When you enroll in DeltaCare, select a Participating Dentist from the list.  This location is now the center for all of your dental needs.

After you have enrolled, you will receive a Combined Evidence of Coverage and Disclosure Form that fully describes the benefits of your dental plan as well as a DeltaCare membership card.  This card will have the address and telephone number of your participating panel dentist.  To receive all necessary dental care covered by the plan, simply call your selected provider to make an appointment.

Remember to always contact your selected panel dentist.  Dental services which are not performed by your panel provider nor prior authorized by PMI will not be covered by the DeltaCare program.

·         WHO CAN JOIN

You can also enroll your eligible dependents, which include your lawful spouse and unmarried children; including step-children, legally adopted and foster children to the limiting age as specified by state law.

Ö   NO CLAIM FORMS
The dental location you choose provides all primary dental services.  There are no claim forms to complete or percentage of usual charges for you to pay.   

Ö   NO DEDUCTIBLES
In the DeltaCare program there are no required deductibles to pay so your benefits begin immediately.   

Ö   NO DOLLAR LIMIT OF DENTAL BENEFITS
No annual limit.   

Ö   NO PRE-EXISTING CONDITONS RESTRICTED
These conditions are not excluded in a DeltaCare program.  Exception: Work in progress.  

Ö   PREPAID PLAN SAVES ON DENTAL COST
Your out-of-pocket savings could be substantial.  You know the exact cost prior to treatment and this aids in better fiscal planning for you and your family.   

Ö   QUALITY REVIEW OF DENTAL PROVIDERS
On site audit of participating dental locations to insure that established standards of quality are maintained. 

Ö   SPECIALTY SERVICES
The DeltaCare program offers services in dental specialty areas.  These include periodontics (treatment of diseased gums and bone), endodontics (root canal therapy), and oral surgery procedures.

·         SUMMARY OF BENEFITS   

The DeltaCare program provides all reasonable and customary dental care (subject to the provisions, limitations and exclusions as shown in the Combined Evidence of Coverage and Disclosure Form) if care is rendered by your assigned DeltaCare panel dentist.  There is no cost for covered services to the primary enrollee or eligible dependent enrollee except for co-payments on certain procedures.  (See Description of Benefits and Co-payments on reverse side.)   

·         EMERGENCY SERVICES   

You are also covered for out-of-area dental emergencies.  This program will pay dental expenses incurred up to a maximum of $50.00 during each 12 calendar months.  “Out-Of-Area” means 35 miles or more from your selected DeltaCare participating dentist’s office.

SUMMARY OF BENEFITS AND COPAYMENTS
These procedures are performed as needed and deemed necessary by your Provider Dentist subject to the Limitation, Exclusions and Governing Administrative Policies of the program.  

                                                                 Enrollee pays

 DIAGNOSTIC
Oral examination.................................................. No Cost
Bitewing radiograph(s)...................................... No Cost Panoramic film..................................................... No Cost
Pulp vitality tests................................................ No Cost 

 PREVENTIVE
Prophylaxis (adult/child) two per 12 month period
..................................No Cost
Topical application of fluoride including, excluding
 prophylaxis (to age 19)             No Cost   

RESTORATIVE
Amalgam - one surface, primary....................... $ 4.00
Amalgam - four surfaces, primary.................... $ 12.00
Amalgam - one surface, permanent.................. $ 4.00
Amalgam - four surfaces, permanent............... $ 12.00
Resin - one surface, anterior............................. $ 10.00
Sedative filling..................................................... $ 5.00

ORAL SURGERY
Routine extraction - single tooth, each additional
...............................................................................$ 6.00
Surgical removal of erupted tooth.................... $ 10.00
Removal of impacted tooth - soft tissue......... $ 50.00
Removal of impacted tooth - completely bony
...............................................................................$ 90.00
Alveoplasty in conjunction with extraction per
quadrant............................................................... $ 50.00
Frenulectomy - (frenectomy or frenotomy) separate
procedure.............................................................No Cost

PERIODONTICS
Gingivectomy or gingivoplasty, per quadrant
............................................................................. $150.00
Root planing & periodontal scaling, gingival
curettage, per quadrant....................................$ 40.00
Osseous surgery, flap entry & closure, per quadrant
..............................................................................$275.00

PROSTHETICS
Crown - resin (laboratory)................................. $ 50.00
Crown - porcelain/ceramic................................. $180.00
Crown - porcelain fused to metal*................... $180.00
Crown - full cast metal*..................................... $180.00
Crown - prefabricated stainless steel,
primary/permanent    .......................................... $ 35.00
Denture - complete upper or lower................... $225.00
Denture - upper or lower partial w/metal lingual or
palatal bar, clasps & acrylic saddles, acrylic base
or cast metal framework......................................$275.00
Denture repair – laboratory............................... $ 25.00
Partial denture repair (per repair)...................... $ 25.00
Denture reline/rebase chairside 
(complete or partial)............................................ $ 30.00
Bridge pontic - metal*........................................ $180.00

*Precious and semi-precious metals, if used, will be charged to the enrollee at the additional cost of the metal.  This applies to crowns, bridges, and cast post and cores. 

  ENDODONTICS
Root canal therapy – anterior........................... $ 55.00
Root canal therapy – bicuspid.......................... $110.00 
Root canal therapy – molar............................... $165.00   ADJUNCTIVE GENERAL SERVICES Palliative (emergency) treatment of dental pain
..................................................................................$ 10.00
Local anesthesia................................................... No Cost Consultation.......................................................... $ 20.00 Office visits after regularly scheduled hours................$ 20.00 ORTHODONTICS Start-up fees......................... $ 350.00
Dependent children to age 19............................. $1800.00 
Adults and covered full-time students.............. $2000.00

Disclaimer: Professional Benefit Administrators has no liability for providing or guaranteeing service and has no liability or responsibility for the quality of service rendered

DeltaCare

Plan A33

(California)

Presented by

Professional Benefit
Administrators.

  (770) 963-3939

1 (800) 578-2082
www.pbainsurance.net