2026 Delta Dental Enhanced PPO
Basic Information
Plan ID
Plan #: 03366
Plan Year
2026
Offered To
Employees
Benefit Type
Dental
Full-Time Employee * Contribution Per Pay Period
Employee Only - $14.33
Employee & Spouse - $30.09
Employee & Child(ren) - $25.80
Employee & Family - $41.56
Employee & Spouse - $30.09
Employee & Child(ren) - $25.80
Employee & Family - $41.56
Part-Time Employee * Contribution Per Pay Period
Employee Only - $24.36
Employee & Spouse - $51.15
Employee & Child(ren) - $43.85
Employee & Family - $70.65
Employee & Spouse - $51.15
Employee & Child(ren) - $43.85
Employee & Family - $70.65
Basics
Overview
Delta Dental PPO is the dentist network for this plan. This plan pays in-network benefits when your care is either provided or authorized by your Delta Dental PPO network dentist. Basic procedures by a Premier or non Delta Dental dentist will be covered at a lower percentage.
If your network dentist does not provide or authorize your care, the charges are considered out-of-network.
You are encouraged to obtain a predetermination 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
Network: $0 per individual/$0 per family each calendar year
Non-PPO network: $50 per individual/$150 family each calendar year
Non-PPO network: $50 per individual/$150 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
Orthodontia 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 100% program allowance
- Basic procedures: 80% of Premier dentist fee 70% of program allowance for non Delta Dental providers.
- Major restorative procedures: 50% of Premier dentist fee or program allowance Orthodontia 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
Orthodontia 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 100% program allowance
- Basic procedures: 80% of Premier dentist fee 70% of program allowance for non Delta Dental providers.
- Major restorative procedures: 50% of Premier dentist fee or program allowance Orthodontia 50% of Premier dentist fee or program allowance
You are responsible for amounts not covered by the dental plan.
Maximum Annual Benefit
Annual Benefit Maximum:
Network: $3,000 per individual each calendar year
Non-PPO Network: $2,000 per individual each calendar year.
(Network and Non-PPO Network Maximum Combined for a total benefit of $2,000).
Diagnostic and Preventative services do not count towards annual maximum.
Network: $3,000 per individual each calendar year
Non-PPO Network: $2,000 per individual each calendar year.
(Network and Non-PPO Network Maximum Combined for a total benefit of $2,000).
Diagnostic and Preventative services do not count towards annual maximum.
Overall Lifetime Maximum Benefit
Orthodontia only: $2,000 per each covered member.
Other Services
X-rays (Basic Imaging)
Preventive and Diagnostic service:
PPO Network Provider:100%
Premier Network Provider: 100% of the maximum contract amount allowed which is the amount Delta Dental would pay
Non-Network: 100% of the maximum contract amount allowed which is the amount Delta Dental would pay (deductible waived)
PPO Network Provider:100%
Premier Network Provider: 100% of the maximum contract amount allowed which is the amount Delta Dental would pay
Non-Network: 100% of the maximum contract amount allowed which is the amount Delta Dental would pay (deductible waived)
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, those requiring periodontal maintenance and those in an active orthodontic treatment plan.
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, those requiring periodontal maintenance and those in an active orthodontic treatment plan.
Fluoride treatments
Preventive and Diagnostic service:
PPO or Premier Network Provider: 100% of the maximum contract amount allowed which is the amount Delta Dental would pay (Deductible waived)
Non-Network: 100% of the maximum contract amount allowed which is the amount Delta Dental would pay (deductible waived)
Two per calendar year
PPO or Premier Network Provider: 100% of the maximum contract amount allowed which is the amount Delta Dental would pay (Deductible waived)
Non-Network: 100% of the maximum contract amount allowed which is the amount Delta Dental would pay (deductible waived)
Two per calendar year
Routine exams
Preventive and Diagnostic service:
PPO and Premier Network Provider: 100%
Non-Network: 100% of the maximum contract amount allowed which is the amount Delta Dental would pay (deductible waived) Two per calendar year
PPO and Premier Network Provider: 100%
Non-Network: 100% of the maximum contract amount allowed which is the amount Delta Dental would pay (deductible waived) Two per calendar year
Sealants
Basic procedures service for children to age 15:
PPO Network Provider: 80%
80% of Premier dentist fee and 70% 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.
PPO Network Provider: 80%
80% of Premier dentist fee and 70% 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
Network: 50% of Delta's approved fee
Non-PPO Network: 50% of Delta's approved fee
Orthodontia lifetime maximum benefit of $2,000 per person (adults and dependent children). Payments are made in two installments: once banding has occurred and 12 months later. You must be enrolled in the Enhanced plan throughout the entire treatment.
Non-PPO Network: 50% of Delta's approved fee
Orthodontia lifetime maximum benefit of $2,000 per person (adults and dependent children). Payments are made in two installments: once banding has occurred and 12 months later. You must be enrolled in the Enhanced plan throughout the entire treatment.
Retainers
(Covered under the Orthodontia benefit)
PPO Network Provider: 50% of the maximum contract amount allowed which is the amount Delta Dental would pay
Premier or 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.
