| Plan Details | ||
|---|---|---|
| Plan Name | DeltaCare USA DHMO | |
| Effective Dates | Jan 01, 2024 to Jan 01, 2025 | |
| Benefits | In-Network | |
| Annual Deductible/Individual | N/A | |
| Annual Deductible/Family | N/A | |
| Annual Plan Maximum | N/A | |
| Diagnostic and Preventive Services | copays vary between $0 and $45 depending on service | |
| Basic Services | copays vary between $0 and $205 depending on service | |
| Major Services | copays vary between $0 and $205 depending on service | |
| Orthodontia Services | copays vary between $0 and $1900 depending on service | |