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SafeGuard HMO Dental Plan

Dental & VisionBenefi ts provided by SafeGuard Health Plans, Inc.

Underwritten by SafeHealth Life Insurance Company

Summary of Benefi ts

Schedule of Benefi ts, Exclusions & Limitations

Please refer to your Certifi cate of Insurance for full benefi t information.

Member Services (800) 880-1800SGC1006D-SOB 1/05

This Schedule of Benefits lists the services available to you under your SafeGuard plan, aswell as the co-payments associated with each service. There are other factors that impacthow your plan works and those are included here in the Exclusions & Limitations. We havealso 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 selectedSafeGuard general dentist. If you choose to receive services from a SafeGuard contractedspecialty care provider (periodontics, oral surger y, 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 atwww.safeguard.net.

DENTAL HMO PLAN SGC1006DSCHEDULE OF BENEFITS

Diagnostic TreatmentD0120 Periodic oral evaluation $0D0140 Limited oral evaluation - problem focused $0D0150 Comprehensive oral evaluation - new or established patient $0D0160 Detailed and extensive oral evaluation - problem focused, by report $0D0170 Re-evaluation - limited, problem focused (established patient;

not post-operative visit) $0D0180 Comprehensive periodontal evaluation - new or established patient $0D0210 X-rays intraoral - complete series - including bitewings (once every 2 years) $0D0220 X-rays intraoral - periapical - first film $0D0230 X-rays intraoral - periapical - each additional film $0D0240 X-rays intraoral - occlusal film $0D0270 X-rays bitewing - single film $0D0272 X-rays bitewings - two films $0D0274 X-rays bitewings - four films (once every 6 months) $0D0330 X-rays panoramic film $0D0350 Oral/facial photographic images $0D0460 Pulp vitality tests $0D0470 Diagnostic casts $0D0472 Accession of tissue, gross examination, preparation and transmission of

written report $0D0473 Accession of tissue, gross and microscopic examination, preparation and

transmission of written report $0D0999 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 $0D1120 Prophylaxis - child $0D1201 Topical application of fluoride (including prophylaxis) - child $0D1203 Topical application of fluoride (excluding prophylaxis) - child $0

Code Service Co-payment

Benefits provided by SafeGuard Health Plans, Inc.


D1330 Oral hygiene instructions $0D1351 Sealant - per tooth $10D1510 Space maintainer - fixed - unilateral $40D1515 Space maintainer - fixed - bilateral $40D1520 Space maintainer - removable - unilateral $40D1525 Space maintainer - removable - bilateral $40D1550 Recementation of space maintainer $10

Restorative TreatmentD2140 Amalgam - one surface, primary or permanent $0D2150 Amalgam - two surfaces, primary or permanent $0D2160 Amalgam - three surfaces, primary or permanent $0D2161 Amalgam - four or more surfaces, primary or permanent $0D2330 Resin-based composite - one surface, anterior $0D2331 Resin-based composite - two surfaces, anterior $0D2332 Resin-based composite - three surfaces, anterior $0D2335 Resin-based composite - four or more surfaces or involving incisal

angle, anterior $0D2390 Resin-based composite crown, anterior $0D2391 Resin-based composite, one surface, posterior $65D2392 Resin-based composite, two surfaces, posterior $75D2393 Resin-based composite, three surfaces, posterior $80D2394 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 $130D2520 Inlay - metallic - two surfaces $140D2530 Inlay - metallic - three or more surfaces $150D2542 Onlay - metallic-two surfaces $146D2543 Onlay - metallic - three surfaces $156D2544 Onlay - metallic - four or more surfaces $162D2610 Inlay - porcelain/ceramic - one surface $496D2620 Inlay - porcelain/ceramic - two surfaces $524D2630 Inlay - porcelain/ceramic - three or more surfaces $558D2642 Onlay - porcelain/ceramic - two surfaces $542D2643 Onlay - porcelain/ceramic - three surfaces $585D2644 Onlay - porcelain/ceramic - four or more surfaces $620D2650 Inlay - resin-based composite - one surface $326D2651 Inlay - resin-based composite - two surfaces $388D2652 Inlay - resin-based composite - three or more surfaces $408D2662 Onlay - resin-based composite - two surfaces $354D2663 Onlay - resin-based composite - three surfaces $417D2664 Onlay - - resin-based composite - four or more surfaces $446D2710 Crown - resin-based composite (indirect) $110D2712 Crown - 3/4 resin-based composite (indirect) $195D2720 Crown - resin with high noble metal $195D2721 Crown - resin with predominantly base metal $195



