Orthodontic Limitations This program provides coverage for orthodontic treatment plans provided through DeltaCare Primary Care orthodontists. The cost to the patient for the treatment plan is listed in the Schedule of Benefits and Copayments subject to the following: 1. Orthodontic treatment must be provided by a DeltaCare orthodontist. 2. Plan benefits cover active comprehensive orthodontic treatment. They include initial examination, diagnosis, consultation, initial banding, active treatment, de-banding and the retention phase of treatment. The retention phase includes the initial construction, placement and adjustments to retainers and office visits. 3. Should a patient’s coverage be canceled or terminated for any reason, and at the time of cancellation or termination be receiving any orthodontic treatment, the patient and not DeltaCare will be responsible for payment of balance due for treatment provided after cancellation or termination. In such a case the patient’s payment shall be based on the provider’s allowable fee at the beginning of treatment. The amount will be pro-rated over the number of months to completion of the treatment and, will be payable by the patient on such terms and conditions as are arranged between the patient and the orthodontist. 4. If treatment is not required or the patient chooses not to start treatment after the diagnosis and consultation have been completed by the orthodontist, the patient will be charged a consultation fee of $25 in addition to diagnostic record fees. 5. Comprehensive orthodontic treatment (Phase II) consists of repositioning all or nearly all of the permanent teeth in an effort to make the patient’s occlusion as ideal as possible. This treatment usually requires complete fixed appliances; however, when the DeltaCare orthodontist deems it suitable, a European or removable appliance therapy may be substituted at the same coinsurance amount as for fixed appliances. Orthodontic Exclusions 1. Lost, stolen or broken orthodontic appliances, functional appliances, headgear, retainers and expansion appliances; 2. Retreatment of orthodontic cases; 3. Changes in treatment necessitated by accident of any kind, and/or lack of patient cooperation; 4. Surgical procedures incidental to orthodontic treatment; 5. Myofunctional therapy; 6. Surgical procedures related to cleft palate, micrognathia, or macrognathia; 7. Treatment related to temporomandibular joint disturbances; 8. Supplemental appliances not routinely utilized in typical Phase II orthodontics; 9. Restorative work caused by orthodontic treatment; 10. Phase I* orthodontics is an exclusion as well as activator appliances and minor treatment for tooth guidance and/or arch expansion; 11. Extractions solely for the purpose of orthodontics; 12. Treatment that began prior to the start of coverage will be prorated: Payment is based on the balance remaining after the down payment and charges prior to the date of eligibility are deducted, except for Orthodontic treatment plans transferred to DDWA from Willamette, which will be prorated based on the amount of months the patient still has remaining in treatment, and any applicable patent co-payments; 13. Charges and/or payments incurred before transfer after banding has been initiated will be prorated: Payment is based on the balance remaining after the down payment and charges prior to the date of eligibility are deducted, except for Orthodontic treatment plans transferred to DDWA from Willamette, which will be prorated based on the amount of months the patient still has remaining in treatment, and any applicable patent co-payments 14. Transfer after banding has been initiated (except for Orthodontic treatment plans transferred to DDWA from Willamette; 2024-01-03100-BB 19 DCL 20240101