PPO Network Provider: 50% of the maximum contract amount allowed which is the amount Delta Dental would pay
Premier or 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.
Other Dental Services
Anesthesia
Basic procedures service:
PPO Network Providers: 80%
80% of Premier dentist fee and 70% of program allowance for non Delta Dental providers.
PPO Network Providers: 80%
80% of Premier dentist fee and 70% of program allowance for non Delta Dental providers.
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:
PPO Network Providers: 50%
Premier or 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.
PPO Network Providers: 50%
Premier or 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.
Dentures
Major Restorative procedures service:
PPO Network Providers: 50%
Premier or Non-Network: 50% of the maximum contract amount allowed which is the amount Delta Dental would payafter deductible
Balance billing by your dentist may apply. You are responsible for these charges.
PPO Network Providers: 50%
Premier or Non-Network: 50% of the maximum contract amount allowed which is the amount Delta Dental would payafter deductible
Balance billing by your dentist may apply. You are responsible for these charges.
Extractions
Basic procedures service:
PPO Network Providers: 80%
80% of Premier dentist fee and 70% of the maximum contract amount allowed which is the amount Delta Dental would pay after deductible for non Delta Dental providers.
PPO Network Providers: 80%
80% of Premier dentist fee and 70% of the maximum contract amount allowed which is the amount Delta Dental would pay after deductible for non Delta Dental providers.
Fillings
Basic procedures service:
PPO Network Providers: 80%
80% of Premier dentist fee and 70% of the maximum contract amount allowed which is the amount Delta Dental would payafter deductible for non Delta Dental providers.
Balance billing by your dentist may apply. You are responsible for these charges.
PPO Network Providers: 80%
80% of Premier dentist fee and 70% of the maximum contract amount allowed which is the amount Delta Dental would payafter deductible for non Delta Dental providers.
Balance billing by your dentist may apply. You are responsible for these charges.
Gingivectomy
Basic procedures service:
PPO Network Providers: 80%
80% of Premier dentist fee and 70% of the maximum contract amount allowed which is the amount Delta Dental would payafter deductible for non Delta Dental providers.
PPO Network Providers: 80%
80% of Premier dentist fee and 70% of the maximum contract amount allowed which is the amount Delta Dental would payafter deductible for non Delta Dental providers.
Restorations
(Inlays & Onlays only)
Major Restorative procedures service:
PPO Network Provider: 50%
Premier or 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.
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:
PPO Network Provider: 50%
Premier or 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.
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
Major Restorative procedures service:
PPO Network Provider: 50%
Premier or Non-Network: 50% of the maximum contract amount allowed which is the amount Delta Dental would pay after deductible
PPO Network Provider: 50%
Premier or Non-Network: 50% of the maximum contract amount allowed which is the amount Delta Dental would pay after deductible
Inlays
Major Restorative procedures service:
PPO Network Provider: 50%
Premier or 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.
PPO Network Provider: 50%
Premier or 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.
Onlays
Major Restorative procedures service:
PPO Network Provider: 50%
Premier or 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.
PPO Network Provider: 50%
Premier or 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.
Oral surgery
Basic procedures service:
PPO Network Providers: 80%
80% of Premier dentist fee and 70% of the maximum contract amount allowed which is the amount Delta Dental would payafter deductible.
Balance billing by your dentist may apply. You are responsible for these charges.
PPO Network Providers: 80%
80% of Premier dentist fee and 70% of the maximum contract amount allowed which is the amount Delta Dental would payafter deductible.
Balance billing by your dentist may apply. You are responsible for these charges.
Periodontal surgery
Basic procedures service:
PPO Network Providers: 80%
80% of Premier dentist fee and 70% of the maximum contract amount allowed which is the amount Delta Dental would payafter deductible for non Delta Dental providers.
Balance billing by your dentist may apply. You are responsible for these charges.
PPO Network Providers: 80%
80% of Premier dentist fee and 70% of the maximum contract amount allowed which is the amount Delta Dental would payafter deductible for non Delta Dental providers.
Balance billing by your dentist may apply. You are responsible for these charges.
Prescription drugs
Not covered
Root canals
Basic procedures service:
PPO Network Providers: 80%
80% of Premier dentist fee and 70% of the maximum contract amount allowed which is the amount Delta Dental would payafter deductible program allowance for non Delta Dental providers.
Balance billing by your dentist may apply. You are responsible for these charges.
PPO Network Providers: 80%
80% of Premier dentist fee and 70% of the maximum contract amount allowed which is the amount Delta Dental would payafter deductible program allowance for non Delta Dental providers.
Balance billing by your dentist may apply. You are responsible for these charges.
Space maintainers
Preventive and Diagnostic service:
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived) of the maximum contract amount allowed which is the amount Delta Dental would pay
PPO or Premier Network Provider: 100%
Non-Network: 100% (deductible waived) of the maximum contract amount allowed which is the amount Delta Dental would pay
Splinting
Not covered
TMJ (Temporomandibular joint syndrome)
Not covered