D2722 Crown - resin with noble metal $195D2740 Crown - porcelain/ceramic substrate $195D2750 Crown - porcelain fused to high noble metal $195D2751 Crown - porcelain fused to predominantly base metal $195D2752 Crown - porcelain fused to noble metal $195D2780 Crown - 3/4 cast high noble metal $195D2781 Crown - 3/4 cast predominantly base metal $195D2782 Crown - 3/4 cast noble metal $195D2790 Crown - full cast high noble metal $195D2791 Crown - full cast predominantly base metal $195D2792 Crown - full cast noble metal $195D2794 Crown - titanium $195D2910 Recement inlay, onlay, or partial coverage restoration $10D2915 Recement cast or prefabricated post and core $10D2920 Recement crown $10D2930 Prefabricated stainless steel crown - primary tooth $35D2931 Prefabricated stainless steel crown - permanent tooth $35D2932 Prefabricated resin crown $45D2933 Prefabricated stainless steel crown with resin window $35D2940 Sedative filling $0D2950 Core build up, including any pins $15D2951 Pin retention - per tooth, in addition to restoration $15D2952 Cast post and core in addition to crown $15D2953 Each additional cast post - same tooth $15D2954 Prefabricated post and core in addition to crown $15D2957 Each additional prefabricated post - same tooth $15D2980 Crown repair, by report $15

EndodonticsAll procedures exclude final restorationD3110 Pulp cap - direct $0D3120 Pulp cap - indirect $0D3220 Therapeutic pulpotomy $5D3221 Pulpal debridement, primary and permanent teeth $5D3230 Pulpal therapy with resorbable filling - primary anterior tooth $5D3240 Pulpal therapy with resorbable filling - primary posterior tooth $5D3310 Root canal - anterior, per tooth $75D3320 Root canal - bicuspid, per tooth $120D3330 Root canal - molar, per tooth $180D3332 Incomplete endodontic therapy; inoperable, unrestorable or

fractured tooth $75D3346 Retreatment of root canal - anterior, per tooth $95D3347 Retreatment of root canal - bicuspid, per tooth $140D3348 Retreatment of root canal - molar, per tooth $200D3410 Apicoectomy/periradicular surgery - anterior $85D3421 Apicoectomy/periradicular surgery - bicuspid, 1st root $85D3425 Apicoectomy/periradicular surgery - molar, 1st root $85D3426 Apicoectomy/periradicular surgery - each additional root $50D3430 Retrograde filling - per root $50D3450 Root amputation - per root $60



PeriodonticsPeriodontal 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 $125D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or

bounded teeth spaces - per quadrant $25D4240 Gingival flap procedure, including root planing - four or more contiguous

teeth or bounded teeth spaces - per quadrant $135D4241 Gingival flap procedure, including root planing - one to three contiguous

teeth or bounded teeth spaces - per quadrant $135D4260 Osseous surgery (including flap entry and closure) - four or more

contiguous teeth or bounded teeth spaces - per quadrant $250D4261 Osseous surgery (including flap entry and closure) - one to three

contiguous teeth or bounded teeth spaces - per quadrant $250D4341 Periodontal scaling and root planing - four or more teeth - per quadrant $45D4342 Periodontal scaling and root planing - one to three teeth, per quadrant $45D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis$45D4910 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 $225D5120 Complete lower denture $225D5130 Immediate upper denture $300D5140 Immediate lower denture $300D5211 Upper partial - resin base (including clasps, rests and teeth) $245D5212 Lower partial - resin base (including clasps, rests and teeth) $245D5213 Upper partial - cast metal base with resin saddles (including clasps,

rests and teeth) $275D5214 Lower partial - cast metal base with resin saddles (including clasps,

