrant $135 D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth spaces - per quadrant $135 D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces - per quadrant $250 D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces - per quadrant $250 D4341 Periodontal scaling and root planing - four or more teeth - per quadrant $45 D4342 Periodontal scaling and root planing - one to three teeth, per quadrant $45 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis$45 D4910 Periodontal maintenance procedures - following active therapy (2 in a 12 month period) $36 Removable Prosthodontics Replacement limit 1 every 5 years. Relines, tissue conditioning and rebases are limited to 1 per denture during any 12 consecutive months. Includes up to 3 adjustments within 6 months of delivery. D5110 Complete upper denture $225 D5120 Complete lower denture $225 D5130 Immediate upper denture $300 D5140 Immediate lower denture $300 D5211 Upper partial - resin base (including clasps, rests and teeth) $245 D5212 Lower partial - resin base (including clasps, rests and teeth) $245 D5213 Upper partial - cast metal base with resin saddles (including clasps, D5214 rests and teeth) $275 Lower partial - cast metal base with resin saddles (including clasps, rests and teeth) $275 D5410 Adjust complete denture - upper $10 D5411 Adjust complete denture - lower $10 D5421 Adjust partial denture - upper $10 D5422 Adjust partial denture - lower $10 D5510 Repair broken complete denture base $24 D5520 Replace missing or broken teeth $10 D5610 Repair resin denture base $24 D5620 Repair cast framework $24 D5630 Repair or replace broken clasp $24 D5640 Replace broken teeth - per tooth $10 D5650 Add tooth to existing partial denture $10 D5660 Add clasp to existing partial denture $10 D5710 Rebase complete upper denture $50 D5711 Rebase complete lower denture $50 D5720 Rebase upper partial denture $50 D5721 Rebase lower partial denture $50 D5730 Reline complete upper denture (chairside) $30 D5731 Reline complete lower denture (chairside) $30 D5740 Reline upper partial denture (chairside) $30

6 Code Service Co-payment D5741 Reline lower partial denture (chairside) $30 D5750 Reline complete upper denture (laboratory) $50 D5751 Reline complete lower denture (laboratory) $50 D5760 Reline upper partial denture (laboratory) $50 D5761 Reline lower partial denture (laboratory) $50 D5820 Interim partial denture - upper $0 D5821 Interim partial denture - lower $0 D5850 Tissue conditioning - upper $10 D5851 Tissue conditioning - lower $10 Crowns/Fixed Bridges - Per Unit Replacement limit 1 every 5 years. Crowns using noble or high noble metal will have additional fees. Cases involving 7 or more crowns and/or fixed bridge units in the same treatment plan require additional $125 member fee per unit in addition to co-pay. $75 fee per crown/bridge unit above co-pay for porcelain on molars. D6205 Pontic - indirect resin-based composite $195 D6210 Pontic - cast high noble metal $195 D6211 Pontic - cast predominantly base metal $195 D6212 Pontic - cast noble metal $195 D6214 Pontic - titanium $195 D6240 Pontic - porcelain fused to high noble metal $195 D6241 Pontic - porcelain fused to predominantly base metal $195 D6242 Pontic - porcelain fused to noble metal $195 D6245 Pontic - porcelain/ceramic $195 D6250 pontic - resin with high noble metal $195 D6251 pontic - resin with predominantly base metal $195 D6252 pontic - resin with noble metal $195 D6600 Inlay - porcelain/ceramic, two surfaces $140 D6602 Inlay - cast high noble metal, two surfaces $140 D6603 Inlay - cast high noble metal, three or more surfaces $150 D6604 Inlay - cast predominantly base metal, two surfaces $140 D6605 Inlay - cast predominantly base metal, three or more surfaces $150 D6606 Inlay - cast noble metal, two surfaces $140 D6607 Inlay - cast noble metal, three or more surfaces $150 D6608 Onlay -porcelain/ceramic, two surfaces $156 D6609 Onlay - porcelain/ceramic, three or more surfaces $156 D6610 Onlay - cast high noble metal, two surfaces $156 D6611 Onlay - cast high noble metal, three or more surfaces $156 D6612 Onlay - cast predominantly base metal, two surfaces $156 D6613 Onlay - cast predominantly base metal, three or more surfaces $156 D6614 Onlay - cast noble metal, two surfaces $156 D6615 Onlay - cast noble metal, three or more surfaces $156 D6710 Crown - indirect resin-based composite $195 D6720 Crown - resin with high noble metal $195 D6721 Crown - resin with predominantly base metal $195 D6722 Crown - resin with noble metal $195 D6740 Crown - porcelain/ceramic $195 D6750 Crown - porcelain fused to high noble metal $195 D6751 Crown - porcelain fused to predominantly base metal $195 D6752 Crown - porcelain fused to noble metal $195 D6780 Crown - 3/4 cast high noble metal $195 D6781 Crown - 3/4 cast predominantly base metal $195 D6782 Crown - 3/4 cast noble metal $195

