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Orthodontic treatment is subject to the olloNNin : <br />A. Orthodontic treatment must be provided b a member of the Plan's orthodontic <br />� <br />panel. <br />B. Plan benefits cover 24 months of active usual and customary orthodontic treatment <br />and an additional 24 months of retention. Treatment that extends beyond such time <br />periods will be subject to a per-office-visit charge of $25.00. <br />C. 'he fol1mving are not included as an orthodontic benefit: <br />1. Diagnostic Records: <br />a. Cephalometric -rays and other -rays if needed; <br />b. Diagnostic tracings of cephalometr c -rays; <br />C. photographs; <br />d. Study models; <br />2. Replacement or repair of lost or broken appliances; <br />3. Retreatent of orthodontic cases; <br />4. Treatment in progress at inception of eligibility; <br />5. Changes In treatment necessitated by an accident; <br />6. orthodontic treatment that involves: <br />a. Ma llo- facial surgery, m ofunctional therapy, cleft palate, n c 'ognathia, <br />nacrogiossia <br />b. Surgically exposing impacted teeth (maxillary cuspids); C. Hormonal imbalances or other factors causing growth a developmental <br />abnormalities; . <br />d. Treatment related to temporomandibular joint disturbances; <br />e. Lingually placed direct bonded appliances and arch wires (invisible <br />braces). <br />f. Functional appliances that are used in conjunction with fixed appliances, <br />g. First Phase treatment, defined as any orthodontic treatment that occurs <br />hale deciduous primary or baby teeth are still in the mouth. <br />D. Should a member terminate from the Plan for any reason and at that time be <br />receiving orthodontic treatment, the member and not Safeguard shall be responsible <br />for payment of the balance due for treatment performed after termination, The <br />p ' , .� $2,050.00 ecludin members a anent shall be based upon a m�mum copa meat o g <br />p r of months to <br />an charges for diagnostic records, shall be prorated over the number <br />completion of active treatment, and be payable on such terms and conditions as are <br />arranged between the member and the orthodontist. <br />E. The retention phase of treatment, if required, shall include the construction, <br />la em nt and adjustment o retainers, the rmammur�n cost o which shalt not exceed <br />2o.00. <br />F. If a member does not require treatment or chooses not to Mart treatment after the <br />participating rovider has completed a diagnosis and consultation, the member will <br />be charged a consultation fee o $25.00 in addition to the fees for such diagnostic <br />records. <br />CA 4/91 <br />