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Below explanation is for California plan only

DeltaCare USA Dental HMO plan
Phone (310) 678-6315

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.

DeltaCare USA RATES (ALL Ages)

	Plan CAA54	Plan CAA55
Individual Annual Premium	$101.80	$ 90.76
Individual +1 dependent	$158.53	$140.68
Individual +2 or more dependents	$227.56	$201.16
	You pay more up front with a higher annual premium. You pay lower copayments on certain procedures.	You pay less up front with a lower annual premium. You pay higher copayments on certain procedures.
Sample of Covered Procedures	You pay	You pay
Office Visit	$10	$15
Exam	No cost	No cost
Bitewing X-rays	No cost	No cost
Full Mouth X-rays	No cost	No cost
Cleaning (once every 7 months)	$20	$25
Crown (upgrade charges may apply)	$325	$325
Tooth Extraction, non-surgical	$40	$45
Teeth Whitening (per arch)	$125	$125
Periodontal Scaling, limited to four quadrants during any 12 consecutive months	$80	$85
Child Orthodontics	$2,600	$2,700
Adult Orthodontics	$2,800	$2,900
APPLICATIONS	CAA 54 Application	CAA 55 Application

DeltaCare USA

Advantages

DeltaCare USA is our prepaid plan that features set copayments, no annual deductibles and no maximums for covered benefits. Enrollees must select a primary care dentist in the DeltaCare USA network from whom they receive treatment as in a traditional dental HMO.¹

Our DeltaCare USA plans promote great dental health for your enrollees and their families with quality dental benefits at an affordable cost. By covering many diagnostic and preventive services at no cost or with very low copayments, we encourage regular preventive dental visits. Enrollees select a DeltaCare USA dentist to provide most covered services¹. All of our network dentists’ offices are independently-owned, and must adhere to Delta Dental’s standards of care, quality and service.

Benefits

• Extensive benefits
• No deductible or annual dollar maximums
• No copayments or low copayments for most diagnostic and preventive services
• Coverage for more than 250 procedures, including additional cleanings, bleaching, and tooth whitening
• No exclusions for pre-existing conditions or missing teeth
• Clearly defined out-of-pocket costs
• Low turnover of network dentists; enrollees can establish a long-term relationship with their dentists
• Ability to change selected or assigned network dentists via telephone or Internet
• Easy referrals to a large specialty care network
• No claim forms to complete
• Expanded business hours for toll-free customer service
• Outstanding quality assurance program that includes credentialing, a quality management program and regular office visits.

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Plan CAA 54 Application (better coverage)

Plan CAA 55 Application (lower premium)

DeltaCare USA DHMO Northern California Dentist Database
DeltaCare USA DHMO Southern California Dentist Database
YOU MUST CHOOSE A PRIMARY DENTIST TO PUT ON OUR APPLICATION.

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