7 Code Service Co-payment D6790 Crown - full cast high noble metal $195 D6791 Crown - full cast predominantly base metal $195 D6792 Crown - full cast noble metal $195 D6794 Crown - titanium $195 D6930 Recement bridge $15 D6940 Stress breaker $25 D6970 Cast post and core in addition to bridge retainer $15 D6971 Cast post as part of bridge retainer $15 D6972 Prefabricated post and core in addition to bridge retainer $15 D6973 Core build up for retainer, including any pins $15 D6976 Each additional cast post - same tooth $15 D6977 Each additional prefabricated post - same tooth $15 D6980 Fixed partial denture repair, by report $20 Oral Surgery Includes routine post operative visits/treatment. Surgical removal of impacted teeth not covered unless pathology (disease) exists. Surgical removal of wisdom tooth/third molar for orthodontic reasons only is not covered. D7111 Extraction, coronal remnants - deciduous tooth $6 D7140 Extraction - erupted tooth or exposed root (elevation and/or forceps removal) $6 D7210 Surgical removal of erupted tooth $15 D7220 Extraction - removal of impacted tooth - soft tissue $40 D7230 Extraction - removal of impacted tooth - partially bony $60 D7240 Extraction - removal of impacted tooth - completely bony $80 D7241 Extraction - removal of impacted tooth - completely bony, with unusual surgical complications $80 D7250 Surgical extraction - removal of residual tooth roots $0 D7286 Biopsy of oral tissue - soft $20 D7310 Alveoloplasty in conjunction with extractions - per quadrant $40 D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $15 D7320 Alveoloplasty not in conjunction with extractions - per quadrant $60 D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $20 D7471 Removal of lateral exostosis (maxilla or mandible) $50 D7510 Incision and drainage of abscess - intraoral soft tissue $0 D7511 Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) $0 D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure $0 D7963 Frenuloplasty $0 Orthodontics The following orthodontic treatment co-payments apply only when services are performed by your selected SafeGuard general dentist. If your general dentist does not provide orthodontic care, you may receive care from a SafeGuard contracted orthodontist and your co-payments will be 75% of that orthodontist's usual fees. A listing of contracted orthodontists can be found online at or you may call Member Services. (See "Orthodontic Exclusions & Limitations" later in this document for further information.) D8070 Comprehensive orthodontic treatment of the transitional dentition (full treatment case - including fixed/removable appliances) $1,600 D8080 Comprehensive orthodontic treatment of the adolescent dentition (full treatment case - including fixed/removable appliances) $1,600 D8090 Comprehensive orthodontic treatment of the adult dentition (full treatment case - including fixed/removable appliances) $1,800

8 Code Service Co-payment D8660 Consultation $0 D8680 Retention phase (including fee for fixed/removable retainers and monthly visits for 24 months) $0 D8999 Orthodontic treatment plan and records (pre/post x-rays, photos, study models) $350 Adjunctive General Services D9110 Palliative (emergency) treatment of dental pain - minor procedure $10 D9211 Regional block anesthesia $0 D9212 Trigeminal division block anesthesia $0 D9215 Local anesthesia $0 D9310 Consultation (diagnostic service provided by dentist other than practitioner providing treatment) $20 D9430 Office visit for observation (during regularly scheduled hours) - no other services performed $5 D9440 Office visit - after regularly scheduled hours $20 D9450 Case presentation, detailed and extensive treatment planning $0 D9999 Unspecified adjunctive procedure, by report $10 Current Dental Terminology American Dental Association

