How do I find a dentist?What services are covered?Can my kids get braces?
Network Options: Low Plan PPO Network or High Plan Premier Network
Delta Dental is there to help you understand and use your insurance to get the dental care you need. On their website you will find an easy to use Cost Estimator, tools to help you find a provider, and a mobile to make accessing your cards and plan information a snap.
(800) 521-2651 | deltadental.com
Dental Plan
Stay in network to save
Visit a dentist in the PPO network to maximize your savings. These dentists have agreed to reduced fees, and you won't get charged more than your expected share of the bill. Find a PPO dentist at deltadental.com. If you can't find a PPO dentist, consider a Delta Dental Premier dentist. These dentists have agreed to set fees and offer another opportunity to save.
Out-of-network Coverage
A dentist who is “out-of-network” means the provider hasn’t agreed to negotiated rates. The plan pays benefits based on a Fee Schedule charge for a particular service. If the out-of-network provider charges more, you’ll be responsible for paying the amount that exceeds the Fee Schedule limit plus the applicable coinsurance and deductible.
Visit a dentist in the PPO network to maximize your savings. These dentists have agreed to reduced fees, and you won't get charged more than your expected share of the bill. Find a PPO dentist at deltadental.com. If you can't find a PPO dentist, consider a Delta Dental Premier dentist. These dentists have agreed to set fees and offer another opportunity to save.
Out-of-network Coverage
A dentist who is “out-of-network” means the provider hasn’t agreed to negotiated rates. The plan pays benefits based on a Fee Schedule charge for a particular service. If the out-of-network provider charges more, you’ll be responsible for paying the amount that exceeds the Fee Schedule limit plus the applicable coinsurance and deductible.
LOW PLAN - PPO NETWORK
In-Network
Out-of-Network*
Annual Deductible
January 1 - December 31
January 1 - December 31
You pay up to
$75 per individual / $150 per family
$75 per individual / $150 per family
Annual Maximum
January 1 - December 31
January 1 - December 31
Plan pays up to
$1,500 per individual
$1,500 per individual
Plan pays up to
$1,000 per individual
$1,000 per individual
Waiting Period
None for Preventive, Basic, or Major Services
Preventive Services
Exams & Cleanings (limited to 2 routine visits in any calendar year), Sealants (up to age 15), Fluoride (up to age 19), Space Maintainers, and Panoramic X-rays (once every 5 years)
Exams & Cleanings (limited to 2 routine visits in any calendar year), Sealants (up to age 15), Fluoride (up to age 19), Space Maintainers, and Panoramic X-rays (once every 5 years)
Plan pays
100% of covered services
No Deductible Applies
100% of covered services
No Deductible Applies
Plan pays
80% of UCR
No Deductible Applies
80% of UCR
No Deductible Applies
Basic & Major Services
Restorative, Oral Surgery, Extractions, Endodontics, Periodontics, Implants, Prosthodontics-fixed & Removable, Renture Repair-reline, Rebase, and Adjustments
Restorative, Oral Surgery, Extractions, Endodontics, Periodontics, Implants, Prosthodontics-fixed & Removable, Renture Repair-reline, Rebase, and Adjustments
You pay
50% AD
50% AD
You pay
60% of UCR, AD
60% of UCR, AD
Orthodontic Services
Not Covered
Not Covered
AD: After Deductible
UCR: Usual, Customary & Reasonable fees
* Providers may charge more than the plan allows when you receive services out-of-network. It is recommended that you ask the out-of-network provider about their billed charges before planning care.
This information is designed to help you choose a benefit plan for 2022-2023 only. Please refer to the Plan Documents provided by the carrier for information regarding coverage, limitations and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.
UCR: Usual, Customary & Reasonable fees
* Providers may charge more than the plan allows when you receive services out-of-network. It is recommended that you ask the out-of-network provider about their billed charges before planning care.
This information is designed to help you choose a benefit plan for 2022-2023 only. Please refer to the Plan Documents provided by the carrier for information regarding coverage, limitations and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.
EMPLOYEE COST PER PAY PERIOD
Employee Only
Employee + Spouse
Employee + Child
Employee + Children
Employee + Family
$1.95
$4.78
$4.49
$4.78
$8.10
Stay in network to save
Visit a dentist in the Premier network to maximize your savings. These dentists have agreed to reduced fees, and you won't get charged more than your expected share of the bill. Find a Premier dentist at deltadental.com.
