Alert
Pediatric Essential Health Benefits Plans
PPO annual maximumNone
per covered person
Premier & OON annual maximumNone
per covered person
PPO annual out of pocket maximum
$350/$700
$350/$700
Premier & OON annual out of pocket maximumNo limit
PPO deductible$135/$405
Applied to P&D
Premier & OON deductible$135/$405
Applied to P&D
Preventive & Diagnostic
Oral exams/evaluations100%
Cleanings100%
Bitewing X-rays100%
Sealants100%
Age limits apply
Topical fluoride100%
Age limits apply
In-office A1C diabetes testing100%
Basic Services
Composite (white) fillings50%
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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PPO annual maximumNone
per covered person
Premier & OON annual maximumNone
per covered person
PPO annual out of pocket maximum
$350/$700
$350/$700
Premier & OON annual out of pocket maximumNo limit
PPO deductible$35/$105
Not applied to P&D
Premier & OON deductible$35/$105
Not applied to P&D
Preventive & Diagnostic
Oral exams/evaluations100%
Cleanings100%
Bitewing X-rays100%
Sealants100%
Age limits apply
Topical fluoride100%
Age limits apply
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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PPO & Premier annual maximumNone
per covered person
Out of network annual maximumNone
per covered person
PPO & Premier annual out of pocket maximum$350/$700
Out of network annual out of pocket maximumNo limit
PPO & Premier deductible$135/$405
Applied to P&D
Out of network deductible$135/$405
Applied to P&D
Preventive & Diagnostic
Oral exams/evaluations100%
Cleanings100%
Bitewing X-rays100%
Sealants100%
Age limits apply
Topical fluoride100%
Age limits apply
In-office A1C diabetes testing100%
Basic Services
Composite (white) fillings50%
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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PPO & Premier annual maximumNone
per covered person
Out of network annual maximumNone
per covered person
PPO & Premier annual out of pocket maximum$350/$700
Out of network annual out of pocket maximumNo limit
PPO & Premier deductible$35/$105
Not applied to P&D
Out of network deductible$35/$105
Not applied to P&D
Preventive & Diagnostic
Oral exams/evaluations100%
Cleanings100%
Bitewing X-rays100%
Sealants100%
Age limits apply
Topical fluoride100%
Age limits apply
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.
