You must use a DMO dentist.
There are three DeltaCare programs available through the Small Business
Advantage: Plan 750, Plan 775 and Plan 790. Each DeltaCare program offers these
benefits
- No claim forms
- No dollar limit on dental benefits (no annual
maximum)
- No deductibles, no or low patient copayments on
all covered services, so patients know their exact cost prior to treatment
- No pre-existing conditions restricted,
excluding orthodontic and other services in progress
- Professional treatment standards
- Access to specialty care
DeltaCare - Plans 750, 775 and 790
Patient Copayments
|
Service
Description
No waiting periods!
|
Plan 750
|
Plan 775
|
Plan 790
|
|
Cleaning
(adult/child)
|
No
Cost
|
No
Cost
|
No
Cost
|
|
Bitewing
x-rays
|
No
Cost
|
No
Cost
|
No
Cost
|
|
Fluoride
application (child)
|
No
Cost
|
No
Cost
|
No
Cost
|
|
Amalgam
filling - two surfaces, primary
|
No
Cost
|
No
Cost
|
$18
|
|
Single
tooth extraction (routine)
|
$3
|
$6
|
$18
|
|
Sealant,
per tooth
|
$10
|
$10
|
$10
|
|
Periodontal
scaling and root planing (per quadrant)
|
$15
|
$45
|
$45
|
|
Crown
(full cast noble metal)
|
$90
|
$195
|
$225
|
|
Root
canal, therapy - molar (excluding final restoration)
|
$135
|
$180
|
$180
|
|
Complete
upper or lower denture
|
$110
|
$225
|
$250
|
This is a summary
sheet. It is not a contract, nor does it replace the program policy or
brochure.
|