Dental benefits that are affordable and easy to understand

DeltaCare® USA

Alpha Dental of Utah, Inc.

Individual & Family™

DeltaCare® USA

Preferred Plan for Families

Dental beneﬁts that are

aordable and easy to understand

Get dental care right away with DeltaCare USA

Is a DeltaCare USA plan right for me?

With easy-to-understand set costs and aordable pricing, DeltaCare USA is

great for budget-conscious people. DeltaCare USA plans feature:

• Set costs (also known as copayments) for covered dental services

• No waiting periods on any covered procedures, even major services

• Low or no copays for diagnostic and preventive care

To use your plan, you’ll need to see your chosen DeltaCare USA dentist.

But don’t worry! If you need emergency dental care, even when you’re

away from home, you’ll be covered by an emergency services provision

Underwriter

Alpha Dental of Utah, Inc.

257 E. 200 South, Suite 850

Salt Lake City, UT 84111

Claims and Correspondence

P.O. Box 1803

Alpharetta, GA 30023

Customer Service

888-857-0337

deltadentalins.com

Please consult the plan policy for a description of plan beneﬁts, limitations and exclusions. View the full copayment

schedule, plus limitations and exclusions or call 888-857-0337.

Delta Dental Insurance Company acts as the DeltaCare USA administrator in all states.

Delta Dental and DeltaCare USA are registered marks of Delta Dental Plans Association.

PB_DCU_UT_I_FAM_PRF_23

How does DeltaCare USA work?

If you’re familiar with HMO-style insurance

plans, you’ll ﬁnd DeltaCare USA easy to

understand.

When you visit your chosen DeltaCare USA

dentist for care, you’ll just pay the copayments

listed in your plan documents for any covered

services you receive. Because there are no

waiting periods or deductibles (minimum

amounts you must pay before your plan will

begin helping with your costs), you can make

the most of your beneﬁts the ﬁrst day your

coverage begins.

You won’t need an ID card to get care. Just

give your information to your dentist and they

can ﬁnd your coverage.

Important tips

• You’ll visit your chosen DeltaCare USA primary care dentist for care. It’s easy to

change your dentist anytime online or by phone.

• Find a DeltaCare USA dentist near you at with Find a Dentist search. Browse

the built-in Yelp® and DentaQual® ratings to help you ﬁnd a dentist you’ll love.

• Review the plan highlights on the next page to see the copayments for the

most common covered services. You can also view the full copayment schedule

or the Health Care Exchange (Marketplace) plans page for more information.

Read your policy carefully. This brochure provides a brief description of the important features of your policy. This is

not the insurance policy and only the policy provisions will control. The policy itself sets forth in detail the rights and

obligations of both you and your insurance company. It is therefore important that you read your policy carefully.

Changes received between the ﬁrst and 15th of the month are eective immediately. Changes received on the 16th

through the end of the month will be eective on the ﬁrst of the next month.

HCR_DCU #134496 (06/22)

PB_DCU_UT_I_FAM_PRF_23

Alpha Dental Individual & Family™

DeltaCare® USA | Preferred Plan for Families

Plan Highlights

Deductibles and Maximums Pediatric Benefits

(up to age 18)

Adult Benefits

(age 19 and older)

Deductible

Enrollee

Family

None

Out-of-Pocket Maximum

After this amount is reached, the plan

pays 100% of the remaining covered

services per Calendar Year.

$375 one pediatric enrollee

$750 two or more pediatric

enrollees

None

Sample of Covered Services

Procedure

Code

Description

Copayment Amount

Pediatric

Benefits

Adult

Benefits

Diagnostic and Preventive Services

D0999 Office visit No cost $5

D0120 Periodic oral exam — established patient $5 $5

D0150 Comprehensive oral evaluation — new or

established patient

$5 $5

D0210 Complete series of x-rays $5 $5

D0220 Periapical x-ray of tooth’s root $5 $5

D0230 Periapical x-ray of tooth’s root, each additional

image

$5 $5

D0272 Bitewing x-rays (2 images) $5 $5

D0274 Bitewing x-rays (4 images) $5 $5

D0330 Panoramic x-ray $5 $5

D1110 Prophylaxis (cleaning) — adult $5 $5

D1120 Prophylaxis (cleaning) — child $5 Not a benefit

D1208 Fluoride treatment $5 Not a benefit

D1351 Sealant — per tooth $5 Not a benefit

Featured benefits represent the most frequently used services covered under your plan; other services are also covered. After

enrollment, DeltaCare USA will make available a complete list of covered services and copayments, along with any limitations and

exclusions that apply. If applicable, service areas are detailed in the limitations and exclusions.

Copayments and procedure descriptions referenced above are intended to clarify the delivery of benefits under the DeltaCare USA

plan. They are not to be interpreted as CDT-2022 descriptors or nomenclature, which are under copyright by the American Dental

Association.

A copayment is the amount the enrollee pays for covered services at the time of treatment.

PB_DCU_UT_I_FAM_PRF_23

Procedure

Code

Description

Copayment Amount

Pediatric

Benefits

Adult

Benefits

Basic Services

D2140 Amalgam (silver-colored) filling, 1 surface Not a benefit $14

D2150 Amalgam (silver-colored) filling, 2 surfaces Not a benefit $25

D2160 Amalgam (silver-colored) filling, 3 surfaces Not a benefit $30

D2330 Resin (tooth-colored) filling, front tooth, 1

surface

Not a benefit $35

D2331 Resin (tooth-colored) filling, front tooth, 2

surfaces

Not a benefit $40

D2332 Resin (tooth-colored) filling, front tooth, 3

surfaces

Not a benefit $45

D2391 Resin (tooth-colored) filling, back tooth, 1

surface

Not a benefit $40

D2392 Resin (tooth-colored) filling, back tooth, 2

surfaces

Not a benefit $55

D2393 Resin (tooth-colored) filling, back tooth, 3

surfaces

Not a benefit $65

Endodontics

D3310 Root canal, front tooth Not a benefit $229

D3320 Root canal, premolar tooth Not a benefit $272

D3330 Root canal, molar tooth Not a benefit $371

Periodontics

D4260 Periodontal surgery, per quadrant Not a benefit $360

D4341 Periodontal scaling and root planing — four or

more teeth per quadrant

Not a benefit $50

D4910 Periodontal maintenance Not a benefit $50

Oral Surgery

D7140 Extraction (removal) of a fully exposed tooth Not a benefit $35

D7210 Extraction of erupted (exposed) tooth Not a benefit $35

D7240 Extraction of fully impacted tooth, completely

bony

Not a benefit $125

Major Services

D2750 Crown, porcelain and precious metal Not a benefit $354

D2790 Crown, precious metal Not a benefit $354

D5110 Full upper denture Not a benefit $510

D6240 Bridge pontic, porcelain and precious metal Not a benefit $354

D6750 Bridge crown, porcelain and precious metal Not a benefit $354

Orthodontics

D8090 Adult services Not a benefit $3,250

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