California HMO Plans
Benefits
When you enroll in DeltaCare, you select a participating dental office from the network directory to take care of dental needs for you and your family. After you have enrolled, you will receive a Combined Evidence of Coverage and Disclosure Form that fully describes the benefits of your dental program, and a DeltaCare membership card.
This card will have the address and telephone number of your participating network dentist. To receive all necessary dental care covered by the program, simply call you selected dental office to make an appointment. Remember to always contact your network dentist. Dental services which are not performed by this dentist or are not authorized in advance by PMI will not be covered under the DeltaCare program.
Diagnostic
| Code | Procedure | Enrollee Pays |
|---|---|---|
| 120, 140, 150, 160, 170, 180 | Periodic oral evaluation, Limited oral evaluation, Comprehensive oral evaluation, Detailed and extensive oral evaluation, Re-evaluation - limited, Comprehensive periodontal evaluation | No Cost |
| 210, 220. 230, 240 | Intraoral radiographs - complete series (including bitewings limited to 1 series every 24 months), Intraoral periapical film, Intraoral occlusal film | No Cost |
| 250, 260 | Extraoral - first film, each additional film | No Cost |
| 270, 272, 274, 277 | Bitewing radiograph, single file, two films, four films - limited to 1 series every 6 months, vertical bitewings - 7 to 8 films | No Cost |
| 330 | Panoramic film | No Cost |
| 415 | Collection of microorganisms for culture and sensitivity, Caries susceptibility tests | No Cost |
| 460 | Pulp vitality tests | No Cost |
| 470 | Diagnostic casts | No Cost |
| 472, 473, 474 | Accession of tissue, gross examination (microscopic and including assessment of surgical margins for presence of disease), preparation and transmission of written report | No Cost |
| 999 | Unspecified diagnostic procedure, by report | $5 |
Preventive
| Code | Procedure | Enrollee Pays |
|---|---|---|
| 1110 | Prophylaxis adult, 1 per 6 month period, additional cleaning will be charged a $45.00 copayment | No Cost |
| 1120 | Prophylaxis child, 1 per 6 month period, additional cleaning will be charged a $35.00 copayment | No Cost |
| 1201, 1203 | Topical application of fluoride including/excluding prophylaxis to age 19, one per 6 month period, additional application will be charged a $35.00 copayment | No Cost |
| 1310, 1330 | Oral hygiene instructions, Nutritional counseling for control of dental disease | No Cost |
| 1351 | Sealant, per tooth - limited to permanent molars through age 15 | $10.00 |
| 1515, 1520, 1525 | Space maintainers - removable and fixed, unilateral and bilateral | $25.00 |
| 1550 | Re-Cementation of space maintainer | No Cost |
Restorative Dentistry
When there are more than six crowns in the same treatment plan, an Enrollee may be charged an additional $100.00 per crown, beyond the 6th unit.
| Code | Procedure | Enrollee Pays |
|---|---|---|
| 2141, 2150, 2160, 2161 | Amalgam - 1 to 4 anterior surfaces, primary or permanent | No Cost |
| 2330, 2332, 2335 | Resin-based composite - 1 to 4 anterior surfaces (four or more surfaces or involving incisal angle(anterior) | No Cost |
| 2390 | Resin-based composite crown, anterior | $35.00 |
| 2391 | Resin-based composite - one surface, posterior | $55.00 |
| 2392 | Resin-based composite - two surfaces, posterior | $65.00 |
| 2393 | Resin-based composite - three surfaces, posterior | $75.00 |
| 2394 | Resin-based composite - four or more surfaces, posterior | $85.00 |
| 2510, 2520, 2530, 2542, 2543, 2544 | Inlay & Onlay, metallic, 1 to 4 or more surfaces | No Cost |
| 2610 | Inlay-porcelain/ceramic - 1 surface | $165.00 |
