My Benefits



	Benefits summary Emergency services Specialist Services Benefits, limitations and exclusions Description of benefits and copayments (Schedule A) Limitations of benefits (Schedule B) Benefits that are not covered (Schedule B)

SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS

The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program. Please refer to Schedule B for further clarification of benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered.

Text that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA program and is not to be interpreted as CDT-2007 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation.

D0100-D0999	I. DIAGNOSTIC

D1000-D1999	II. PREVENTIVE

D2000-D2999	III. RESTORATIVE

D3000-D3999	IV. ENDODONTICS

D4000-D4999	V. PERIODONTICS

D5000-D5899	VI. PROSTHODONTICS (removable)

D5900-D5999	VII. MAXILLOFACIAL PROSTHETICS - Not Covered

D6000-D6199	VIII. IMPLANT SERVICES – Not Covered

D6200-D6999	IX. PROSTHODONTICS, FIXED

D7000-D7999	X. ORAL AND MAXILLOFACIAL SURGERY

D8000-D8999	XI. ORTHODONTICS – Not Covered

D9000-D9999	XII. ADJUNCTIVE GENERAL SERVICES

Procedures not listed above are not covered however may be available at the Contract Dentist's "filed fees."

"Filed fees" means the Contract Dentist's fees on file with Delta Dental. Questions regarding these fees should be directed to the Customer Service department at (800) 422-4234.