Dental benefits that are affordable and easy to understand

DeltaCare® USA

Delta Dental

Individual & Family™

DeltaCare® USA

Family Dental HMO

Dental beneﬁts that are

aordable and easy to understand

Get dental care right away with DeltaCare USA

Is a DeltaCare USA plan right for me?

With easy-to-understand set costs and aordable pricing, DeltaCare USA is

great for budget-conscious people. DeltaCare USA plans feature:

• Set costs (also known as copayments) for covered dental services

• No waiting periods on any covered procedures, even major services

• Low or no copays for diagnostic and preventive care

To use your plan, you’ll need to see your chosen DeltaCare USA dentist.

But don’t worry! If you need emergency dental care, even when you’re

away from home, you’ll be covered by an emergency services provision

Underwriter

Delta Dental of California

560 Mission Street, Suite 1300

San Francisco, CA 94105

Claims and Correspondence

P.O. Box 1803

Alpharetta, GA 30023

Customer Service

888-282-8528

deltadentalins.com

Please consult the plan policy for a description of plan beneﬁts, limitations and exclusions. View the full copayment

schedule, plus limitations and exclusions or call 888-282-8528.

Delta Dental Insurance Company acts as the DeltaCare USA administrator in all states.

Delta Dental and DeltaCare USA are registered marks of Delta Dental Plans Association.

PB_DCU_CA_I_FAM_PRF_23

How does DeltaCare USA work?

If you’re familiar with HMO-style insurance

plans, you’ll ﬁnd DeltaCare USA easy to

understand.

When you visit your chosen DeltaCare USA

dentist for care, you’ll just pay the copayments

listed in your plan documents for any covered

services you receive. Because there are no

waiting periods or deductibles (minimum

amounts you must pay before your plan will

begin helping with your costs), you can make

the most of your beneﬁts the ﬁrst day your

coverage begins.

You won’t need an ID card to get care. Just

give your information to your dentist and they

can ﬁnd your coverage.

Important tips

• You’ll visit your chosen DeltaCare USA primary care dentist for care. It’s easy to

change your dentist anytime online or by phone.

• Find a DeltaCare USA dentist near you at with Find a Dentist search. Browse

the built-in Yelp® and DentaQual® ratings to help you ﬁnd a dentist you’ll love.

• Review the plan highlights on the next page to see the copayments for the

most common covered services. You can also view the full copayment schedule

or the Health Care Exchange (Marketplace) plans page for more information.

Read your policy carefully. This brochure provides a brief description of the important features of your policy. This is

not the insurance policy and only the policy provisions will control. The policy itself sets forth in detail the rights and

obligations of both you and your insurance company. It is therefore important that you read your policy carefully.

Changes received between the ﬁrst and 15th of the month are eective immediately. Changes received on the 16th

through the end of the month will be eective on the ﬁrst of the next month.

HCR_DCUSA #134496 (05/22)

HL_DCU_CA_I_FAM_PRF_23

Delta Dental Individual & Family™

DeltaCare® USA | Family Dental HMO

Plan Highlights

Deductibles and Maximums Pediatric Benefits

(up to age 19)

Adult Benefits

(age 19 and older)

Deductible

Enrollee

Family

None

Out-of-Pocket Maximum

After this amount is reached, the plan

pays 100% of the remaining covered

services per Calendar Year.

$350 one pediatric enrollee

$700 two or more pediatric

enrollees

None

Sample of Covered Services

Procedure

Code

Description

Copayment Amount

Pediatric

Benefits

Adult

Benefits

Diagnostic and Preventive Services

D0999 Office visit No charge No charge

D0120 Periodic oral exam — established patient No charge No charge

D0150 Comprehensive oral evaluation — new or

established patient

No charge No charge

D0210 Complete series of x-rays No charge No charge

D0220 Periapical x-ray of tooth’s root No charge No charge

D0230 Periapical x-ray of tooth’s root, each additional

image

No charge No charge

D0272 Bitewing x-rays (2 images) No charge No charge

D0274 Bitewing x-rays (4 images) No charge No charge

D0330 Panoramic x-ray No charge No charge

D1110 Prophylaxis (cleaning) — adult No charge No charge

D1120 Prophylaxis (cleaning) — child No charge Not covered

D1208 Fluoride treatment No charge No charge

D1351 Sealant — per tooth No charge Not covered

Featured benefits represent the most frequently used services covered under your plan; other services are also covered. After