| 2620 | Inlay-porcelain/ceramic - 2 surfaces | $190.00 |
| 2630 | Inlay-porcelain/ceramic - 3 surfaces | $200.00 |
| 2642 | Onlay-porcelain/ceramic - 2 surfaces | $185.00 |
| 2643 | Onlay-porcelain/ceramic - 3 surfaces | $205.00 |
| 2644 | Onlay-porcelain/ceramic - 4 or more surfaces | $220.00 |
| 2650 | Inlay - resin-based composite - 1 surface | $105.00 |
| 2651 | Inlay - resin-based composite - 2 surfaces | $120.00 |
| 2652 | Inlay - resin-based composite - 3 surfaces | $145.00 |
| 2662 | Onlay - resin-based composite - 2 surfaces | $140.00 |
| 2663 | Onlay - resin-based composite - 3 surfaces | $155.00 |
| 2664 | Onlay - resin-based composite - 4 or more surfaces | $185.00 |
| 2710 | Crown - resin based composite | $50.00 |
| 2712 | Crown - 3/4 resin-based composite | $50.00 |
| 2720 | Crown - resin with high noble metal | $195.00 |
| 2721 | Crown - resin with predominantly base metal | $95.00 |
| 2722 | Crown - resin with noble metal | $135.00 |
| 2740 | Crown - porcelain/ceramic substrate | $240.00 |
| 2750 | Crown - porcelain fused to high noble metal | $240.00 |
| 2751 | Crown - porcelain fused to predominantly base metal | $140.00 |
| 2752 | Crown - porcelain fused to noble metal | $180.00 |
| 2780 | Crown - 3/4 cast high noble metal | $210.00 |
| 2781 | Crown - 3/4 cast predominantly base metal | $110.00 |
| 2782 | Crown - 3/4 cast noble metal | $150.00 |
| 2783 | Crown - 3/4 porcelain/ceramic | $240.00 |
| 2790 | Crown - full cast high noble metal | $210.00 |
| 2791 | Crown - full cast predominantly base metal | $110.00 |
| 2792 | Crown - full cast noble metal | 150.00 |
| 2794 | Crown - titanium | $240.00 |
| 2910, 2915, 2920 | Recement inlay, onlay or partial coverage restoration. Recement Cast or prefabricated post and core. Recement Crown | No Cost |
| 2930, 2931 | Prefabricated stainless steel crown - primary or permanent tooth | $15.00 |
| 2932 | Prefabricated resin crown - anterior primary tooth | $25.00 |
| 2933 | Prefabricated stainless steel crown with resin window - anterior primary tooth | $20.00 |
| 2940 | Sedative filling | $ 5.00 |
| 2950 | Core buildup, including any pins | $15.00 |
| 2951 | Pin retention - per tooth in addition to restoration | $10.00 |
| 2952 | Cast post and core in addition to crown - includes canal preparation | $35.00 |
| 2953 | Each additional cast post - same tooth- includes canal preparation | $25.00 |
| 2954 | Prefabricated post and core in addition to crown - base metal post; includes canal preparation | $20.00 |
| 2957 | Each additional prefabricated post - same tooth - base metal post includes; canal preparation | $15.00 |
| 2971 | Additional procedures to construct new crown under existing partial denture framework | $28.00 |
| 2980 | Crown repair, by report | $15.00 |
Endodontics
| Code | Procedure | Enrollee Pays |
|---|---|---|
| 3110, 3120 | Pulp capping (indirect or direct) | No Cost |
| 3220 | Therapeutic Pulpotomy (excluding final restoraton) - removal of pulp coronal to the dentinocemental junction and application | No Cost |
| 3221 | Pulpal debridement, primary and permanent teeth | $10.00 |
| 3230, 3240 | Pupal therapy (resorbabla filling) - anterior or posterior, primary tooth (excluding final restoration | $20.00 |
| 3310 | Root canal - anterior (excluding final restoration) | $55.00 |
| 3320 | Root canal - bicuspid (excluding final restoration) | $120.00 |
| 3330 | Root Canal - molar (excluding final restoration) | $250.00 |
| 3331 | Treatment of root canal obstruction; non-surgical access | $55.00 |
| 2221 | Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth | $55.00 |
| 3333 | Internal root repair of perforation defects | $55.00 |
| 3346 | Retreatment of previous root canal therapy - anterior | $85.00 |
