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Appendix B - Orthodontic Treatment <br />1. General Provisions. <br />a. Orthodontic treatment is covered only if the Participating Provider prepares the treatment plan <br />prior to starting treatment. The treatment plan is based on an examination that must take place <br />while the Enrollee is covered under this Contract. The examination must show a diagnosis of <br />an abnormal occlusion that can be corrected by orthodontic treatment. <br />b. The Enrollee must remain covered under this Contract for the entire length of treatment. The <br />Enrollee must follow the post -treatment plan and keep all appointments after the Enrollee is <br />de -banded to avoid additional Copayments. <br />c. Copayments may be adjusted based upon the services necessary to complete the treatment if <br />orthodontic treatment is started prior to the effective date of coverage. <br />d. The Copayment may be prorated if coverage terminates prior to completion of treatment. The <br />services necessary to complete treatment will be based on the Reasonable Cash Value after <br />coverage terminates. <br />e. The Enrollee is responsible for payment of the Copayments listed below for pre -orthodontic <br />and orthodontic services. The Pre -Orthodontic Service Copayments will be credited towards <br />the Orthodontic Service Copayment due if the Enrollee accepts the treatment plan. The <br />Copayment for limited orthodontic treatment may be prorated based on the treatment plan. <br />f. The General Office Visit Copayment listed in Appendix A is charged at each visit for orthodontic <br />treatment. Services provided in connection with orthodontic treatment are subject to the <br />Service Copayments listed in Appendix A. <br />2. Pre -Orthodontic Service Copayment. <br />Initial orthodontic exam: $25 <br />Study models and X-rays: $125 <br />Case presentation: $0 <br />3. Orthodontic Service Copayment. <br />Comprehensive Orthodontic Service Copayment: $1,500 <br />The following orthodontic procedures are Covered Services under this benefit: <br />D8020 Limited orthodontic treatment of the transitional dentition <br />D8030 Limited orthodontic treatment of the adolescent dentition <br />D8040 Limited orthodontic treatment of the adult dentition <br />D8060 Interceptive orthodontic treatment of the transitional dentition <br />D8070 Comprehensive orthodontic treatment of the transitional dentition <br />D8080 Comprehensive orthodontic treatment of the adolescent dentition <br />D8090 Comprehensive orthodontic treatment of the adult dentition <br />Current Dental Terminology (CDT) 0 2020 American Dental Association. <br />All rights reserved. <br />001 L-WA811(5/20) 29 <br />