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Orthodontic Covered Services Orthodontic treatment Is governed by the Schedule of Benefits. If Dental Benefits terminate after the start of Orthodontic treatment, You will be responsible for any additlonal incurred charges for any remaining Orthodontic treatment. Yearly Maximums The Schedule of Benefits lists the Yearly maximums for Covered Services, if applicable, Covered Services After Dental Coverage Ends Dental services received after You or Your dependent's coverage terminates are not covered. Your Selected General Dentist must complete any dental procedure started on you before your termination, abiding by the terms and conditions of the plan. Orthodontic treatment is governed by the Orthodontic limitations listed in the Schedule of Benefits, If coverage from the plan ends after the start of Orthodontic treatment, You or Your dependent will be responsible for any costs Orthodontic treatment after coverage ends, Non -Covered Services IMPORTANT: If you opt to receive dental services that are not covered services under this plan, a participating dental provider may charge you his or her usual and customary rate for those services. Prior to providing a patient with dental services that are not a covered benefit, the dentist should provide to the patient a treatment plan that Includes each anticipated service to be provided and the estimated cost of each service. If you would like more information about dental coverage options, you may call member services at (800) 880- 1800 or your insurance broker. To fully understand your coverage, you may wish to carefully review this evidence of coverage. Other Charges All other charges You may be required to pay under this evidence of coverage are listed in the Schedule of Benefits. You must pay all Co -Payments, or the percentage of the Maximum Allowed Charge that We are not responsible for under the group contract. Reimbursement Provisions You are financially responsible for the cost of any services received from Out -of -Network Dentist unless those services were arranged by Your or Your dependent's Selected General Dentist or were required to treat an Emergency Dental Condition. When You or Your dependent receive a Covered Service from an Out -of -Network Dentist for an Emergency Dental Condition, You should request that the Out -of -Network Dentist bill Us. If the Dentist refuses to bill Us but agrees to bill You, You should immediately submit the bill to Us In accordance with the sub -section titled Emergency Dental Care. If you receive a bill or have paid for a Covered Service and seek reimbursement, please contact SafeGuard at (800) 880-1800. Once you have paid your Co -Payments for Covered Services at Your Selected General Dentist Office, you are no responsible for any other payments for Covered Services, Specialty Care Referrals During the course of treatment, Your Selected General Dentist may encounter situations that require the services of a Specialty Care Dentist. Your Selected General Dentist is responsible for determining when the services of a Specialty Care Dentist are necessary. How Specialty Care is accessed Is determined by Your plan. Some plans allow self -referral while others require that Your Selected General Dentist refer You directly to a provider whose practice is limited to Specialty Care, Please consult the Schedule of Benefits for full information. GCERT2011-DHMO-EOC 25C-23 9