Page 16 - Demo

Delta Dental DHMO Plan Options
Low and High Plan Benefits Summary
Online Important Tools Forms
When you enroll in a DeltaCare USA Plan, you’ll choose a primary care dentist from their network of private practice dentists. You must visit your primary care dentist to receive benefits. If you do not select a
dentist, Delta Dental will select one for you. Family members may select a different dentist (up to a maximum of three per family) within the covered service area. Find a provider at: www.deltadentalins.com.
For DeltaCare USA (DHMO) call 1-800-422-4234.
Important Note: No out-of-state coverage available under this plan.
DeltaCare USA M74* Low DHMO Plan
DeltaCare USA 15B High DHMO Plan
Member Pays
Deductible
Single/Family
Plan Year Maximum
No charge
No charge
None
None
Preventive Services
Oral Exams Bitewing X-rays X-rays Intraoral Cleanings
Fluoride Treatment Sealants
$0
$0 $45 $0 $0 $0
$0
$0
$0
$5
$0
$15
Basic Services
Amalgam restorations Resin restorations Extractions - Simple Root Canal Periodontics - Surgery
$0
$35
$80
$245
$360
$12
$26
$120
$365
$385
Major Services (Lab Fees Included**) Crowns
Pontics
Partials
Complete Dentures Implants
$485 $485 $610 $510 Not covered
$395 $395 $395 $365 Not covered
Orthodontia
Child Adult
$2,100 $2,250
$1,900 $2,100
Employee Monthly Contribution
Low DHMO Plan Contribution
High DHMO Plan Contribution
Employee Only
$7.30
$12.60
Employee + 1
$12.07
$23.41
Employee & Family
$17.85
$34.19
*Contracted Specialists under the Low DHMO are not covered at a member copay. The member will pay 75% of the specialist’s discounted filed fees.
**Lab fees are included in DeltaCare services with the exception of a convenience fee for same day crowns.
16 | BPS Employee Benefits Guide
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