| 3347 | Retreatment of previous root canal therapy - bicuspid | $150.00 |
| 3348 | Retreatment of previous root canal therapy - molar | $280.00 |
| 3351 | Apexification/recalcification - initial visit | $75.00 |
| 3352 | Apexification/recalcification - interim medication replacement | $50.00 |
| 3353 | Apexification/recalcification - final visit | $50.00 |
| 3410 | Apicoectomy/periradicular surgery - anterior | $60.00 |
| 3421 | Apicoectomy/periradicular surgery - bicuspid | $70.00 |
| 3425 | Apicoectomy/periradicular surgery - molar | $80.00 |
| 3426 | Apicoectomy/periradicular surgery - each additional root | $50.00 |
| 3430 | Retrograde filling - per root | $60.00 |
| 3450 | Root amputation, per root | No Cost |
| 3920 | Hemisection not including root canal therapy | $30.00 |
Periodontics
| Code | Procedure | Enrollee Pays |
|---|---|---|
| 4210 | Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant | $130.00 |
| 4211 | Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant | $80.00 |
| 4240 | Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant | $130.00 |
| 4241 | Gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth spaces per quadrant | $80.00 |
| 4245 | Apically positioned flap | $125.00 |
| 4249 | Clinical crown lengthening - hard tissue | $125.00 |
| 4560 | Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant | $280.00 |
| 4261 | Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant | $225.00 |
| 4263 | Bone replacement graft - first site in quadrant | $205.00 |
| 4264 | Bone replacement graft - each additional site in quadrant | $70.00 |
| 4270 | Pedicle soft tissue graft procedure | $205.00 |
| 4271 | Free soft tissue graft procedure (including donor site surgery) | $205.00 |
| 4274 | Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area | $45.00 |
| 4341 | Periodontal scaling and root planing - four or more teeth per quadrant | $25.00 |
| 4342 | Periodontal scaling and root planing - one to three teeth per quadrant | $20.00 |
| 4355 | Full mouth debridement to enable comprehensive evaluation and diagnosis | $25.00 |
| 4910 | Periodontal maintenance - limited to 1 treatment each 6 month period | $15.00 |
| 4910 | Additional periodontal maintenance (within 6 month period) | $55.00 |
Prosthodontics (removable)
| Code | Procedure | Enrollee Pays |
|---|---|---|
| 5110, 5120 | Complete denture - maxillary & mandibular | $145.00 |
| 5130, 5140 | Immediate denture - maxillary & mandibular | $165.00 |
| 5211, 5212 | Maxillary or Mandibular partial denture - resin base | $120.00 |
| 5213, 5214 | Maxillary or Mandibular partial denture - cast metal framework with resin denture bases | $160.00 |
| 5225, 5226 | Maxillary or Mandibular partial denture - flexible base | $210.00 |
| 5410, 5411, 5421, 5422 | Adjust complete or partial denture | $10.00 |
| 5510 | Repair broken complete denture base | $20.00 |
| 5520 | Replace missing or broken teeth (each tooth) | $10.00 |
| 5610, 5620, 5630 | Repair resin denture base or cast framework | $20.00 |
| 5640, 5650, 5660 | Add tooth or clasp to existing structure | $10.00 |
| 5670, 5671 | Replace all teeth and acrylic on cast metal framework | $135.00 |
| 5710, 5711, 5720, 5721 | Rebase complete or partial denture | $55.00 |
| 5730, 5731, 5740, 5741 | Reline complete or partial denture (chairside) | $20.00 |
| 5750, 5751, 5760, 5761 | Reline complete or partial denture (laboratory) | $60.00 |
| 5820, 5821 | Interim partial denture - limited to 1 in any 12 consecutive months | $75.00 |
| 5850, 5851 | Tissue conditioning | No Cost |
Prosthodontics
Fixed each retainer and each pontic constitutes a unit in a fixed partial denture (bridge). When a crown and/or pontic exceed six units, an enroll may be charged an additional $100.00 per unit, beyond the 6th unit.
| Code | Procedure | Enrollee Pays |
|---|---|---|
| 6210 | Pontic - cast high noble metal | $210.00 |
| 6211 | Pontic - cast predominantly base metal | $110.00 |
| 6212 | Pontic - cast noble metal | $150.00 |
| 6240 | Pontic - porcelain fused to high noble metal | $240.00 |
| 6241 | Pontic - porcelain fused to predominantly base metal | $140.00 |
| 6242 | Pontic - porcelain fused to noble metal | $180.00 |
| 6245 | Pontic - porcelain/ceramic | $240.00 |
| 6250 | Pontic - resin with high noble metal | $195.00 |
| 6251 | Pontic - resin with predominantly base metal | $95.00 |
| 6252 | Pontic - resin with noble metal | $135.00 |
| 6600 | Inlay - porcelain/ceramic, two surfaces | $190.00 |
| 6601 | Inlay - porcelain/ceramic, three or more surfaces | $200.00 |
| 6602, 6603 | Inlay - Cast high noble metal | $100.00 |
| 6604, 6605 | Inlay - cast predominantly base metal | No Cost |
| 6606, 6607 | Inlay cast noble metal | $40.00 |
| 6608 | Onlay - porcelain/ceramic, two surfaces | $185.00 |
| 6609 | Onlay - porcelain/ceramic, three or more surfaces | $205.00 |
| 6610, 6611 | Onlay - Cast high noble metal | $100.00 |
| 6612, 6613 | Onlay - cast predominantly base metal | No Cost |
| 6614, 6615 | Onlay cast noble metal | $40.00 |
| 6720 | Crown - resin with high noble metal | $195.00 |
| 6721 | Crown - resin with predominantly base metal | $95.00 |
| 6722 | Crown - resin with noble metal | $135.00 |
| 6740 | Crown - porcelain/ceramic | $240.00 |
| 6750 | Crown - Porcelain fused to high noble metal | $240.00 |
| 6751 | Crown - porcelain fused to predominantly base medal | $140.00 |
| 6752 | Crown - porcelain fused to noble metal | $180.00 |
| 6780 | Crown - 3/4 cast high noble metal | $210.00 |
| 6781 | Crown - 3/4 cast predominantly base metal | $110.00 |
| 6782 | Crown - 3/4 cast noble metal | $150.00 |
| 6783 | Crown 3/4 porcelain/ceramic | $240.00 |
| 6790 | Crown - full cast high noble metal | $210.00 |
| 6791 | Crown - full cast predominantly base metal | $110.00 |
| 6792 | Crown - full cast noble metal | $150.00 |
| 6930 | Recement fixed partial denture | No Cost |
| 6940 | Stress Breaker | No Cost |
| 6970 | Cast post and core in addition to fixed partial denture retainer | $35.00 |
| 6971 | Cast post as part of fixed partial denture retainer | $35.00 |
| 6972 | Prefabricated post and core in addition to fixed partial denture retainer | $20.00 |
| 6973 | Core buildup for retainer, including any pins | $15.00 |
| 6976 | Each additional cast post - same tooth | $25.00 |
| 6977 | Each additional prefabricated post - same tooth - base metal post | $15.00 |
| 6980 | Fixed partial denture repair, by report | $15.00 |
Oral and Maxillofacial Surgery
| Code | Procedure | Enrollee Pays |
|---|---|---|
| 7111 | Extraction, coronal remnants - deciduous tooth | No Cost |
| 7140 | Extraction, erupted tooth or exposed root | $5.00 |
| 7210 | Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth | $25.00 |
| 7220 | Removal of impacted tooth - soft tissue | $50.00 |
| 7230 | Removal of impacted tooth - partially bony | $70.00 |
| 7240 | Removal of impacted tooth - completely bony | $90.00 |
| 7241 | Removal of impacted tooth - completely bony with unusual surgical complications | $110.00 |
| 7250 | Surgical removal of residual tooth roots (cutting procedure) | No cost |
| 7270 | Tooth reimplantation and/or stabilization of accidently evulsed or displaced tooth | $85.00 |
| 7280 | Surgical access of an unerupted tooth | $90.00 |
| 7282 | Mobilization of erupted or malpositioned tooth to aid eruption | $90.00 |
| 7293 | Placement of device to facilitate eruption of impacted tooth | No Cost |
| 7286 | Biopsy of oral tissue - soft | No Cost |
| 7310, 7311 | Alveoloplasty in conjunction with extractions | $50.00 |
| 7320, 7321 | Alveoloplasty not in conjunction with extractions | $70.00 |
| 7450, 7451 | Removal of benign odontogenic cyst or tumor | No Cost |
| 7471 | Removal of lateral exostosis | No Cost |
| 7472, 7473 | Removal of torus | No Cost |
| 7510 | Incision and drainage of abscess | No Cost |
| 7960 | Frenulectomy - separate procedure | No Cost |
| 7970 | Excision hyperplastic tissue - per arch | $55.00 |
| 7971 | Excision of pericoronal gingiva | $55.00 |
Orthodontics
| Code | Procedure | Enrollee Pays |
|---|---|---|
| Includes: 210, 322, 330, 340, 350, 470 | The benefit for pre-treatment records and diagnostic services includes: Intraoral - complete series (including bitewings), Tomographic survay, Panoramic film, Celhalometic film, Oral/facial photographic images. diagnostic casts | $200.00 |
| Includes: 210, 470 | The benefit for post-treatment records includes: Intraoral - complete series, diagnostic casts | $70.00 |
| 8010 | Limited orthodontic treatment of the primary dentition | $950.00 |
| 8020, 8030 | Limited orthodontic treatment of the transitional or adolescent (to age 19) dentition | $950.00 |
| 8040 | Limited orthodontic treatment of the adult dentition | $1150.00 |
| 8050, 8060 | Interceptive orthodontic treatment of the primary or transitional dentition | $950.00 |
| 8070, 8080 | Comprehensive orthodontic treatment of the transitional or adolescent (to age 19) dentition | $1700.00 |
| 8090 | Comprehensive orthodontic treatment of the adult dentition | $1900.00 |
| 8660 | Pre-orthodontic treatment visit | $25.00 |
| 8680 | Orthodontic retention (removal of appliances, construction and placement of removable retainers) | $275.00 |
| 8999 | Unspecified orthodontic procedure, by report - includes treatment planning session | $100.00 |
Adjunctive General Services
| Code | Procedure | Enrollee Pays |
|---|---|---|
| 9110 | Palliative (emergency) treatment of dental pain | $5.00 |
| 9211 | Regional block anesthesia | No Cost |
| 9212 | Trigeminal division block anesthesia | No Cost |
| 9215 | Local anesthesia | No Cost |
| 9220 | Deep sedation/general anesthesia - first 30 minutes | $165.00 |
| 9221 | Deep sedation/general anesthesia - each additional 15 minutes | $80.00 |
| 9241 | Intravenous conscious sedation analgesia - first 30 minutes | $165.00 |
| 9242 | Intravenous conscious sedation analgesia - each additional 15 minutes | $80.00 |
| 9310 | Consultation (diagnostic service provided by dentist or physician other that practitioner providing treatment) | $10.00 |
| 9430 | Office visit for observation | $5.00 |
| 9440 | Office visit - after regularly scheduled hours | $25.00 |
| 9450 | Case Presentation, detailed and extensive treatment planning | No Cost |
| 9950 | Occlusal guard by report - limited to 1 in 3 years | $100.00 |
| 9951 | Occlusal adjustment, limited | $35.00 |
| 9952 | Occlusal adjustment, complete | $55.00 |
| 9972 | External bleaching - per arch - limited to one bleaching tray and gel for two weeks of self treatment | $125.00 |
| 9999 | Unspecified adjunctive procedure, by report - includes failed appointments without 24 hour notice - pre 15 minutes of appointment time - up to an overall maximum of $40.00 | $10.00 |
| The above procedures are performed as needed and deemed necessary by your attending network dentist subject to the limitations, exclusions and governing administrative policies of the program |
The above procedures are performed as needed and deemed necessary by your attending network dentist subject to the limitations, exclusions and governing administrative policies of the program.
This brochure constitutes only a summary of the plan and is not a full list of the Limitations and Exclusions. The plan contract must be consulted to determine the exact terms and conditions of coverage. A plan contract will be sent to you upon enrollment. A full refund of premium is available if you wish to cancel the plan within 15 days of receiving the plan contract.