DeltaCare USA® Plan Disclosures

1.       If you are in the state of WY, you do not need to select a primary care dental facility, but you must visit a DeltaCare USA dentist to receive benefits. If you’re in any of the following states, you do not need to select a primary care facility, and you can maximize your savings when you visit a DeltaCare USA dentist, although you may visit any licensed dentist and receive out-of-network coverage: AK, CT, LA, ME, MS, MT, NC, ND, NH, OK, SD, VT. If you're in the state of ID, you do need to select a primary care facility, and, while you can maximize your savings when you visit a DeltaCare USA dentist, you may visit any licensed general dentist and receive out-of-network coverage. Refer to your plan booklet for details about out-of-network benefits.

2.       The number of covered procedures varies by plan.

3.       Verify that the dentist is your selected DeltaCare USA primary care dentist before each appointment. In the following states, you can change your dentist any time without contacting Delta Dental: AK, CT, LA, ME, MS, MT, NC, ND, NH, OK, SD, VT, WY.

4.       You may have to complete a claim form if you visit an out-of-network dentist, such as for limited emergency treatment or if you live in the following states: AK, CT, ID, LA, ME, MS, MT, NC, ND, NH, OK, SD, VT.

5.       In MA, you cannot select more than three primary care dental facilities per family.

6.       In TX, three weeks is a reasonable amount of time to wait for a routine, non-urgent appointment.

DeltaCare USA is underwritten in these states by these entities: AL — Alpha Dental of Alabama, Inc.; AZ — Alpha Dental of Arizona, Inc.; CA — Delta Dental of California; AR, CO, IA, MA, ME, MI, MN, NC, ND, NE, NH, OK, OR, RI, SC, SD, VT, WA, WI, WY — Dentegra Insurance Company; AK, CT, DC, DE, FL, GA, KS, LA, MS, MT, TN, WV — Delta Dental Insurance Company; HI, ID, IL, IN, KY, MD, MO, NJ, OH, TX — Alpha Dental Programs, Inc.; NV — Alpha Dental of Nevada, Inc.; UT — Alpha Dental of Utah, Inc.; NM — Alpha Dental of New Mexico, Inc.; NY — Delta Dental of New York, Inc.; PA — Delta Dental of Pennsylvania; VA — Delta Dental of Virginia. Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these states. These companies are financially responsible for their own products.

Delta Dental is a registered trademark of Delta Dental Plans Association.