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Below explanation is for California plan only

DeltaCare USA Dental HMO plan 
(877)566-5454 Toll Free
When you enroll in DeltaCare USA, you select a PMI network dentist to provide your dental care. With DeltaCare USA, you must visit your selected primary care dentist in order to receive benefits. When you need specialty care, your primary care dentist can obtain a referral. Advantages of the DeltaCare USA plan include low or no copayments for services, no deductibles and no maximums on services provided by primary care dentists.

                 Dues are easy to afford:

 
(A) Deductibles None
(B) Lifetime Maximums None
(C) Professional Services An Enrollee may be required to pay a Copayment amount for each procedure as shown in the Description of Benefits and Copayments, subject to the Limitations and Exclusions.
Copayments range by category of service. Examples are as follows:
Diagnostic Services No Cost - $ 5
Preventive Services No Cost - $150
Restorative Services No Cost - $425
Endodontic Services $25 - $725
Periodontic Services $50 - $650
Prosthodontic Services, Removable $20 - $600
Prosthodontic Services, Fixed $25 - $425
Oral and Maxillofacial Surgery $35 - $230
Orthodontic Services No Cost - $2,700
Adjunctive General Services No Cost - $70

NOTE: Some services may not be covered. Certain services may be covered only if provided by specified providers, or may be subject to an additional charge.

Limitations apply to the frequency with which some services may be obtained. For example: cleanings are limited to once in each 6-month period; replacment of removable and fixed dentures and crowns is limited to once in any 5-year period.
(D) Outpatient Services Not Covered
(E) Hospitalization Services Not Covered
(F) Emergency Health Coverage The Enrollee may receive a maximum Benefit up to $100 per emergency, per Enrollee for out-of-area Emergency Services.
(G) Ambulance Services Not Covered
(H) Prescription Drug Services Not Covered
(I) Durable Medical Equipment Not Covered
(J) Mental Health Services Not Covered
(K) Chemical Dependency Services Not Covered
(L) Home Health Services Not Covered
(M) Other Not Covered

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Download DeltaCare USA DHMO .pdf Application

DeltaCare USA DHMO Dentist Network Database
YOU MUST CHOOSE A PRIMARY DENTIST TO PUT ON OUR DHMO APPLICATION.
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Phone:   (310) 827-7286  |   Fax:   (310) 827-0256
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