9 Dental Terminology Definitions These definitions are designed to give you a layman s understanding of some dental terminology in order for you to better understand your plan; they are not full descriptions. Amalgam: Anterior: Bicuspid: Bridge: Crown: Endodontics: Oral Surgery: Orthodontics: Periodontics: Posterior: Primary Teeth: Prophylaxis: Prosthodontics: Quadrant: Resin-based Composite: A silver filling Teeth that are in the front of the mouth Most people have four bicuspid teeth; they are located immediately preceding the molar teeth with two in each quadrant of the mouth. A replacement for one or more missing teeth that is permanently attached to the teeth adjacent to the empty space(s). A covering created to place over a tooth to strengthen and/or replace tooth structure. A crown can be made of different materials (noble, high noble), base metal, porcelain or porcelain and metal. Procedures that treat disease and injury to the inside of the tooth (the nerve or pulp). Surgery to remove teeth, reshape portions of the bone in the mouth, or biopsy suspect areas of the mouth. Braces and other procedures to straighten the teeth. Procedures related to treatment of the supporting structures of the teeth (gums, underlying bone). Teeth that set towards the back of the mouth. The first set of teeth ( baby teeth). Teeth cleaning Procedures related to the replacement of teeth with removable appliances like dentures or partial dentures. One of the four equal sections into which your mouth can be divided (some procedures like periodontics are done in quadrants). Tooth-colored (white) fillings

10 Exclusions and Limitations Exclusions 1. Services performed by a general dentist or dentist whose practice is limited to providing Specialty Care, not contracted with SafeGuard without prior approval by SafeGuard, (except for out of area emergency services). 2. Any dental services, or appliances which are determined to be not reasonable and/or necessary for maintaining or improving the member s dental health, as determined by the SafeGuard Selected General Dentist. 3. Any procedures not specifically listed as a covered benefit in the Schedule of Benefits. 4. Dental procedures or services performed solely for cosmetic purposes or solely for appearance. 5. Orthognathic surgery. 6. General anesthesia or intravenous sedation. 7. Any inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, prescriptions or medications. 8. Replacement of dentures, crowns, appliances or bridgework that have been lost, stolen, or damaged due to abuse, misuse, or neglect. 9. Treatment of malignancies, cysts, or neoplasms. 10. Procedures, appliances, or restorations whose main purpose is to change the vertical dimension of occlusion, correct congenital, developmental, or medically induced dental disorders including, but not limited to treatment of myofunctional, myoskeletal, or temporomandibular joint disorders unless otherwise specified as an orthodontic benefit on the Schedule of Benefits. 11. Dental implants and services associated with the placement of implants, prosthodontic restoration of dental implants, and specialized implant maintenance services. 12. Precision attachments. 13. Dental procedures initiated prior to the member s eligibility under this Plan or started after the member s termination from the Plan. 14. Dental services provided for or paid by a federal or state government agency or authority, political subdivision, or other public program other than Medicaid or Medicare. 15. Dental services required while serving in the Armed Forces of any country or international authority or relating to a declared or undeclared war or acts of war. 16. Services considered unnecessary or experimental in nature. 17. Dental procedures or appliances for minor tooth guidance or for the control of harmful habits such as thumb sucking and tongue thrusting. 18. Any dental procedure or treatment unable to be performed in the dental office due to the general health or physical limitations of the member including, but not limited to physical or emotional resistance, inability to visit the dental office, or allergy to commonly utilized local anesthetics. 19. Dental services relating to injuries which are self-inflicted. 20. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization of complete and partial dentures. 21. Treatment or extraction of primary teeth when exfoliation (normal shedding and loss) is imminent. EL s - Farm Bureau