rests and teeth) $275D5410 Adjust complete denture - upper $10D5411 Adjust complete denture - lower $10D5421 Adjust partial denture - upper $10D5422 Adjust partial denture - lower $10D5510 Repair broken complete denture base $24D5520 Replace missing or broken teeth $10D5610 Repair resin denture base $24D5620 Repair cast framework $24D5630 Repair or replace broken clasp $24D5640 Replace broken teeth - per tooth $10D5650 Add tooth to existing partial denture $10D5660 Add clasp to existing partial denture $10D5710 Rebase complete upper denture $50D5711 Rebase complete lower denture $50D5720 Rebase upper partial denture $50D5721 Rebase lower partial denture $50D5730 Reline complete upper denture (chairside) $30D5731 Reline complete lower denture (chairside) $30D5740 Reline upper partial denture (chairside) $30



D5741 Reline lower partial denture (chairside) $30D5750 Reline complete upper denture (laboratory) $50D5751 Reline complete lower denture (laboratory) $50D5760 Reline upper partial denture (laboratory) $50D5761 Reline lower partial denture (laboratory) $50D5820 Interim partial denture - upper $0D5821 Interim partial denture - lower $0D5850 Tissue conditioning - upper $10D5851 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 $195D6210 Pontic - cast high noble metal $195D6211 Pontic - cast predominantly base metal $195D6212 Pontic - cast noble metal $195D6214 Pontic - titanium $195D6240 Pontic - porcelain fused to high noble metal $195D6241 Pontic - porcelain fused to predominantly base metal $195D6242 Pontic - porcelain fused to noble metal $195D6245 Pontic - porcelain/ceramic $195D6250 pontic - resin with high noble metal $195D6251 pontic - resin with predominantly base metal $195D6252 pontic - resin with noble metal $195D6600 Inlay - porcelain/ceramic, two surfaces $140D6602 Inlay - cast high noble metal, two surfaces $140D6603 Inlay - cast high noble metal, three or more surfaces $150D6604 Inlay - cast predominantly base metal, two surfaces $140D6605 Inlay - cast predominantly base metal, three or more surfaces $150D6606 Inlay - cast noble metal, two surfaces $140D6607 Inlay - cast noble metal, three or more surfaces $150D6608 Onlay -porcelain/ceramic, two surfaces $156D6609 Onlay - porcelain/ceramic, three or more surfaces $156D6610 Onlay - cast high noble metal, two surfaces $156D6611 Onlay - cast high noble metal, three or more surfaces $156D6612 Onlay - cast predominantly base metal, two surfaces $156D6613 Onlay - cast predominantly base metal, three or more surfaces $156D6614 Onlay - cast noble metal, two surfaces $156D6615 Onlay - cast noble metal, three or more surfaces $156D6710 Crown - indirect resin-based composite $195D6720 Crown - resin with high noble metal $195D6721 Crown - resin with predominantly base metal $195D6722 Crown - resin with noble metal $195D6740 Crown - porcelain/ceramic $195D6750 Crown - porcelain fused to high noble metal $195D6751 Crown - porcelain fused to predominantly base metal $195D6752 Crown - porcelain fused to noble metal $195D6780 Crown - 3/4 cast high noble metal $195D6781 Crown - 3/4 cast predominantly base metal $195D6782 Crown - 3/4 cast noble metal $195



D6790 Crown - full cast high noble metal $195D6791 Crown - full cast predominantly base metal $195D6792 Crown - full cast noble metal $195D6794 Crown - titanium $195D6930 Recement bridge $15D6940 Stress breaker $25D6970 Cast post and core in addition to bridge retainer $15D6971 Cast post as part of bridge retainer $15D6972 Prefabricated post and core in addition to bridge retainer $15D6973 Core build up for retainer, including any pins $15D6976 Each additional cast post - same tooth $15D6977 Each additional prefabricated post - same tooth $15D6980 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 $6D7140 Extraction - erupted tooth or exposed root (elevation and/or

forceps removal) $6D7210 Surgical removal of erupted tooth $15D7220 Extraction - removal of impacted tooth - soft tissue $40D7230 Extraction - removal of impacted tooth - partially bony $60D7240 Extraction - removal of impacted tooth - completely bony $80D7241 Extraction - removal of impacted tooth - completely bony, with unusual

surgical complications $80D7250 Surgical extraction - removal of residual tooth roots $0D7286 Biopsy of oral tissue - soft $20D7310 Alveoloplasty in conjunction with extractions - per quadrant $40D7311 Alveoloplasty in conjunction with extractions - one to three teeth or

tooth spaces, per quadrant $15D7320 Alveoloplasty not in conjunction with extractions - per quadrant $60D7321 Alveoloplasty not in conjunction with extractions - one to three teeth

or tooth spaces, per quadrant $20D7471 Removal of lateral exostosis (maxilla or mandible) $50D7510 Incision and drainage of abscess - intraoral soft tissue $0D7511 Incision and drainage of abscess - intraoral soft tissue - complicated

(includes drainage of multiple fascial spaces) $0D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure $0D7963 Frenuloplasty $0

OrthodonticsThe following orthodontic treatment co-payments apply only when services are performedby your selected SafeGuard general dentist. If your general dentist does not provideorthodontic care, you may receive care from a SafeGuard contracted orthodontist and yourco-payments will be 75% of that orthodontist's usual fees. A listing of contractedorthodontists can be found online at www.safeguard.net 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 (fulltreatment case - including fixed/removable appliances) $1,600

D8080 Comprehensive orthodontic treatment of the adolescent dentition (fulltreatment case - including fixed/removable appliances) $1,600

D8090 Comprehensive orthodontic treatment of the adult dentition (fulltreatment case - including fixed/removable appliances) $1,800




D8660 Consultation $0D8680 Retention phase (including fee for fixed/removable retainers and monthly

visits for 24 months) $0D8999 Orthodontic treatment plan and records (pre/post x-rays, photos,

study models) $350

Adjunctive General ServicesD9110 Palliative (emergency) treatment of dental pain - minor procedure $10D9211 Regional block anesthesia $0D9212 Trigeminal division block anesthesia $0D9215 Local anesthesia $0D9310 Consultation (diagnostic service provided by dentist other than

practitioner providing treatment) $20D9430 Office visit for observation (during regularly scheduled hours) - no other

services performed $5D9440 Office visit - after regularly scheduled hours $20D9450 Case presentation, detailed and extensive treatment planning $0D9999 Unspecified adjunctive procedure, by report $10

Current Dental Terminology © American Dental Association


These definitions are designed to give you a “layman’s understanding” of some dentalterminology in order for you to better understand your plan; they are not full descriptions.

Amalgam: A silver filling

Anterior: Teeth that are in the front of the mouth

Bicuspid: Most people have four bicuspid teeth; they are located immediatelypreceding the molar teeth with two in each quadrant of the mouth.

Bridge: A replacement for one or more missing teeth that is permanently attachedto the teeth adjacent to the empty space(s).

Crown: A covering created to place over a tooth to strengthen and/or replacetooth structure. A crown can be made of different materials (noble, highnoble), base metal, porcelain or porcelain and metal.

Endodontics: Procedures that treat disease and injury to the inside of the tooth(the nerve or pulp).

Oral Surgery: Surgery to remove teeth, reshape portions of the bone in the mouth, orbiopsy suspect areas of the mouth.

Orthodontics: Braces and other procedures to straighten the teeth.

Periodontics: Procedures related to treatment of the supporting structures of the teeth(gums, underlying bone).

Posterior: Teeth that set towards the back of the mouth.

Primary Teeth: The first set of teeth (“baby” teeth).

Prophylaxis: Teeth cleaning

Prosthodontics: Procedures related to the replacement of teeth with removable applianceslike dentures or partial dentures.

Quadrant: One of the four equal sections into which your mouth can be divided(some procedures like periodontics are done in quadrants).

Resin-basedComposite: Tooth-colored (white) fillings

Dental Terminology Definitions


EL’s - Farm Bureau

Exclusions1. 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/ornecessary for maintaining or improving the member’s dental health, as determined bythe 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 forappearance.

