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Below explanation is for California plan only

DeltaCare USA Senior Dental HMO plan 
Toll free (877)566-5454
When you enroll in DeltaCare USA, you select a PMI network dentist to provide your dental care. With DeltaCare USA, you must visit your selected primary care dentist in order to receive benefits. When you need specialty care, your primary care dentist can obtain a referral. Advantages of the DeltaCare USA plan include low or no copayments for services, no deductibles and no maximums on services provided by primary care dentists.

Dues are easy to afford:

  • Only $135 per year for a single membership
  • PLUS a one-time $15 administration fee

 
(A) Deductibles None
(B) Lifetime Maximums None
(C) Professional Services An Enrollee may be required to pay a Copayment amount for each procedure as shown in the Description of Benefits and Copayments, subject to the Limitations and Exclusions.
Copayments range by category of service. Examples are as follows:
Diagnostic Services   No Cost - $5
Preventive Services No Cost - $150
Restorative Services No Cost - $425
Endodontic Services No Cost - $475
Periodontic Services $45 - $450
Prosthodontic Services, Removable $20 - $495
Prosthodontic Services, Fixed $20 - $425
Oral and Maxillofacial Surgery $35 - $150
Adjunctive General Services No Cost - $50

NOTE: Some services may not be covered. Certain services may be covered only if provided by specified providers, or may be subject to an additional charge.

Limitations apply to the frequency with which some services may be obtained. For example: cleanings are limited to once in each 6-month period; replacment of removable and fixed dentures and crowns is limited to once in any 5-year period.
(D) Outpatient Services Not Covered
(E) Hospitalization Services Not Covered
(F) Emergency Health Coverage The Enrollee may receive a maximum Benefit up to $100 per emergency, per Enrollee.
(G) Ambulance Services Not Covered
(H) Prescription Drug Services Not Covered
(I) Durable Medical Equipment Not Covered
(J) Mental Health Services Not Covered
(K) Chemical Dependency Services Not Covered
(L) Home Health Services Not Covered
(M) Other Not Covered

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Download DeltaCare USA Senior DHMO .pdf Application

DeltaCare USA DHMO Dentist Network Database
YOU MUST CHOOSE A PRIMARY DENTIST TO PUT ON OUR APPLICATION.
Or you can fill in this form to have your Senior DeltaCare Dental HMO Insurance brochure with pricing & application mailed to you. Further information on our plans is shown below. Or just call us Toll-free at 877-Look4Life (877-566-5454).
Senior DeltaCare Dental HMO Insurance Coverage Requested
Our Ages
(over age 65)		   My Age       Spouse's Age  
People Covered

Customer Information
Full Full Name
E-mail
Street Address
City
County
State
Zip Code
Home Phone
Work Phone
FAX

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Barricks Insurance Services
13900 NW Passage #302, Marina Del Rey, CA 90292
Phone:   (310) 827-7286    |   Fax:   (310) 827-0256
Toll-Free 1-877-Look4Life  (1-877-566-5454)

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