Primary enrollee, spouse (includes domestic partner) and eligible dependent
children to age 26
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
Out-of-Network: No
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
* 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
Customer Service
Claims Address
P.O. Box 997330
Sacramento, CA 95899-7330
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**
(D & P)
100 % 50 %
Basic Services
100 % 50 %
(root canals)
100 % 50 %
100 % 50 %
100 % 50 %
Major Services
100 % 50 %
50 % 50 %
Orthodontic Benefits
100% 100%
Orthodontic Maximums
Separate $3,000 Lifetime maximum per person
Dental Accident Benefits
100% (separate $1,000 maximum
per person per calendar year)