Please check your SPD or call Member Services at 80 for more information. You are responsible for any remaining costs (“balance billing”) from the non-participating dentist.Īditionally, you can choose to become a patient of the 32BJ Dental Center located at 25 West 18th Street, New York, NY. Delta Dental will reimburse you directly up to the same amount that they would pay a participating dentist for the same services minus your coinsurance amount. You can also use a non-participating dentist, but you will need to submit a claim to Delta Dental for reimbursement. You can find a participating dentist near you by searching or by contacting Delta Dental at 80. When you use a participating dentist, you get the most out of your benefit. If you live outside New York State, you are covered by the Delta Dental PPO network. If you live in New York State, you are covered by the Delta Dental NY Select network. The Delta Dental network that covers you depends on where you live. Your Dental Plan has a large network of participating dentists in and outside of the New York City metropolitan area, administered by Delta Dental.
You are limited to one copay per episode of treatment for intensive outpatient mental health or substance abuse services. You are limited to one copay per calendar year for outpatient radiation therapy and chemotherapy. *You have no copay for outpatient maternity services. You pay a $250 copay at a Non-preferred Hospital, and the Plan pays 100% of the remaining costs. You pay a $75 copay at a Preferred Hospital or an Independent Facility (a facility not affiliated with a hospital), and the Plan pays 100% of the remaining costs. You pay a $1,000 copay per admission at a Non-preferred hospital, and the Plan pays 100% of the remaining costs. You pay a $100 copay per admission at a Preferred Hospital, and the Plan pays 100% of the remaining cost.
You pay 50% after the deductible and any charges above the allowed amount. You pay a $250 copay at a Non-preferred Hospitals, and the Plan pays 100% of the remaining costs. You pay a $100 copay at a Preferred Hospital or an Independent Facility (a facility not affiliated with a hospital), and the Plan pays 100% of the remaining cost. United Nations Group 374610-A, D, G, I, M1, M2, M3, M4, M5, M6, M7, M8 PPO Services provided by Empire HealthChoice Assurance, Inc., a licensee of the Blue Cross and. Hi-tech radiology (CAT, MRI, PET, MRA and nuclear studies)
After the second visit, you pay a $200 copay per visit, and the Plan pays 100% of the remaining costs. You pay a $100 copay per visit for first two visits, and the Plan pays 100% of the remaining costs. When you stay in-network, you do not have a deductible or coinsurance payments to worry about. If you only see doctors that are in-network and only use facilities that are in-network, the chart below lists all of the copays you might have to pay.
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