2026 Delta Dental Basic PPO

Plan Details

Plan #: 03365

Delta Dental PPO is the dentist network for this plan. Visit a PPO dentist to maximize your savings.

This plan pays most benefits at a percentage. You are encouraged to obtain a pre-determination of benefits from Delta for services greater than $300, or for crowns or bridges.

This document is a summary. Please refer to the plan Evidence of Coverage (EOC) for more details.

Plan Information

Plan Year:

2026

Offered To:

Employees

Full-Time Employee * Contribution Per Pay Period:

Employee Only - $0.00
Employee & Spouse/Registered Domestic Partner - $0.00
Employee & Child(ren) - $0.00
Employee & Family - $0.00

Part-Time Employee * Contribution Per Pay Period:

Employee Only - $10.03
Employee & Spouse/Registered Domestic Partner - $21.06
Employee & Child(ren) - $18.05
Employee & Family - $29.09

Basics

Deductible:

$50 per individual each calendar year
$150 per family each calendar year

Coinsurance:

Network: Delta Dental PPO providers
- Preventive and diagnostic: 100% of the negotiated rate
- Basic procedures: 80% of the negotiated rate
-Major restorative procedures: 50% of the negotiated rate

Non-PPO Network: Delta Dental Premier or non-Delta Dental providers
- Preventive and diagnostic: 100% of Premier dentist fee or program allowance
- Basic procedures: 80% of Premier dentist fee or program allowance
- Major restorative procedures: 50% of Premier dentist fee or program allowance

You are responsible for amounts not covered by the dental plan.

Out-of-Pocket Maximum:

N/A

Annual Benefit Maximum:
$1,500 per individual

Diagnostic and Preventive services do not count towards the annual maximum.

Maximum Annual Benefit:

Annual Benefit Maximum:

$1,500 per individual

Diagnostic and Preventative services do not count towards annual maximum.

Overall Lifetime Maximum Benefit:

Orthodontia is not covered.

Other Services

X-rays (Basic Imaging):

Preventive and diagnostic service:
100% (deductible waived)
Non-Network: *100% of the maximum contract amount allowed which is the amount Delta Dental would pay (deductible waived).
Balance billing by your dentist may apply. You are responsible for these charges.

Preventive Dental Care

Cleanings:

Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%

Non-Network: *100% of the maximum contract amount allowed which is the amount Delta Dental would pay (deductible waived).Balance billing by a Non-Network dentist may apply. You are responsible for these charges. *It is to your advantage to select a dentist who is a Delta Dental Dentist, since a lower percentage of the dentist’s fees may be covered by this plan if you select a dentist who is not a Delta Dental Dentist.

Plan allows up to three cleanings/year. The third cleaning applies to certain conditions including diabetics, pregnancy, and those requiring periodontal maintenance.

Fluoride treatments:

Preventive and diagnostic service:
100% (deductible waived)
Two per calendar year
Premier Network provider and Non-Network: *100% of the maximum contract amount allowed which is the amount Delta Dental would pay (deductible waived).
Balance billing by your dentist may apply. You are responsible for these charges.

Routine exams:

Preventive and diagnostic service:
100% (deductible waived)
Two per calendar year
Premier Network Provide and Non-Network: 100% of the maximum contract amount allowed which is the amount Delta Dental would pay (deductible waived)
Balance billing by your dentist may apply. You are responsible for these charges.

Sealants:

Basic procedures service for children to age 15:
80% after deductible
Non-Network: *80% of the maximum contract amount allowed which is the amount Delta Dental would pay.
Balance billing by your dentist may apply. You are responsible for these charges.

Orthodontic Services

Orthodontia:

Not covered

Retainers:

Not covered

Other Dental Services

Anesthesia:

Basic procedures service:
80% after deductible
Non-Network: *80% of the maximum contract amount allowed which is the amount Delta Dental would pay.
Balance billing by your dentist may apply. You are responsible for these charges.

Bridges:

Major Restorative procedures service:
50% after deductible
Non-Network: 50% of the maximum contract amount allowed which is the amount Delta Dental would pay after deductible.

Balance billing by your dentist may apply. You are responsible for these charges.

Crown:

Major Restorative procedures service:
50% after deductible
Non-Network: *50% of the maximum contract amount allowed which is the amount Delta Dental would pay.
Balance billing by your dentist may apply. You are responsible for these charges.

Dentures:

Extractions:

Basic procedures service:
80% after deductible.
Non-Network: 80% of the maximum contract amount allowed which is the amount Delta Dental would pay.
Balance billing by your dentist may apply. You are responsible for these charges.

Fillings:

Basic procedures service:
80% after deductible.
Non-Network: *80% of the maximum contract amount allowed which is the amount Delta Dental would pay.
Balance billing by your dentist may apply. You are responsible for these charges.

Gingivectomy:

Basic procedures service:
80% after deductible
Non-Network: 80% of the maximum contract amount allowed which is the amount Delta Dental would pay.
Balance billing by your dentist may apply. You are responsible for these charges.

Restorations:

(Inlays & Onlays only)
Major Restorative procedures service:
50% after deductible
Non-Network: *50% of the maximum contract amount allowed which is the amount Delta Dental would pay.
Balance billing by your dentist may apply. You are responsible for these charges.

Gold foil restorations are not a benefit of most Delta Dental plans. Delta Dental may make an allowance for a corresponding amalgam restoration, and the patient is responsible for the remainder of the fee.