ORTHODONTIC BENEFITS
Phase One: Interceptive Orthodontic Treatment, Usual and Customary Charges
Phase Two: Eruption of Permanent Teeth (pre & post).
No new records fee moving into phase two.
Maximum fee charged to the member will be $2195.00* for under age 19
and $2395.00* for over age 19. Extractions not included.
Plan benefits cover 24 months of usual and customary orthodontic treatment.
Benefits apply to members in family plan only.
Limitations
- No benefits are available if orthodontic treatment began prior to membership in
American Dental Plan.
- Additional fees may be charged by the doctor for:
a. Extractions
b. Care required in excess of 24 months
c. Ceramic or Gold Appliances
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d. Accidents occurring during the period of treatment.
e. Cases involving surgical orthodontics.
f. Cases involving myofunctional therapy.
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- If the membership expires during the course of treatment, member is obligated to
pay total usual and customary charges.
- Choice of Orthodontists is limited to list of participating Orthodontists.
- No benefits qualify for any work done outside the doctor's office.
Additional Charges
Missed appointments (w/o 48 hr notice)
Lost or non-repairable retainer (per arch)
Lost or broken headgear
Records fee
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$ 25.00
$ 95.00
$ 48.00
$ 85.00
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Lost metal bands
Diagnostic X-rays and Study Models
Retainer Fabrication and Debanding (each arch)
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$ 39.00
$175.00
$165.00
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TMJ AND OTHER X-RAYS NOT INCLUDED