Dental Coverage at a Glance
Delta Dental will pay a specified percentage of allowed expenses after you pay any applicable deductibles or coinsurance.
The following chart summarizes what the Plan will reimburse you for covered services. Note: All benefits are subject to Delta Dental's usual, reasonable and customary allowances.
Provisions
Coverage
Choice of Dentist
Any; for maximum benefits, use a PPO or Premier Dentist
Annual Deductible*
Delta Dental PPO Network
  • $25/person and $75/family
Delta Dental Premier Network or Non-Participating Dentist
  • $50/person and $150/family
For all covered services
Diagnostic and Preventive Care
No deductible
You pay 15% of eligible preventive care, including:
  • Two exams/year
  • Full-mouth X-rays and Panorex films once every five years
  • Bitewing X-rays twice/year for dependents up to age 18; once/year for adults age 18 and older
  • Two cleanings/year
  • Fluoride treatments
  • Space maintainers
Basic Care
Deductible required
You pay 15% of eligible basic care, including:
  • Fillings
  • Root canals
  • Extractions
  • Oral surgery
  • Treatment of the gums (periodontia)
  • Sealants for eligible dependents under age 16
  • Permanent first molars through age 8
  • Second molars through age 15
Major Care
Deducible required
You pay 15% of eligible major care, including:
  • Crowns
  • Inlays
  • Onlays
  • Cast restorations
  • Bridges
  • Implants
Annual Maximum
$2,500/person (excludes orthodontia)
Orthodontia Benefit
You pay 50% of covered expenses; lifetime maximum benefit of $2,000/person
* If you use only Delta Dental PPO dentists throughout the full calendar year, you will pay the lower deductible. If at any time you use a non-participating dentist or a Delta Dental dentist who is only in the Premier network, the higher deductible will apply. The maximum total deductible you will pay in any calendar year is $50/person or $150/family because you won't be required to pay a separate deductible for using both a PPO dentist and a Delta Dental Premier or non-participating dentist.
In addition to your coinsurance, you are responsible for any charges over what Delta Dental will allow. Please note that the annual deductible, annual maximum and orthodontia lifetime maximum are the same regardless of whether services are received by a Delta Dentist or non-participating dentist.
Reimbursement to members who do not use a Delta Dentist is based on the prevailing fee. The prevailing fee is the applicable percentage of the lesser of the fee charged or the fee which satisfies the majority of Delta Dentists for a single procedure as determined by Delta Dental of California.