Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 4420 Deltacare USA DHMO Plan Description •  Deltacare USA promotes great dental health for you and your family with quality dental benefits at an affordable cost. Deltacare USA plans are designed to encourage you and your family to visit the dentist regularly to main- tain your dental health. Today, over 1.2 million enrollees are covered by Deltacare USA plans. •  When you enroll, you select a primary contract dentist to provide services. The Deltacare USA network consists of private practice dental facilities that have been carefully screened for quality. Deltacare USA DHMO Enrollment Option: •  Your chosen primary contract dentist will take care of the dental needs for each enrolled family member. If you require treatment from a specialist, your primary dentist will handle the referral for you. • A family may elect up to 3 dentists. •  After you have enrolled, you will receive a membership packet that includes an identification card and an Evidence of Coverage that fully describes the benefits of your plan. Also included in this packet is the name, address and phone number of your primary dentist. •  Under the Deltacare USA program, many services are covered at no cost, while others have copayments (amount you pay your primary dentist) for certain benefits. Please note: Dental services that are not performed by your chosen primary dentist, or are not covered under provisions for emergency care, must be preauthorized by the Administrator to be covered by your Deltacare USA program. Please see complete fee schedule available at open enrollment meetings or by visiting Human Resources. NOTE: Deltacare USA DHMO is available across the United States with the exception of MA, MN & ND. If you reside in MA, MN or ND and wish to know more about your benefits, please call Human Resources. PATIENT PAY Periodic oral exam (D0120) No Charge Bitewing x-ray, single film (D0270) No Charge Prophylaxis cleaning, adult (D1110) $5.00 Amalgam restoration, single surface (D2140) $8.00 Crown, porcelain fused to metal (D2750) $395.00 Root canal, anterior $125.00 Complete denture, maxillary (D5110) $365.00