|
DELTA
PREFERRED OPTION (DPO) |
DELTACARE |
|
DPO
PROVIDER |
DELTA
DENTAL PROVIDER (NOT PART OF DPO NETWORK) |
NON-NETWORK
PROVIDER |
DHMO
1, 2 |
| PLAN
FEATURES |
| Calendar-Year
Deductible |
$75/person
or
$150/family (doesn't apply to diagnostic and preventive services) |
$75/person
or
$150/family (doesn't apply to diagnostic and preventive services) |
$75/person
or
$150/family (doesn't apply to diagnostic and preventive services) |
None |
|
Plan
Maximum
|
|
|
|
|
- Diagnostic,
Preventive, Basic and Major Service
|
$2,
500/calendar year |
$2,
500/calendar year |
$2,
500/calendar year |
None |
|
|
$1,00/calendar
year; $2,000 lifetime maximum |
$1,00/calendar
year; $2,000 lifetime maximum |
$1,00/calendar
year; $2,000 lifetime maximum |
None |
| PLAN
BENEFITS |
| Diagnostic
and Preventive Benefits |
100%
of DPO-approved fee (no deductible applies) |
80%
of DPO-approved fee (no deductible applies) |
80%
of Delta-approved fee; you pay remaining 20% plus fees above approved
amount |
100% |
| Basic
and Major Benefits |
80%
of DPO-approved fee |
70%
of DPO-approved fee |
70%
of Delta-approved fee; you pay remaining 30% plus fees above approved
amount |
100% |
| Orthodontia
Benefits |
70%
of DPO-approved fee (subject to a $1,000/person calendar-year maximum
and a $2,000/person lifetime maximum) 3 |
70%
of Delta-approved fee (subject to a $1,000/person calendar-year maximum
and a $2,000/person lifetime maximum) 3 |
70%
of Delta-approved fee (subject to a $1,000/person calendar-year maximum
and a $2,000/person lifetime maximum); you pay remaining 30% plus
fees above approved amount 3 |
- Up
to age 19: 100% after $350 start-up fee; $1,600 copay (for 24
months of standard orthodontia treatment; additional fee may apply
after 24 months)
- Adults
and verified full-time students: 100% after $350 start-up fee;
$1,800 copay (for 24 months of standard orthodontia treatment;
additional fee may apply after 24 months)
|
| Dental
Work Performed by a Pedodontist 4 |
Percentage
of approved fee varies based on type of service |
Percentage
of approved fee varies based on type of service |
Percentage
of approved fee varies based on type of service |
Pedodontic
referrals must be pre-authorized by DeltaCare.
- Up
to age 4: 100% of approved fee, minus any applicable copays
- Age
4 and older: 50% of approved fee, minus any applicable copays
|
1. Services
received from a non-DeltaCare dentist are not covered, except in an
emergency while out of town (i.e., more than 35 miles from a DeltaCare
dental office).
2. The plan will reimburse up to $100 of a non-network emergency dental
care each year.
3. Up to age 19 with a $25 deductible.
4. A pedodontist is a dentist who specializes in the growth
and development of children's teeth.
|
