DeltaCare USA DHMO Plan
Group #07742
Benefits made easy
When you enroll in a DeltaCare USA plan, you'll choose a primary care dentist of our carefully screened, private-practice Dentists. You must visit your primary care Dentist to receive benefits
Budget friendly costs
With your DeltaCare USA plan, there are no surprises. You'll know your copayments and your out-of-pocket costs are clearly defined before treatment begins.
A partner in oral health
Your DeltaCare USA plan encourages regular dental care with an extensive list of covered services to help you stay healthy.
Convenient services
We make it easy for you – there are no claim forms to complete, and no plan ID card is required to receive treatment.
| Service | DeltaCare® USA DHMO Plan |
|---|---|
| Calendar year maximum (per person) | N/A |
| Calendar year deductible (waived on Preventive & Diagnostic) | |
| Per person | N/A |
| Family aggregate | N/A |
| Preventive & Diagnostic | |
| Exams, cleanings (each twice in a calendar year) | No cost |
| Bitewing x‐rays (twice per calendar year for persons 18 and younger, once per calendar year for persons age 19 and over) | No cost |
| Complete series of radiographic images (once per five years) | No cost |
| Fluoride treatment (once in a calendar year, children to age 19) | No cost |
| Sealants (once per 3 years, permanent molars, children to age 15) | $10 per tooth |
| Space maintainers (1 per arch, per lifetime, to age 14) | $12 - $70 |
| Periodontal maintenance (2 per calendar year ‐ with history of periodontal disease) | TBD |
| Basic services | |
| Simple restorations (including composite restorations on back teeth) | No cost - $85 |
| Endodontics (root canal) | $110 - $350 |
| Surgical periodontics | No cost - $130 |
| General periodontics | No cost - $130 |
| Oral surgery | TBD |
| Simple extractions | $5 - $130 |
| Major services | |
| Crowns, gold restorations (over natural teeth – once per tooth per five years) | $160 - $380 |
| Implants, implant related services | $1,025+ |
| TMJ therapy, TMJ appliance | TBD |
| Bridgework | $170 - $380 |
| Full and partial dentures | $335 - $415 |
| Crown Replacement (1 every 5 Years) | $160 - $380 |
| Orthodontics | |
| Full comprehensive treatment (per patient: Adult & Child, to age 26) | $1,900/$2,100 |
| Lifetime maximum (per patient: Adult & Child, to age 26) | N/A |
| Download |
*** DeltaCare® USA DHMO members must choose and visit their selected DeltaCare® USA dentist to receive benefits. Implant copays vary by service.
Your dentist's network will impact how much you pay. Dentists that help participate in the Delta Dental PPO will have the lowest costs and will save you the most out of pocket expense. Dentists that participate in Delta Dental Premier, are participating Delta Dental dentists, but you will pay a greater portion of the cost if utilized. If you receive services from a non-participating, out of network dentists, you will pay the most out of pocket and are responsible for your coinsurance amount plus the difference between Delta Dental's approved fee and the dentist submitted fee for the claim.
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Continuous Orthodontic coverage
You may be able to continue orthodontic coverage when you switch.
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Delta Dental of New Jersey is a part of Delta Dental Plans Association. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.