enrollment, DeltaCare USA will make available a complete list of covered services and copayments, along with any limitations and

exclusions that apply. If applicable, service areas are detailed in the limitations and exclusions.

Copayments and procedure descriptions referenced above are intended to clarify the delivery of benefits under the DeltaCare USA

plan. They are not to be interpreted as CDT-2022 descriptors or nomenclature, which are under copyright by the American Dental

Association.

A copayment is the amount the enrollee pays for covered services at the time of treatment.

HL_DCU_CA_I_FAM_PRF_23

Procedure

Code

Description

Copayment Amount

Pediatric

Benefits

Adult

Benefits

Basic Services

D2140 Amalgam (silver-colored) filling, 1 surface $25 $25

D2150 Amalgam (silver-colored) filling, 2 surfaces $30 $30

D2160 Amalgam (silver-colored) filling, 3 surfaces $40 $40

D2330 Resin (tooth-colored) filling, front tooth, 1

surface

$30 $30

D2331 Resin (tooth-colored) filling, front tooth, 2

surfaces

$45 $45

D2332 Resin (tooth-colored) filling, front tooth, 3

surfaces

$55 $55

D2391 Resin (tooth-colored) filling, back tooth, 1

surface

$30 $30

D2392 Resin (tooth-colored) filling, back tooth, 2

surfaces

$40 $40

D2393 Resin (tooth-colored) filling, back tooth, 3

surfaces

$50 $50

Endodontics

D3310 Root canal, front tooth $195 $200

D3320 Root canal, premolar tooth $235 $235

D3330 Root canal, molar tooth $300 $300

Periodontics

D4260 Periodontal surgery, per quadrant $265 $265

D4341 Periodontal scaling and root planing — four or

more teeth per quadrant

$55 $55

D4910 Periodontal maintenance $30 $30

Oral Surgery

D7140 Extraction (removal) of a fully exposed tooth $65 $65

D7210 Extraction of erupted (exposed) tooth $120 $115

D7240 Extraction of fully impacted tooth, completely

bony

$160 $160

Major Services

D2750 Crown, porcelain and precious metal Not covered $300

D2790 Crown, precious metal Not covered $300

D5110 Full upper denture $300 $400

D6240 Bridge pontic, porcelain and precious metal Not covered $300

Orthodontics

D8080 Pediatric services

$350 Not covered

Orthodontic Services for Pediatric Enrollees must meet medical necessity as determined by a Contract Dentist.

Can you read this document? If not, we can have somebody help you read it. You may also be able to get this document

written in your language. For free help, please call

(TTY: 711).

¿Puede leer este documento? Si no, podemos encontrar a alguien que lo ayude a leerlo. También puede obtener este

documento escrito en su idioma. Para obtener ayuda gratuita, llame al

(servicio de retransmisión TTY

deben llamar al 711). (Spanish)

您能自行閱讀本文件嗎？如果不能，我們可請人幫助您閱讀。您還可以請人以您的語言撰寫本文件。如需免費幫助，請致電

(TTY: 711)。(Chinese)

Nababasa mo ba ang dokumentong ito? Kung hindi, may tao kaming makakatulong sa iyong basahin ito. Maaari mo ring

makuha ang dokumentong ito nang nakasulat sa iyong wika. Para sa libreng tulong, pakitawagan ang

(TTY: 711). (Tagalog)





(TTY: 711). (Vietnamese)

