DeltaCare USA Dental Brochure FEHBP - Kaiser Permanente

1 We keep you smiling Kaiser Foundation Health Plan of Georgia, USAP rovided by Delta Dental Insurance CompanyThe DeltaCare USA program is the prepaid plan available to FEHBP members for additional premiumSCGACS04 USA is a Dental program that provides you and your family with quality Dental benefits at an affordable cost. The DeltaCare USA program is designed to encourage you and your family to visit the dentist regularly to maintain your Dental you enroll, you select a contract dentist to provide services.

2 The DeltaCare USA network consists of private practice Dental facilities that have been carefully screened for USA is administered by Delta Dental Insurance Company (Delta Dental ). These benefits are neither offered nor guaranteed under contract with the FEHB Program, but are made available to all enrollees and family members who become members of a Kaiser Foundation Health Plan of Georgia, Inc., FEHBP health plan To DeltaCare USA Quality, Convenience, Predictable CostsEnroll in DeltaCare USA and you ll enjoy these features:Quality Extensive benefits for you and your family No restrictions on pre existing conditions, except for work in progress Large, stable network of dentists, so you can enjoy a long term relationship with your dentistConvenience No claim forms to complete Expanded business hours for toll free customer service.

3 From 8 to 8 costs No deductibles Out of pocket costs are clearly defined Out of area Dental emergency coverage up to $100 per emergency No annual or lifetime dollar maximums except for accidental injuryFind a DeltaCare USA dentistSelect from among the many conveniently located DeltaCare USA contracted general dentists. To find the most current listing of DeltaCare USA Dental offices you can: Visit our website at Under Find a dentist, select DeltaCare USA as your network. Call Customer Service at 800-422-4234 for help in finding a DeltaCare USA of Benefits and CopaymentsPlan GAA11 SCHEDULE ADescription of Benefits and CopaymentsThe Benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the Program.

4 Please refer to Schedule B for further clarification of Benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA program and is not to be interpreted as CDT-2020 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal DESCRIPTION ENROLLEE PAYSD0100-D0999 I.

5 DIAGNOSTIC - When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist s filed fees. *D0120 Periodic oral evaluation established patient ..No CostD0140 Limited oral evaluation problem focused ..No CostD0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver ..No CostD0150 Comprehensive oral evaluation new or established patient ..No CostD0160 Detailed and extensive oral evaluation problem focused, by report ..No CostD0170 Re evaluation limited, problem focused (established patient; not post operative visit) ..No CostD0171 Re evaluation post operative office visit.

6 $ Comprehensive periodontal evaluation new or established patient ..No CostD0190 Screening of a patient ..No CostD0191 Assessment of a patient ..No CostD0210 Intraoral complete series of radiographic images limited to 1 series every 24 months ..No CostD0220 Intraoral periapical first radiographic image ..No CostD0230 Intraoral periapical each additional radiographic image ..No CostD0240 Intraoral occlusal radiographic image ..No CostD0250 Extraoral 2D projection radiographic image created using a stationary radiation source, and detector ..No CostD0251 Extraoral posterior Dental radiographic image.

7 No CostD0270 Bitewing single radiographic image ..No CostD0272 Bitewings two radiographic images ..No CostD0273 Bitewings three radiographic images ..No CostD0274 Bitewings four radiographic images limited to 1 series every 6 months ..No CostD0277 Vertical bitewings 7 to 8 radiographic images ..No CostD0330 Panoramic radiographic image ..No CostD0419 Assessment of salivary flow by measurement ..No CostD0460 Pulp vitality tests ..No CostD0470 Diagnostic casts ..No CostD0472 Accession of tissue, gross examination, preparation and transmission of written report ..No CostDescription of Benefits and CopaymentsPlan GAA11D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report.

8 No CostD0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report ..No CostD0601 Caries risk assessment and documentation, with a finding of low risk 1 every 3 years ..No CostD0602 Caries risk assessment and documentation, with a finding of moderate risk 1 every 3 years ..No CostD0603 Caries risk assessment and documentation, with a finding of high risk 1 every 3 years ..No CostD0999 Unspecified diagnostic procedure, by report includes office visit, per visit (in addition to other services).

9 $ II. PREVENTIVE - When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist s filed fees. *D1110 Prophylaxis cleaning adult 1 D1110, D1120 or D4346 per 6 month period ..$ Prophylaxis cleaning child 1 D1110, D1120 or D4346 per 6 month period ..$ Topical application of fluoride varnish child to age 19; 1 D1206 or D1208 per 6 month period ..No CostD1208 Topical application of fluoride excluding varnish child to age 19; 1 D1206 or D1208 per 6 month period ..No CostD1310 Nutritional counseling for control of Dental disease.

10 No CostD1330 Oral hygiene instructions ..No CostD1351 Sealant per tooth limited to permanent molars through age 15 ..$ Preventive resin restoration in a moderate to high caries risk patient permanent tooth limited to permanent molars through age 15 ..$ Sealant repair per tooth limited to permanent molars through age 15 ..$ Interim caries arresting medicament application per tooth child to age 19; 1 per 6 month period ..No CostD1510 Space maintainer fixed unilateral per quadrant ..$ Space maintainer fixed bilateral, maxillary ..$ Space maintainer fixed bilateral, mandibular ..$ Space maintainer removable unilateral per quadrant.