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)

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.

(A) Deductibles	None
(B) Lifetime Maximums	None
(C) Professional Services	An Enrollee may be required to pay a Copayment amount for each procedure as shown in the Schedule of Benefits and Copayments, subject to the Limitations and Exclusions.

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	No Cost - $475
Periodontic Services	$45 - $450
Prosthodontic Services, Removable	$20 - $495
Prosthodontic Services, Fixed	$20 - $425
Oral and Maxillofacial Surgery	$35 - $150
Adjunctive General Services	No Cost - $50
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.
(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 Schedule of Benefits and Copayments in this Disclosure Form/Contract.