Alert

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On October 10, we will be upgrading our phone system. This enhancement will improve your future experience. It may result in additional wait times during our transition. We appreciate your understanding and patience as we work to serve you better.

On October 10, our call center will be closed for staff training between 12 PM and 1 PM ET.
On October 9, due to the enhancement to our phone system, our IVR will be unavailable for self-service from 6.30 PM through 11:59 PM ET.

Essential Health Benefits Enhanced Family PPO Plan III (1500)

Starting at
$45.70

 

Benefit Summary

PPO calendar year maximum$1,500
per adult enrollee
Premier & OON calendar year maximum$1,000
per adult enrollee
PPO annual out of pocket maximumNo limit
 
Premier & OON annual out of pocket maximumNo limit
 
PPO deductible$25/$75
per adult enrollee (not applied to P&D)
Premier & OON deductible$50/$150
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) fillings80%
 
                                                  Major Services
Endodontics50%
 
Periodontics50%
 
Oral surgery50%
 
Crowns50%
 
Onlays50%
 
Prosthodontics (dentures, bridges)50%
 
Denture repairs50%
 
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$35/$105
per pediatric enrollee (not applied to P&D)
Premier & OON deductible$35/$105
per pediatric enrollee (not 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) 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 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