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DeltaCare Insurance Company

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DeltaCare Insurance Company

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DeltaCare® USA PAA48 Individual/Family Dental Program

Plan details for 1 person(s) living in PA 17601 starting 01/01/2015

DeltaCare® USA PAA48 Individual/Family Dental Program

Annual Premium: $105.00

Disclosure Form/Contract
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  • Summary
  • Deductibles
  • Maximums
  • Diagnostic (exams, x-rays)
  • Preventive (cleanings)
  • More Links
    • Basic Services (fillings)
    • Endodontics (root canal)
    • Periodontics (gum treatment)
    • Oral Surgery (extractions)
    • Major Services (dentures, crowns)
    • Orthodontics (braces)
    • General Services
    • Additional Services
    • Plan Documents

Summary

Summary
Deductible per calendar year per person: $0
Maximum per calendar year per person: $0
This is only a summary of benefits subject to the limitations and exclusions of the plan. Actual copayment amounts vary by specific procedure(s).

You Pay
Office visit: $5
Exams: $0
X-rays: $0
Cleanings: $15
Fillings: $26 - $100
Root canals: $150 - $270
Gum treatment: $55 - $440
Extractions: $35 - $155
Denture repair: $45
Crowns: $295 - $395
Orthodontics: $2,300 - $2,500

Deductibles

Deductibles
Deductible per calendar year per person: $0
Deductible per calendar year per family: $0
Temporomandibular Joint Dysfunction (TMJ) per person: Not a covered benefit
Accident injury per person: Subject to procedures, copayments, limitations and exclusions as defined in the Disclosure Form/Contract.

Maximums

Maximums
Maximum per calendar year per person (excludes orthodontic maximum): $0
Maximum per calendar year per family (excludes orthodontic maximum): $0
Orthodontic benefits per lifetime per person: $0
Orthodontic benefits per lifetime per family: $0
Temporomandibular Joint Dysfunction (TMJ) per lifetime per person: Not a covered benefit

Diagnostic (exams, x-rays)

Diagnostic (exams, x-rays)
This is only a summary of benefits subject to the limitations and exclusions of the plan. Actual copayment amounts vary by specific procedure(s).

You Pay
Exam - periodic: $0
Exam - comprehensive: $0
X-ray - full mouth: $0
X-ray - intraoral (first image): $0
X-ray - intraoral (each additional image): $0
X-ray - bitewing (two images): $0
X-ray - bitewing (four images): $0
Waiting period: None

Preventive (cleanings)

Preventive (cleanings)
This is only a summary of benefits subject to the limitations and exclusions of the plan. Actual copayment amounts vary by specific procedure(s).

You Pay
Teeth cleaning - adult: $15
Teeth cleaning - child: $15
Fluoride: $0
Sealant: $10
Waiting period: None

Basic Services (fillings)

Basic Services (fillings)
This is only a summary of benefits subject to the limitations and exclusions of the plan. Actual copayment amounts vary by specific procedure(s).

You Pay
Filling - silver-colored (one surface): $26
Filling - silver-colored (two surfaces): $36
Filling - tooth-colored/composite (one surface, front): $35
Filling - tooth-colored/composite (one surface, back): $65
Filling - tooth-colored/composite (two surfaces, back): $75
Waiting period: -

Endodontics (root canal)

Endodontics (root canal)
This is only a summary of benefits subject to the limitations and exclusions of the plan. Actual copayment amounts vary by specific procedure(s).

You Pay
Root canal (front): $150
Root canal (molar): $270
Waiting period: None

Periodontics (gum treatment)

Periodontics (gum treatment)
This is only a summary of benefits subject to the limitations and exclusions of the plan. Actual copayment amounts vary by specific procedure(s).

You Pay
Gum disease treatment: $440
Gum cleanings: $55
Waiting period: None

Oral Surgery (extractions)

Oral Surgery (extractions)
This is only a summary of benefits subject to the limitations and exclusions of the plan. Actual copayment amounts vary by specific procedure(s).

You Pay
Simple tooth extraction: $35
Surgical removal of erupted tooth: $40
Waiting period: None

Major Services (dentures, crowns)

Major Services (dentures, crowns)
This is only a summary of benefits subject to the limitations and exclusions of the plan. Actual copayment amounts vary by specific procedure(s).

You Pay
Full denture: $350
Denture repair: $45
Crown: $295 - $395
Implants: Not a covered benefit
Waiting period: None

Orthodontics (braces)

Orthodontics (braces)
This is only a summary of benefits subject to the limitations and exclusions of the plan. Actual copayment amounts vary by specific procedure(s).

You Pay
Orthodontics - child: $2,300
Orthodontics - adult: $2,500
Waiting period: None

General Services

General Services
This is only a summary of benefits subject to the limitations and exclusions of the plan. Actual copayment amounts vary by specific procedure(s).

You Pay
Teeth whitening: Not a covered benefit
Waiting period: None

Additional Services

Additional Services
This is only a summary of benefits subject to the limitations and exclusions of the plan. Actual copayment amounts vary by specific procedure(s).

You Pay
Temporomandibular Joint Dysfunction (TMJ): Not a covered benefit
Accident injury: Subject to procedures, copayments, limitations and exclusions as defined in the Disclosure Form/Contract.
Waiting period: None

Plan Documents

EOC PAA48 Disclosure Form and Contract.pdf (English) | Effective from 01-Jul-2010
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Copyright © 2012 Delta Dental Insurance Company.

The Delta Dental PPO plan (Contract 1230) is underwritten by Delta Dental Insurance Company in MD, NY, PA and TN and by Dentegra Insurance Company in CA and CO. The DeltaCare USA plan (Contract 76777) is underwritten by Alpha Dental Programs, Inc. in MD, by Delta Dental of California in CA, by Delta Dental of New York, Inc. in NY, by Delta Dental of Pennsylvania in PA, by Delta Dental Insurance Company in TN, and by Dentegra Insurance Company in CO. The plans are administered by Delta Dental Insurance Company. These companies are financially responsible for their own products.

AARP endorses the AARP Dental Insurance Plan, administered by Delta Dental Insurance Company. Delta Dental Insurance Company pays royalty fees to AARP for use of its intellectual property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers.