2026 Delta Dental Basic PPO
Basic Information
Plan ID
Plan #: 03365
Plan Year
2026
Offered To
Employees
Benefit Type
Dental
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
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
Employee & Spouse/Registered Domestic Partner - $21.06
Employee & Child(ren) - $18.05
Employee & Family - $29.09
Basics
Overview
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.
Deductible
$50 per individual each calendar year
$150 per family 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.
- 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.
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.
$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.
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.
Preventative 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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
Implants
Not covered
Inlays
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.
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.
Onlays
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.
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.
Oral surgery
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.
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.
Periodontal surgery
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.
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.
Prescription drugs
Not covered
Root canals
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.
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.
Space maintainers
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.
Balance billing by your dentist may apply. You are responsible for these charges.
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.
Balance billing by your dentist may apply. You are responsible for these charges.
Splinting
Not covered
TMJ (Temporomandibular joint syndrome)
Not covered