University of Minnesota – Pediatric Dental Plan
Delta Dental PPO™ & Delta Dental Premier®
Plan Benefit Highlights
| Network(s) | Delta Dental PPO | Delta Dental Premier | Non-participating* |
|---|---|---|---|
| Plan Year Maximum Per person Maximum | N/A | N/A | $1,000 |
| Orthodontic Maximum ***Dentally necessary Orthodontic Care (dependent child only) | N/A | N/A | N/A |
| Deductible *No deductible for any services | N/A | N/A | N/A |
| Eligible dependents | Students and dependent children up to age 19 | ||
Covered Services | Dental Benefit Plan Coverage | ||
| Diagnostic and Preventive Services Exams Cleanings X-rays Fluoride treatments Space Maintainers Sealants Emergency treatment for relief of pain | 100% | 100% | 100% |
| Periodontics Surgical/Nonsurgical periodontics | 100% | 100% | 100% |
| Basic Services 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% | 80% | 80% |
| Endodontics Root canal therapy on permanent teeth Pulpotomies on primary teeth for dependent children | 80% | 80% | 80% |
| Oral Surgery Surgical/Non-surgical extractions All other covered oral surgery | 80% | 80% | 80% |
| Major Restorative Crowns Crown repair | 50% | 50% | 50% |
| Prosthetic Repairs and Adjustments Denture adjustments and repairs Bridge repairs | 50% | 50% | 50% |
| Prosthetics Dentures (full and partial) Bridges Standard implant coverage | 50% | 50% | 50% |
| Orthodontics ***Dentally necessary Orthodontic Care (dependent children up to age 19 only) | 50%*** | 50%*** | 50%*** |