Primary enrollee, spouse (includes domestic partner) and eligible dependent
children to age 26
Deductibles
In-Network: N/A
Out-of-Network: $25 per person, $75 per family, per plan year
Deductibles waived for D & P?
In-Network: N/A
The maximum benefit paid per calendar year is $3,000 per person in-network
The maximum benefit paid per calendar year is $1,000 per person out-of-network
Waiting Period(s)
Basic Benefits
Major Benefits
None
Orthodontics
None
* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.
Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist’s actual fees.
** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier
dentists and program allowance for non-Delta Dental dentists.
Delta Dental of California
100 First St.
San Francisco, CA 94105
866-499-3001
P.O. Box 997330
Sacramento, CA 95899-7330
deltadentalins.com
This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you
have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative.
Plan Benefit Highlights for: PPO $3,000 with Orthodontic
Group No: Active and Cobra, Retirees
Benefits and
Covered Services*
In-PPO Network** Out-of-PPO Network**
Diagnostic & Preventive Services
(D & P)
100 % 50 %
Basic Services
Fillings, simple tooth extractions, sealants
100 % 50 %
(root canals)
Covered Under Basic Services
100 % 50 %
Periodontics (gum treatment)
Covered Under Basic Services
100 % 50 %
Oral Surgery
Covered Under Basic Services
100 % 50 %
Major Services
Crowns, inlays, onlays and cast restorations
100 % 50 %
Prosthodontics
Bridges, dentures, implants
50 % 50 %
Orthodontic Benefits
Adults and dependent children
100% 100%
Orthodontic Maximums
Separate $3,000 Lifetime maximum per person
Dental Accident Benefits
100% (separate $1,000 maximum
per person per calendar year)
50%