11 Exclusions and Limitations 22. Dental services received from any dental facility other than the assigned Contract Dentist including the services of a dental specialist, unless expressly authorized in writing by SafeGuard or as cited under Emergency Services. Limitations 1. Full mouth x-rays are limited to one set every 24 consecutive months and include any combination of periapicals, bitewings and/or panoramic film. 2. Bitewing x-rays are limited to not more than one series of four films in any six month period. 3. Diagnostic casts are limited to aid in diagnosis by the Contracted Dentist for covered benefits; 4. Prophylaxis or periodontal maintenance is limited to one procedure every six months. 5. Benefits for sealants include the application of sealants only to permanent first and second molars with no decay, with no restoration and with the occlusal surface intact, for first molars through age 9 and second molars through age 15. Benefits for sealants do not include the repair or replacement of a sealant on any tooth within three years of its application. 6. Crowns or fixed bridges using noble or high noble metal will have additional fees. 7. There is a $75 fee per crown unit above co-pay for porcelain on molars. 8. Crowns or fixed bridges are limited to replacement 1 every 5 years. 9. Cases involving (7) or more crowns and/or fixed bridge units in the same treatment plan require additional $125 co-payment per unit in addition to co-payment for each crown/bridge unit. 10. Porcelain crowns, porcelain fused to metal or resin with metal type crowns and fixed partial dentures (bridges) are limited to children under 16 years of age. 11. With the exception of pulp caps and pulpotomies, endodontic procedures (e.g. root canal therapy, apicoectomy, retrofill, etc.) are only a benefit on a permanent tooth. 12. A therapeutic pulpotomy on a permanent tooth is limited to palliative treatment when the Contracted Dentist is not performing root canal therapy. 13. Periodontal scaling and root planning are limited to four quadrants during any 12 month period. 14. Full mouth debridement (gross scale) is limited to one treatment in any 12 month period. 15. Relines, tissue conditioning and rebases are limited to one per denture during any 12 consecutive months. 16. Interim partial dentures (stayplates), in conjunction with fixed or removable appliances, are limited to: the replacement of extracted anterior teeth for adults during a healing period when the teeth cannot be added to an existing partial denture; or the replacement of permanent tooth/teeth for children under 16 years of age. 17. Retained primary teeth shall be covered as primary teeth. 18. Benefits provided by a pediatric Dentist are limited to children through age seven following an attempt by the assigned Contracted Dentist to treat the child and upon prior authorization by SafeGuard, less applicable co-payments. Exceptions for medical conditions, regardless of age limitation, will be considered on an individual basis. 19. Soft tissue management programs are limited to periodontal pocket charting, root planning, scaling, curettage, oral hygiene instruction, periodontal maintenance and/or prophylaxis. If an Enrollee declines non-covered services within a soft tissue management program, it does not eliminate or alter the benefit for other covered services. EL s - Farm Bureau

12 Exclusions and Limitations 20. A new removable partial, complete or immediate denture includes after delivery adjustments and tissue conditioning at no additional cost for the first six months after placement if the Enrollee continues to be eligible and the service is provided at the Contracted Dentist s facility where the denture was originally delivered. 21. Surgical removal of impacted teeth is not a covered benefit unless pathology [disease] exists. 22. Surgical removal of wisdom teeth/third molar for orthodontic reasons is not a covered benefit. Orthodontic Exclusions & Limitations If you choose to receive services from a SafeGuard contracted orthodontist, your copayment will be 75% of that orthodontist's usual fee for those services. 1. If a non-contracted general dentist or othodontist provides orthodontic treatment, no benefit will apply and the member will be responsible for all costs associated with such orthodontic treatment. 2. The orthodontic co-payments listed in this Schedule of Benefits apply only when services are provided by your selected SafeGuard general dentist. If your general dentist does not provide orthodontic care, you can be referred through SafeGuard to a contracted orthodontist in your area. Your co-payments will be 75% of that orthodontist s usual fees. 3. Plan benefits shall cover twenty-four (24) months of usual and customary orthodontic treatment and an additional twenty-four (24) months of retention. Treatment extending beyond such time periods will be subject to a per-office-visit charge of $25 dollars. 4. The following are not included as orthodontic benefits: A. Repair or replacement of lost or broken appliances; B. Retreatment of orthodontic cases; C. Treatment in progress at inception of eligibility; D. Interceptive or Phase I orthodontics; E. Changes in treatment necessitated by an accident; F. Treatment involving: 1.) Maxillo-facial surgery, myofunctional therapy, cleft palate, micrognathia, macroglossia; 2.) Hormonal imbalances or other factors affecting growth or developmental abnormalities; 3.) Treatment related to temporomandibular joint disorders; 4.) Lingually placed direct bonded appliances and arch wires ( invisible braces ); and 5.) Functional appliances that are used in conjunction with fixed appliances. 5. The retention phase of treatment shall include the construction, placement, and adjustment of retainers. EL s - Farm Bureau