DeltaCare® USA PAA48 Individual/Family Dental Program
Plan details for 1 person(s) living in PA 17601 starting 01/01/2015
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
| 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
| 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)
|
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)
|
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)
|
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)
|
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)
|
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)
|
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)
|
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)
|
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
|
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
|
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 |
