California HMO Dental Plan for Individuals

Plan Details

We offer an individual or voluntary dental plan through DeltaCare PMI.

With DeltaCare, you select one conveniently located network dentist to provide dental care for you and your family. You pay a small copayment or, for some services, no copayment. There are no deductibles or maximums and virtually no claim forms to worry about.

Please follow this link to search for DeltaCare Providers.

About DeltaCare
PMI offers a dental HMO program, DeltaCare, to take care of the dental care needs for you and your family. The DeltaCare program focuses on preventing dental problems and assuring the delivery of quality dental care.

PMI has contracted with a network of dental offices. Please follow this link to search for DeltaCare Providers. As an enrollee in the DeltaCare program, you select one office for your entire family's needs. PMI's network of dental offices is composed of established dental practices.

Who Can Join
As a California resident, you are eligible to join the Small Business Benefit Plan Trust, Wolfpack Insurance Services DeltaCare program.

Your eligible dependents include your lawful spouse and unmarried children under 19 years old (up to 23 if a full time student), including stepchildren and children placed with you for adoption or foster care. An unmarried child 19 years of age or older may continue to be eligible as a dependent if incapable of self-support because of physical handicap or mental retardation that commenced prior to age 19, provided that the person is legally residing with and dependent upon the eligible member, and PMI received notice of the disability.

No Claim Forms
The dental location you choose provides all primary dental services. There are no claim forms to complete or percentage of usual charges for you to pay.

No Deductibles
With the DeltaCare program, there are no required deductibles so pay, so your benefits begin immediately.

No Dollar Limit of Dental Benefits
No annual maximum

No Pre-Existing Condition Restrictions
Pre-existing conditions are not excluded in the DeltaCare program. Exception: work in progress.

Prepaid Program Saves on Dental Costs
Your out-of-pocket savings could be substantial. You know the exact cost prior to treatment, allowing you to predict future dental expenses.

When you enroll in this program, you are enrolling for a period of one year. This does not apply if your employment is terminated.

Emergency Services
Out-of-area dental emergencies are covered up to a maximum of $100.00. "Out -of-area' means 35 miles of more from your PMI participating dentist's office.

Quality Review of Dental Providers
On-site audits of participating dental locations ensure that established standards of quality are maintained.

Specialty Services
The DeltaCare program offers services in dental specialty areas. These include periodontics (treatment of diseased gums and bone), endodontics (root canal therapy) and oral surgery procedures. If an enrollee is assigned to a dental school clinic for specialist services, those services may be provided by a dentist, a dental instructor a clinician or a dental student under the supervision of a dentist.

The DeltaCare program provides all reasonable and customary dental care (subject to the provisions, limitations and exclusions and governing administrative policies shown in the Combined Evidence of Coverage and Disclosure Form) if care is provided by your assigned PMI network dentist.

When you enroll in DeltaCare, Please follow this link to search for DeltaCare Providers and select a DeltaCare Provider to take care of the 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.

Plan 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.

DeltaCare Program
CODE Procedure Enrollee Pays
Diagnostic
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
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 is more than six crowns in the same treatment plan, an Enrollee may be charged an additional $100.00 per crown, beyond the 6th unit.)

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

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

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)

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.

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

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

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
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

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.

The full Evidence of Coverage may be reviewed by following this link.

How to enroll in DeltaCare for new members


Please select one of the following enrollment methods below.

Enroll Online

Or Enroll by Mail

Click Here To Print an Enrollment Form:
Wolfpack DeltaCare Program

The minimum enrollment period is 12 months.

Monthly payment via automatic deduction.
Month Rates; One person: $33.30, Two persons: $58.90, Three persons or more: $86.60.
A one time enrollment fee of $5.00 is charged to with all new applications.
  1. Submit the first months premium and enrollment fee payment. Complete the enrollment form and sign the Automatic Payment Authorization section on the enrollment form. Be sure to enclose a voided blank check from this account. Also, please call your bank to obtain the ABA number (bank routing number). Starting with your second month, the dues will be deducted from the account specified on the 15th of each month prior to the coverage month (e.g., April dues will be deducted on March 15th). Your coverage will automatically be terminated if your automatic deduction is declined by your bank for insufficient funds, a closed account, etc.
  2. Return the enrollment materials and your first months payment to:
    Gordon Paul
    1368 W. Herndon Avenue, Suite 101
    Fresno, CA 93711
OR

Calendar Year Quarterly payment via check.
Quarterly Rates; One person: $99.90, Two persons $176.70, Three persons or more: $ 259.80.
Quarterly clients are also charged a $3.00 administration fee with each invoice.
A one time enrollment fee of $5.00 is charged to with all new applications.
  1. Submit the first quarterly payment with your enrollment form. Once enrolled, you will be billed on a calendar year quarterly basis. Dues must be paid in full by the 15th of the month prior to the coverage month or your coverage will be automatically terminated. You cannot have a break in coverage.
  2. Return the enrollment form and the first quarterly payment to:
    Gordon Paul
    1368 W. Herndon Avenue, Suite 101
    Fresno, CA 93711
OR

Voluntary List Bill Groups
Month Rates; One person: $30.30, Two persons: $53.50, Three persons or more: $78.60.
A one time enrollment fee of $5.00 is charged to with all new applications.
Voluntary List Bill Groups are invoiced monthly and are charged a $5.00 administration fee with each monthly invoice.
  1. Submit the first payment with your enrollment form. Once enrolled, the employer group will be billed on a monthly basis. Dues must be paid in full by the 15th of the month prior to the coverage month or your coverage will be automatically terminated. You cannot have a break in coverage.
  2. Return the enrollment form and the first monthly payment along with the enrollment fee and administration fee to:
    Gordon Paul
    1368 W. Herndon Avenue, Suite 101
    Fresno, CA 93711
Note: The enrollment information must be received at the latest by the 15th of the month for coverage to begin the 1st of the following month. Incomplete. inaccurate information will cause a delay in your enrollment into the program