Delta Dental Basic Plan

56891NC0110001
Low
PPO

Delta Dental Basic Plan is a Low PPO plan by Delta Dental of North Carolina.

Locations

Delta Dental Basic Plan is offered in the following counties.

Plan Overview

This is a plan overview for 2025 version of Delta Dental Basic Plan 56891NC0110001.
Insurer: Delta Dental of North Carolina
Network Type: PPO
Metal Type: Low
HSA Eligible?:
Plan ID: 56891NC0110001

Cost-Sharing Overview

Delta Dental Basic Plan offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Delta Dental Basic Plan?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Delta Dental Basic Plan offers the following features and referral requirements.

Wellness Program:
Disease Program:
Notice Pregnancy:
Referral Specialist:
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Delta Dental Basic Plan covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Benefits paid at out of network level
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Same benefit level
National Network: Yes

Additional Benefits and Cost-Sharing

Delta Dental Basic Plan includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Routine Dental Services (Adult)
Covered
No Charge 0.00% Coinsurance after deductibleNo Charge 20.00% Coinsurance after deductible Subject to $1,000 annual maximum
Dental Check-Up for Children
Covered
No Charge 0.00% Coinsurance after deductibleNo Charge 0.00% Coinsurance after deductible2.0 Visit(s) per Benefit Period Age and frequency mirror benchmark
Basic Dental Care – Child
Covered
No Charge 50.00% Coinsurance after deductibleNo Charge 50.00% Coinsurance after deductible Age and frequency mirror benchmark
Orthodontia – Child
Covered
No Charge 50.00% Coinsurance after deductibleNo Charge 50.00% Coinsurance after deductible
Major Dental Care – Child
Covered
No Charge 50.00% Coinsurance after deductibleNo Charge 50.00% Coinsurance after deductible Age and frequency mirror benchmark
Basic Dental Care – Adult
Covered
No Charge 50.00% Coinsurance after deductibleNo Charge 60.00% Coinsurance after deductible Subject to annual max 6 month wait
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Accidental Dental
Not Covered

Free Preventive Services

There is no copayment or coinsurance for any of the following Delta Dental Basic Plan preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Ready to sign up for Delta Dental Basic Plan?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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