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SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS |
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| 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-2011 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. |
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I. DIAGNOSTIC
II. PREVENTIVE
III. RESTORATIVE
IV. ENDODONTICS
V. PERIODONTICS
VI. PROSTHODONTICS (removable)
VII. MAXILLOFACIAL PROSTHETICS - Not Covered
VIII. IMPLANT SERVICES - Not Covered
IX. PROSTHODONTICS (fixed)
X. ORAL AND MAXILLOFACIAL SURGERY
XI. ORTHODONTICS
XII. ADJUNCTIVE GENERAL SERVICES
Procedures not listed above are not covered however may be available at the Contract Dentist's "filed fees."
"Filed fees" mean the Contract Dentist's fees on file with the plan. Questions regarding these fees should be directed to the Customer Service department at 800 422-4234.
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