Orthognathic Surgery All orthognathic treatment must be authorized before treatment begins. Benefits will be denied if a Confirmation of Treatment and Cost is not confirmed. Orthognathic treatment performed by a licensed dentist or physician is defined as the necessary surgical procedures or treatment to correct the malposition of the maxilla (upper jawbone) and/or the mandible (lower jawbone). Benefits for orthognathic treatment are paid at 70% of the lesser of the maximum allowable fees or the fees actually charged. The lifetime maximum for orthognathic benefits is $5,000. Complications will be covered only if treatment begins within 30 days of the original treatment. Dental Limitations and Exclusions Limitations Diagnostic — Examination is covered once in a 6-month period; — Full mouth or panoramic X-rays limited to one set every 36 consecutive months; — Bitewing X-rays limited to not more than one series of 4 films in any 6-month period; Preventive — Prophylaxis limited to one treatment in a 6-month period. — Topical application of fluoride or fluoride varnish is covered twice in a calendar year. Preventive therapies (e.g., fluoridated varnishes) approved by DeltaCare are a covered benefit under certain conditions of oral health when performed at the suggested regimen for that therapy. — Fissure sealants are limited to non-carious, non-restored permanent first and second molars through the age of 14. The application of fissure sealants or preventive resin restoration is a covered benefit only once in a 3-year period. — Preventive Resin Restoration is limited to non-carious, non-restored permanent first and second molars through the age of 14. The application of preventive resin restoration or fissure sealant is a covered benefit only once in a 3-year period. — Space maintainers are covered through age 17 for the same quadrant. — The application of caries arresting medicament is a Covered Dental Benefit twice per benefit period per tooth. Restorative — Restorations on the same surface(s) of the same tooth are covered once in a 2-year period; — Crowns are covered once in a 5-year period; — Stainless steel crowns or prefabricated crowns on primary teeth are covered once in a 2-year period; — Crowns on implants are covered as a specialty procedure once in a 5 year period, may be referred to specialist. — Restorations placed on the same tooth within two months of the application of caries arresting medicament are Not a Paid Covered Dental Benefit. Periodontics — Root planing/subgingival curettage is covered once in a 12-month period; — Limited occlusal adjustments are covered once in a 12-month period; — Site specific therapies (localized delivery of antimicrobial agents) are a covered benefit under certain conditions of oral health such as your gums have pocket depth readings of 5mm (or greater); — Periodontal surgery is covered once in a 3-year period; 2024-01-03100-BB 17 DCL 20240101