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Summary of Dental Benefits and Coverage Disclosures Matrix (SDBC) Document Library - California

Plan nameGroupDivision
Delta Dental Individual & Family™ DeltaCare® USA Family Dental HMO (2026 version)7863700034
Delta Dental Individual & Family™ Delta Dental PPO™ Family Dental PPO (2026 version)5025010014
DeltaCare® USA Family Dental HMO for Small Businesses (2026 version)7703600124, 00134, 00144, 00154
DeltaCare® USA Children's Dental HMO for Small Businesses (2026 version)7703600172, 00182, 00192, 00202
Delta Dental PPO™ Family Dental PPO for Small Businesses (2026 version)5003710784, 10794, 10804, 10814, 10824, 10834, 10844, 10854, 10864, 10874, 10884, 10894,, 10904, 10914, 10924, 10934, 10944, 10954, 10964
Delta Delta Dental PPO™ Children's Dental PPO for Small Businesses (2026 version)5003710582, 10592, 10602, 10612, 10622, 10632, 10642, 10652, 10662, 10672, 10682, 10692, 10702, 10712, 10722, 10732, 10742, 10752, 10762
Delta Dental Individual & Family™ Delta Dental PPO™ Family Dental PPO* (2025 version)5003710004
Delta Dental PPO™ Children's Dental PPO* for Small Businesses (2025 version)This plan is associated with a number of Groups/Divisions and are not listed here
Delta Dental Individual & Family™ DeltaCare® USA** Family Dental HMO (2025 version)This plan is associated with a number of Groups/Divisions and are not listed here
DeltaCare® USA Children's Dental HMO** for Small Businesses (2025 version)7703600124, 00134, 00144, 00154
DeltaCare® USA Family Dental HMO for Small Businesses (2025 version)7703600172, 00182, 00192, 00202

Plan nameGroupDivision
 Delta Dental PPO™ - Individual Premium*** (2026 version)1881800005
 DeltaCare® USA - CAA50 Senior Program** (2026 version)7053000002, 00004, 00005, 00006, 01005
 DeltaCare® USA - CAA55** (2026 version)7011600008
 DeltaCare® USA - CAA54** (2026 version)7011600009
 Delta Dental PPO™ - Individual Basic *** (2026 version)1881800004
 DeltaCare® USA - CAA50 Senior Program** (2025 version)7053000002, 00004, 00005, 00006, 01005
 DeltaCare® USA - CAA55** (2025 version)7011600008
 DeltaCare® USA - CAA54** (2025 version)7011600009
 Delta Dental PPO™ - Individual Basic *** (2025 version)1881800004
 Delta Dental PPO™ - Individual Premium*** (2025 version)1881800005

Plan nameGroupDivision
 Delta Dental PPO Protect Plus **** (2025 version)123010505,00505, 20505, 30505
 Delta Dental PPO Protect **** (2025 version)123010504. 00504, 20504, 30504
 Delta Dental PPO Protect Propel**** (2025 version)2244100506
 DeltaCare® USA Essential** (2025 version)7677 7, 7697601001
 15B DeltaCare® USA ** (2024 version)76777 / 7697601001
 Delta Dental PPO Plan A **** (2024 version)01230 / 1710400501
 Delta Dental PPO Plan B **** (2024 version)01230 / 1710400502

 

Plan nameGroupDivision
 DeltaCare® USA - CAE01** (2025 version)7644400001
 DeltaCare® USA – CAE01 ** (2024 version)7644400001

If you live in CA and would like a paper copy of the Summary of Dental Benefits and Coverage Disclosure Matrix SDBC, free of charge, please call our Contact Center at 888.282.9501.

The SDBCs are just summaries. Review the plan booklet and disclosure form  for a complete description of benefits, limitations and exclusions.

*In CA, Delta Dental PPO is underwritten by Delta Dental of California.

Please refer to the policy and disclosure form for a complete list of plan benefits, limitations and exclusions.

**In CA, DeltaCare USA is underwritten by Delta Dental of California and administered by Delta Dental Insurance Company. These companies are financially responsible for their own products.

Please refer to the policy and disclosure form for a complete list of plan benefits, limitations and exclusions.

***In CA, Delta Dental PPO is underwritten by Delta Dental of California and administered by Delta Dental Insurance Company. 

Please refer to the policy and disclosure form for a complete list of plan benefits, limitations and exclusions.

****In CA, the AARP® Dental Insurance Plan is insured by Dentegra Insurance Company (Contract 1230) and administered by Delta Dental Insurance Company. These companies are financially responsible for their own products.

Please refer to the plan COC and disclosure form for a complete list of plan benefits, limitations and exclusions.

AARP endorses the AARP Dental Insurance Plan, administered by Delta Dental Insurance Company. Delta Dental Insurance Company pays royalty fees to AARP for use of its intellectual property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers.