Delta Dental
Plans
Sunset Plans
00464-01300/01301 A – Premier $50 80/80/50 $1,000
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Sunset Plans
00464-01400/01401 C – Premier $50 100/80/50 $1,000
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Sunset Plans
00464-01600/01601 E – Premier $50 100/80/50 $1,500
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Evidence of Coverage
00465 Delta Dental PPO or PPO Premier Plans F-X (EOC)
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Evidence of Coverage
00465 Delta Dental PPO or PPO Premier Plans F-X (EOC)
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Member Benefit Summaries
00465-02100/02101 K – ERS PPO 100/80/50 $1,500 w/Ortho
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Member Benefit Summaries
00465-02200/02201 L – ERS PPO 100/80/50 $1,500
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Member Benefit Summaries
00465-02300/02301 M – ERS PPO 100/80/50 $2,000 w/Ortho
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Member Benefit Summaries
00465-02400/02401 N – ERS PPO (Premier) 100/80/50 $1,500 w/Ortho
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Member Benefit Summaries
00465-02500/02501 O – ERS PPO (Premier) 100/80/50 $2,000
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Member Benefit Summaries
00465-02600/02601 P – ERS PPO (Premier) 100/80/50 $2,000 w/Ortho
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Member Benefit Summaries
00465-02700/02701 Q – VOL PPO 100/80/50 $1,500 w/Ortho
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Member Benefit Summaries
00465-02800/02801 R – VOL PPO 100/80/50 $2,000
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Member Benefit Summaries
00465-02900/02901 S – VOL PPO 100/80/50 $2,000 w/Ortho
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Member Benefit Summaries
00465-03000/03001 T – VOL PPO (Premier) 100/80/50 $1,500 w/Ortho
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Member Benefit Summaries
00465-03100/03101 U – VOL PPO (Premier) 100/80/50 $2,000
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Member Benefit Summaries
00465-03200/03201 V – VOL PPO (Premier) 100/80/50 $2,000 w/Ortho
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Member Benefit Summaries
00465-03300/03301 W – ERS PPO (Premier) 100/80/50 $3,000
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Member Benefit Summaries
00465-03400/03401 X – VOL PPO (Premier) 100/80/50 $3,000
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Benefits and Rates
2026 Delta Dental DPO and DPO (Premier) — benefits & rates
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Benefits and Rates
2026 Delta Dental DPO and DPO (Premier) — benefits and rates
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Benefits and Rates
2026 Delta Dental HMO — benefits & rates
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Benefits and Rates
2026 Delta Dental HMO — benefits and rates
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Benefits and Rates
2026 Delta Dental PPO (Premier) — benefits & rates
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Benefits and Rates
2026 Delta Dental PPO (Premier) — benefits and rates
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Benefits and Rates
2026 Delta Dental PPO (Premier) — benefits and rates
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Benefits and Rates
2026 Delta Dental PPO — benefits & rates
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Benefits and Rates
2026 Delta Dental PPO — benefits and rates
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Evidence of Coverage
71989 DeltaCare DHMO 12A (EOC)
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Evidence of Coverage
71989 DeltaCare DHMO 12A (EOC)
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Member Benefit Summaries
71989-00030, 00031, 00032, 00033 DeltaCare HMO 12A
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Member Benefit Summaries
71989-00030, 00031, 00032, 00033 DeltaCare HMO 12A
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Additional
Claim form
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Member Benefit Summaries
Delta Dental CO PPO $750
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Evidence of Coverage
Delta Dental CO PPO $750 – W2881
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Member Benefit Summaries
Delta Dental CO PPO MAC $1000 with Ortho
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Evidence of Coverage
Delta Dental CO PPO MAC $1000 with Ortho – W2884
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Member Benefit Summaries
Delta Dental CO PPO MAC $2000
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Evidence of Coverage
Delta Dental CO PPO MAC $2000 – W2883
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Member Benefit Summaries
Delta Dental CO PPO Premier $1500
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Evidence of Coverage
Delta Dental CO PPO Premier $1500 – W2882
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Evidence of Coverage
Delta Dental in Texas – 22824
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Evidence of Coverage
Delta Dental in Texas – 22824
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Member Benefit Summaries
Delta Dental in TX – DPO $1500 – 22824-01100 A
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Member Benefit Summaries
Delta Dental in TX – DPO $1500 – 22824-01101 A
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Member Benefit Summaries
Delta Dental in TX – DPO $1500 – 22824-01200 B
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Member Benefit Summaries
Delta Dental in TX – DPO $1500 – 22824-01201 B
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Member Benefit Summaries
Delta Dental in TX – DPO $2000 w/ORTHO – 22824-01300 C
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Member Benefit Summaries
Delta Dental in TX – DPO $2000 w/ORTHO – 22824-01301 C
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Member Benefit Summaries
Delta Dental in TX – DPO $2000 w/ORTHO – 22824-01400 D
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Member Benefit Summaries
Delta Dental in TX – DPO $2000 w/ORTHO – 22824-01401 D
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Member Benefit Summaries
Delta Dental in TX – DPO $2000 – 22824-01600 F
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Member Benefit Summaries
Delta Dental in TX – DPO $2000 – 22824-01601 F
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Member Benefit Summaries
Delta Dental in TX – DPO $2000 – 22824–01500 E
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Member Benefit Summaries
Delta Dental in TX – DPO $2000 – 22824–01501 E
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Member Benefit Summaries
Delta Dental in TX – DPO $3000 w/ORTHO – 22824-01700 G
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Member Benefit Summaries
Delta Dental in TX – DPO $3000 w/ORTHO – 22824-01701 G
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Member Benefit Summaries
Delta Dental in TX – DPO $3000 w/ORTHO – 22824-01800 H
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Member Benefit Summaries
Delta Dental in TX – DPO $3000 w/ORTHO – 22824-01801 H
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ID Card
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ID Card
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- Our Delta Dental enterprise includes Delta Dental of California, Delta Dental of Pennsylvania, Delta Dental of New York, Inc., Delta Dental Insurance Company and other affiliates.
- Please refer to your plan details for more information about your coverage.
- Pell, Nicholas (2019). How much does a root canal cost? The Simple Dollar. https://www.thesimpledollar.com/how-much-does-a-root-canal-cost.
- Gum disease and heart disease: The common thread. Harvard Health Publishing. 2018.
- In California, Delta Dental PPO™ is underwritten by Delta Dental of California, a not-for-profit dental service company.
- Plan benefits may vary based on state requirements. Please refer to the plan Policy for a complete list of plan benefits, limitations, exclusions and policy terms. In the event of any inconsistency between this document and the plan Policy, the terms of the Policy will prevail.
- DeltaCare® USA is underwritten in California by Delta Dental of California. Delta Dental Insurance Company acts as the DeltaCare USA administrator.
Archived plans
Can’t locate your plan? Contact us for access to archived or sunset plan documents.