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Notice

On May 21st, our call center will operate from 8 AM to 11:45 AM and will be closed in the afternoon.

From Friday May 23rd through Friday, August 29, 2025: Customer Service hours will be 8:00 AM – 6:30 PM EST Monday through Thursday and 8:00 AM - 1:00 PM EST on Friday.

To view benefit information and claim status at any time, you can sign into your account or use our Interactive Voice Response System 24/7 at 800-452-9310.

Essential Health Benefits Basic Family PPO I

Starting at
$19.46

 

Benefit Summary

Adult Benefits >19

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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$75/$225
per adult enrollee (not applied to P&D)
Premier & OON deductible$100/$300
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) fillings60%
 
                                                  Major Services
EndodonticsNot covered
 
PeriodonticsNot covered
 
Oral surgeryNot covered
 
CrownsNot covered
 
OnlaysNot covered
 
Prosthodontics (dentures, bridges)Not covered
 
Denture repairsNot covered
 
Orthodontics (medically necessary)Not covered
 
Orthodontics (not medically necessary)Not covered
 
Waiting periodsNone
 
Plan Details Collapse

Pediatric Benefits <19

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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$135/$405
per adult enrollee (applied to P&D)
Premier & OON deductible$135/$405
per adult enrollee (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) 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 Collapse

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.

 

Transparency in coverage