University of Minnesota – Student Dental Plan
Delta Dental PPO™ & Delta Dental Premier®
Plan Benefit Highlights
| Network(s) | Buy-Up Plan with Restorative Services |
|---|---|
| Plan Year Maximum Per person Maximum Diagnostic and preventive services are excluded from the Plan Year | $1,200 |
| Deductible Per person per plan year No deductible for diagnostic and preventive services and non-surgical periodontics | $25/person |
| Covered Services | Student Dental Benefit Plan Coverage |
|---|---|
| Diagnostic & Preventive Services Exams Cleanings X-rays Sealants | 100% |
| Periodontics Nonsurgical periodontics * Please note this service will be subject to the $1,200 annual plan year maximum | 80% |
| Periodontics Surgical periodontics | 80% |
| Basic Services Emergency treatment for relief of pain Amalgam restorations (silver fillings) Composite resin restorations (white fillings) on anterior (front) teeth Composite resin restorations (white fillings) on posterior (back) teeth will be paid at the amalgam allowance | 80% |
| Endodontics Root canal therapy on permanent teeth Pulpotomies on primary teeth for dependent children | 50% |
| Oral Surgery Surgical/Nonsurgical extractions All other covered oral surgery | 50% |
| Major Restorative Crowns | 50% |
| Prosthetic Repairs and Adjustments Denture adjustments and repairs Bridge repairs | 50% |
| Prosthetics Dentures (full and partial) Bridges | 50% |