이 문서를 읽으실 수 있습니까? 읽으실 수 없으면 다른 사람이 대신 읽어드릴 수 있습니다. 한국어로 번역된 문서를 받으실

수도 있습니다. 무료로 도움을 받기를 원하시면

(TTY: 711)번으로 연락하십시오. (Korean)

Դուք կարո՞ղ եք կարդալ այս փաստաթուղթը: Եթե ոչ, նք որևէ կին կգտնենք, ով կօգնի ձեզ կարդալ: Դուք կարող եք նաև

այս փաստաթուղթը ստանալ՝ գրված ձեր լեզվով: Անվճար օգնության համար խնդրում ենք զանգահարել

(TTY՝ 711)

(Armenian)

نﺎﺑز ﻪﺑ ار ﻣ ﻦﯾا ﺪﯿﻧاﻮﺘﺑ ﺖﺳا ﻦﮑﻤﻣ ﻦﯿﻨﭽﻤﮬ .ﺪﻨﮐ ﮏﻤﮐ ﺷ ﻪﺑ ﻣ ﻦﯾا نﺪﻧاﻮﺧ رد ﺎﺗ ﻢﯿﮬاﻮﺨﺑ ﯽﺼﺨﺷ زا ﻢﯾردﺎﻗ ﺎﻣ ،ﺪﯿﻧاﻮﺗ ﯽ ﻪﮐ ﯽﺗرﻮﺻ رد ؟ﺪﯿﻧاﻮﺨﺑ ار ﻣ ﻦﯾا ﺪﯿﻧاﻮﺗ ﯽﻣ ﺎﯾآ

(Persian Farsi) .(711 :TTY) :ﺪﯾﺮﯿﮕﺑ سﺎ هرﺷ ﻦﯾا ﺎﺑ نﺎﮕﯾار ﮏﻤﮐ یاﺮﺑ .ﺪﯿﻨﮐ ﺖﻓﺎﯾرد دﻮﺧ

ةﺪﻋﺎﺴﻤﻠﻟ ﻚﺘﻐﻠﺑ ﺎ

ﺑﻮﺘﻜﻣ ﺪﻨﺘﺴﳌا اﺬﻫ ﲆﻋ لﻮﺼﺤﻟا ﺎ

ﻀﻳأ ﻚﻨﻜ ﺎر .ﺎﻬﺗءاﺮﻗ ﰲ كﺪﻋﺎﺴﻳ ﻦﻣ ﻚﻟ ﺮﻓﻮﻧ نأ ﺎﻨﻨﻜ ،ﻊﻴﻄﺘﺴﺗ ﻻ ﺖﻨﻛ اذإ ؟ﺪﻨﺘﺴﳌا اﺬﻫ ةءاﺮﻗ ﻊﻴﻄﺘﺴﺗ ﻞﻫ

(Arabic) .(TTY: 711) ـﺑ ﻞﺼﺗا ﺔﻴﻧﺎﺠﳌا









󰉎󰉮󰍺󰏱󰍮󰍷󰏲󰏱󰏲󰏟󰉮󰍺󰉮

󰍷󰍠󰊨󰏚󰍺󰉩󰍷



ֿך俑剅׾ֶ铣׫חז׸תַׅֶ铣׫חז׸זְ㜥さחכ갈铣نٓٝذ؍،׾䩛ꂁׇׁגְ׋׌ֹתׅկֿך俑剅׾׀䋞劄ך鎉

铂ח鏬׃׋׮ך׾ֶ鷏׶דֹ׷㜥さ׮֮׶תׅկ搀俱ך؟ه٦زחאְגכծ

(TTY: 711) תדֶ ㉏ ְ さ ׻ ׇֻ׌

ְׁկ (Japanese)

󰒤󰐈󰒤󰒤󰐈

󰐇









  

     

    

(T T Y: 711) (Cambodian)





(TTY: 711) (Thai)



CA-LAP-16

888-282-8978