My Benefits



	Continuity of Care Benefits, Limitations and Exclusions Emergency Services Specialist Services Coordination of Benefits Renewal and Termination of Benefits Cancellation of Enrollment Schedule A Description of Benefits and Copayments Schedule B Limitations and Exclusions

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.

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 (each retainer and each pontic constitutes a unit in a fixed partial denture [bridge])

X. ORAL AND MAXILLOFACIAL SURGERY

XI. ORTHODONTICS

XII. ADJUNCTIVE GENERAL SERVICES

If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed procedures which require a Dentist to provide specialized services, and are referred by the assigned Contract Dentist, must be preauthorized in writing by Delta Dental. The Enrollee pays the Copayment specified for such 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 Delta Dental's Customer Service department at (800) 422-4234.