Page 20 of 22 MET245_SOB_CA (01/25) Fs/f GCERT2010-DHMO-SOB limit 7. Provisional prostheses are to be used for an interim of at least six (6) months duration. Interim prostheses are to be used for a period of at least two (2) months duration. These procedures are to be utilized during restorative treatment to allow adequate time for healing or completion of other procedures. They are not to be used as temporary restorations. Implant Services 1. Implants are limited to no more than once for the same tooth position in a five (5) year period. 2. Repairs of implants are limited to not more than once in a twelve (12) month period. 3. Implant supported prosthetics are limited to no more than once for the same tooth position in a five (5) year period: • when needed to replace congenitally missing teeth; or • when needed to replace natural teeth. 4. The following are limited to no more than two (2) each per year: Implants, Implant supported prosthetics, and Implant abutments. Endodontics 1. The Co-Payments listed for Endodontic procedures do not include the cost of the final restoration. 2. Materials used for canal irrigation are included in the Endodontic procedure fees. Oral Surgery 1. The removal of asymptomatic third molars is not a Covered Service. Pathology (disease) must exist for it to be covered by the program. 2. Includes routine post operative visits/treatments. Periodontics 1. Irrigation (such as Chlorhexidine), is included with the other services rendered that day. 2. Local chemotherapeutic agents are limited to no more than six (6) teeth per arch. Treatment plans involving more than six (6) teeth per arch, require prior Plan approval. 3. Periodontal maintenance is eligible following active periodontal therapy, which includes scaling and root planing, surgery, etc. 4. Periodontal scaling and root planing, is limited to not more than once per Quadrant in any twenty-four (24) month period. 5. Periodontal surgery, including gingivectomy, gingivoplasty and osseous surgery, is limited to no more than one surgical procedure per Quadrant in any thirty-six (36) month period. 6. Periodontal charting for planning treatment of periodontal disease is included as part of overall diagnosis and treatment. No additional charge will apply to You or Your Dependent or Us. Orthodontics 1. If You or Your Dependent require the services of an orthodontist, a referral must first be facilitated by Your Selected General Dentist. If a referral is not obtained before the Orthodontic treatment begins, You will be responsible for all costs associated with any Orthodontic treatment. 2. If You or Your Dependent terminate coverage from the SafeGuard Plan after the start of Orthodontic treatment, You will be responsible for any additional charges incurred for the remaining Orthodontic treatment. 3. Orthodontic treatment must be provided by a Selected General Dentist or Specialty Care Dentist whose specialty is orthodontics or pediatric dentistry for the Co-Payments listed in this SCHEDULE OF BENEFITS to apply. 4. Plan benefits shall cover twenty-four (24) months of usual and customary Orthodontic treatment and an additional twenty-four (24) months of retention. Treatment extending beyond such time periods will be subject to a charge of $25 per visit. 5. The retention phase of treatment shall include the construction, placement, and adjustment of retainers. 6. If You or Your Dependent started orthodontic treatment before Your coverage for Yourself or that Dependent started under this group contract, Continuing Orthodontic treatment is available under this group contract for You or Your Dependent under any of the following circumstances: a. You were covered under the terms of a dental plan provided by SafeGuard and, due to an acquisition, are now covered under the terms of this group contract; b. You were covered under the terms of a dental plan provided by a carrier other than SafeGuard and are now covered under the terms of this group contract because the Contractholder subsequently contracts with SafeGuard; c. You become eligible for DHMO benefits under the terms of this group contract because of Your status as a new employee; or d. You were covered under the terms of a dental plan and received orthodontic services which were not covered because that dental plan did not offer orthodontic coverage. Upon receipt of a completed Continuing Orthodontic Form by Us, with all supporting documentation, We will accept liability for continuing payment of the remaining balance owed, up to a maximum of $1,500 times the percentage of the total treatment remaining as of this group contract’s Effective Date, subject to the section titled DENTAL BENEFITS: LIMITATIONS AND ADDITIONAL CHARGES and DENTAL BENEFITS: EXCLUSIONS. Continuing Orthodontic treatment will be available if You enroll within 30 days of the date You become eligible for benefits under the terms of this group contract.