Orthodontic Coverage
Choose a Delta Dental orthodontist by searching for a dentist on the website and enter "orthodontist" in the keyword field. Coverage varies depending your plan but most Delta Dental plans include:
A dentist who is “out-of-network” means the provider hasn’t agreed to negotiated rates. The plan pays benefits based on a Fee Schedule charge for a particular service. If the out-of-network provider charges more, you’ll be responsible for paying the amount that exceeds the Fee Schedule limit plus the applicable coinsurance and deductible.
Visit a dentist in the Premier network to maximize your savings. These dentists have agreed to reduced fees, and you won't get charged more than your expected share of the bill. Find a Premier dentist at deltadental.com.
Orthodontic Coverage
Choose a Delta Dental orthodontist by searching for a dentist on the website and enter "orthodontist" in the keyword field. Coverage varies depending your plan but most Delta Dental plans include:
- Pre-orthodontic treatment visit
- Exam and start-up records
- X-rays
- Orthodontist-recommended tooth extractions
- Comprehensive orthodontic treatment
- Post-treatment records
A dentist who is “out-of-network” means the provider hasn’t agreed to negotiated rates. The plan pays benefits based on a Fee Schedule charge for a particular service. If the out-of-network provider charges more, you’ll be responsible for paying the amount that exceeds the Fee Schedule limit plus the applicable coinsurance and deductible.
HIGH PLAN - PREMIER NETWORK
In-Network
Out-of-Network*
Annual Deductible
January 1 - December 31
January 1 - December 31
You pay up to
$75 per individual / $150 per family
$75 per individual / $150 per family
Annual Maximum
January 1 - December 31
January 1 - December 31
Plan pays up to
$2,000 per individual
$2,000 per individual
Plan pays up to
$1,500 per individual
$1,500 per individual
Waiting Period
None for Preventive, Basic, Major, or Orthodontic Services
Preventive Services
Exams & Cleanings (limited to 2 routine visits in any calendar year), Sealants (up to age 15), Fluoride (up to age 19), Space Maintainers, and Panoramic X-rays (once every 5 years)
Exams & Cleanings (limited to 2 routine visits in any calendar year), Sealants (up to age 15), Fluoride (up to age 19), Space Maintainers, and Panoramic X-rays (once every 5 years)
Plan pays
100% of covered services
No Deductible Applies
100% of covered services
No Deductible Applies
Plan pays
100% of UCR
No Deductible Applies
100% of UCR
No Deductible Applies
Basic Services
Basic Restorative, Endodontics, Periodontics, and Denture Repair (Reline, Rebase, & Adjustments)
Basic Restorative, Endodontics, Periodontics, and Denture Repair (Reline, Rebase, & Adjustments)
You pay
20% AD
20% AD
You pay
20% of UCR, AD
20% of UCR, AD
Major Services
Major Restorative, Oral Surgery, Simple Extractions, Prosthodontics-fixed & Removable, and Implants
Major Restorative, Oral Surgery, Simple Extractions, Prosthodontics-fixed & Removable, and Implants
You pay
50% AD
50% AD
You pay
50% of UCR, AD
50% of UCR, AD
Orthodontic Services
Adults and Children
Adults and Children
Covers up to 50% AD
Plan pays up to 50% of UCR, AD
Orthodontic Lifetime Maximum
$1,500 per individual
AD: After Deductible
UCR: Usual, Customary & Reasonable fees
* Providers may charge more than the plan allows when you receive services out-of-network. It is recommended that you ask the out-of-network provider about their billed charges before planning care.
This information is designed to help you choose a benefit plan for 2022-2023 only. Please refer to the Plan Documents provided by the carrier for information regarding coverage, limitations and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.
UCR: Usual, Customary & Reasonable fees
* Providers may charge more than the plan allows when you receive services out-of-network. It is recommended that you ask the out-of-network provider about their billed charges before planning care.
This information is designed to help you choose a benefit plan for 2022-2023 only. Please refer to the Plan Documents provided by the carrier for information regarding coverage, limitations and exclusions. If there is a difference between this guide and the Plan Documents, the Plan Documents prevail.
EMPLOYEE COST PER PAY PERIOD
Employee Only
Employee + Spouse
Employee + Child
Employee + Children
Employee + Family
$6.26
$14.78
$14.24
$14.78
$23.30