5. Orthognathic surgery.

6. General anesthesia or intravenous sedation.

7. Any inpatient/outpatient hospital charges of any kind including dentist and/or physiciancharges, 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 verticaldimension of occlusion, correct congenital, developmental, or medically induced dentaldisorders including, but not limited to treatment of myofunctional, myoskeletal, ortemporomandibular joint disorders unless otherwise specified as an orthodontic benefiton the Schedule of Benefits.

11. Dental implants and services associated with the placement of implants, prosthodonticrestoration 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 startedafter 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 internationalauthority 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 harmfulhabits such as thumb sucking and tongue thrusting.

18. Any dental procedure or treatment unable to be performed in the dental office due to thegeneral health or physical limitations of the member including, but not limited to physicalor emotional resistance, inability to visit the dental office, or allergy to commonly utilizedlocal anesthetics.

19. Dental services relating to injuries which are self-inflicted.

20. Precious metal for removable appliances, metallic or permanent soft bases for completedentures, porcelain denture teeth, precision abutments for removable partials or fixedpartial dentures (overlays, implants, and appliances associated therewith) andpersonalization and characterization of complete and partial dentures.

21. Treatment or extraction of primary teeth when exfoliation (normal shedding and loss) isimminent.

Exclusions and Limitations




22. Dental services received from any dental facility other than the assigned Contract Dentistincluding the services of a dental specialist, unless expressly authorized in writing bySafeGuard or as cited under Emergency Services.

Limitations1. 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 andsecond 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 forsealants do not include the repair or replacement of a sealant on any tooth withinthree 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 treatmentplan require additional $125 co-payment per unit in addition to co-payment for eachcrown/bridge unit.

10. Porcelain crowns, porcelain fused to metal or resin with metal type crowns and fixedpartial dentures (bridges) are limited to children under 16 years of age.

11. With the exception of pulp caps and pulpotomies, endodontic procedures (e.g. rootcanal 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 whenthe Contracted Dentist is not performing root canal therapy.

13. Periodontal scaling and root planning are limited to four quadrants during any 12month 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 12consecutive 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 healingperiod when the teeth cannot be added to an existing partial denture; or thereplacement 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 sevenfollowing an attempt by the assigned Contracted Dentist to treat the child and uponprior authorization by SafeGuard, less applicable co-payments. Exceptions for medicalconditions, regardless of age limitation, will be considered on an individual basis.

19. Soft tissue management programs are limited to periodontal pocket charting, rootplanning, scaling, curettage, oral hygiene instruction, periodontal maintenance and/orprophylaxis. If an Enrollee declines non-covered services within a soft tissue managementprogram, it does not eliminate or alter the benefit for other covered services.




20. A new removable partial, complete or immediate denture includes after deliveryadjustments and tissue conditioning at no additional cost for the first six monthsafter placement if the Enrollee continues to be eligible and the service is provided atthe 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 coveredbenefit.

Orthodontic Exclusions & LimitationsIf you choose to receive services from a SafeGuard contracted orthodontist, your co-payment will be 75% of that orthodontist's usual fee for those services.

1. If a non-contracted general dentist or othodontist provides orthodontic treatment, nobenefit will apply and the member will be responsible for all costs associated with suchorthodontic treatment.

2. The orthodontic co-payments listed in this Schedule of Benefits apply only when servicesare provided by your selected SafeGuard general dentist. If your general dentist doesnot provide orthodontic care, you can be referred through SafeGuard to a contractedorthodontist in your area. Your co-payments will be 75% of that orthodontist’s usualfees.

3. Plan benefits shall cover twenty-four (24) months of usual and customary orthodontictreatment and an additional twenty-four (24) months of retention. Treatment extendingbeyond 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 developmentalabnormalities;

3.) Treatment related to temporomandibular joint disorders;4.) Lingually placed direct bonded appliances and arch wires (“invisible braces”);

and5.) Functional appliances that are used in conjunction with fixed appliances.

5. The retention phase of treatment shall include the construction, placement, and adjustmentof retainers.

safeguard hmo dental plan - quotit · pdf filesafeguard hmo dental plan ... d5660 add clasp to...

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