PPO calendar year maximum$1,000
per adult enrollee
Premier & OON calendar year maximum$750
per adult enrollee
PPO annual out of pocket maximumNo limit
Premier & OON annual out of pocket maximumNo limit
PPO deductible$25/$75
per adult enrollee (not applied to P&D)
Premier & OON deductible$50/$150
per adult enrollee (not applied to P&D)
Preventive & Diagnostic
Oral exams/evaluations100%
Cleanings100%
Bitewing X-rays100%
SealantsNot covered
Topical fluorideNot covered
In-office A1C diabetes testing100%
Basic Services
Composite (white) fillings80%
Major Services
Endodontics50%
Periodontics50%
Oral surgery50%
Crowns50%
Onlays50%
Prosthodontics (dentures, bridges)50%
Denture repairs50%
Orthodontics (medically necessary)Not covered
Orthodontics (not medically necessary)Not covered
Waiting periodsNone
Plan Details
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PPO calendar year maximumNone
per pediatric enrollee
Premier & OON calendar year maximumNone
per pediatric enrollee
PPO annual out of pocket maximum$350/$700
1 child/2 or more children
Premier & OON annual out of pocket maximumNo limit
PPO deductible$35/$105
per pediatric enrollee (not applied to P&D)
Premier & OON deductible$35/$105
per pediatric enrollee (not applied to P&D)
Preventive & Diagnostic
Oral exams/evaluations100%
Cleanings100%
Bitewing X-rays100%
Sealants100%
Topical fluoride100%
In-office A1C diabetes testing100%
Basic Services
Composite (white) fillings80%
Major Services
Endodontics50%
Periodontics50%
Oral surgery50%
Crowns50%
Inlays/onlays50%
Prosthodontics (dentures, bridges, implants)50%
Denture repairs50%
Orthodontics (medically necessary)50%
Orthodontics (not medically necessary)Not covered
Waiting periodsNone
Plan Details
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This is a summary of deductible, coinsurance, out-of-pocket limits, and other components of plan design. All coverage provisions, limitations and exclusions can be found in the group contract and certificate of coverage. Some Covered Services for Pediatric Enrollees require that you obtain a Prior Authorization from us before the service is performed. The covered dental services that require Prior Authorization are described in the certificate of coverage. Where Prior Authorization is required but not obtained, Delta Dental can apply a penalty of up to 50% of the charges that would otherwise be covered.
