INFORMATION CONCERNING BENEFITS UNDER THE DELTACARE USA PROGRAM
THIS MATRIX IS INTENDED TO BE USED TO COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THIS DISCLOSURE FORM/CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF PROGRAM BENEFITS AND LIMITATIONS.
Copayments range by category of service. Examples are as follows:
Diagnostic Services
No Cost - $ 5
Preventive Services
No Cost - $150
Restorative Services
No Cost - $425
Endodontic Services
$25 - $725
Periodontic Services
$50 - $650
Prosthodontic Services, Removable
$20 - $600
Prosthodontic Services, Fixed
$25 - $425
Oral and Maxillofacial Surgery
$35 - $230
Orthodontic Services
No Cost - $2,700
Adjunctive General Services
No Cost - $70
NOTE: Some services may not be covered. Certain services may be covered only if provided by specified providers, or may be subject to an additional charge.
Limitations apply to the frequency with which some services may be obtained. For example: cleanings are limited to once in each 6-month period; replacment of removable and fixed dentures and crowns is limited to once in any 5-year period.
(D) Outpatient Services
Not Covered
(E) Hospitalization Services
Not Covered
(F) Emergency Health Coverage
The Enrollee may receive a maximum Benefit up to $100 per emergency, per Enrollee for out-of-area Emergency Services.
(G) Ambulance Services
Not Covered
(H) Prescription Drug Services
Not Covered
(I) Durable Medical Equipment
Not Covered
(J) Mental Health Services
Not Covered
(K) Chemical Dependency Services
Not Covered
(L) Home Health Services
Not Covered
(M) Other
Not Covered
Each individual procedure within each category listed above, and which is covered under the Program has a specific Copayment, which is shown in the Description of Benefits and Copayments in this Disclosure Form/Contract.
