PLAN STUDENT DENTAL DENTAL II
Providers

Any Provider

3 Tiers:
PPO - Preferred Provider Organization network
PREMIER - Premier Delta Dental network
NON-PAR - Dentists who do not participate with Delta Dental

Any Provider

3 Tiers:
PPO - Preferred Provider Organization network
PREMIER - Premier Delta Dental network
NON-PAR - Dentists who do not participate with Delta Dental
Benefit Period Calendar Year

Calendar Year
Annual Deductible $0 $0
Coinsurance

0%

0%
Maximum Annual Benefit $1,000 Per member
*$2,000, up to $4,000 with annual carryover
Diagnostic & Preventative Care

Dental Cleaning, Oral Evaluations, X-rays, Sealant Applications, Space Maintainers, Diagnostic Tests, Biopsy of Oral Tissue, Maintenance Therapy

 Deductible: None
Coinsurance: 0%
Max Annual Ben: $1,000

Deductible: None
Coinsurance: 0%
Max Annual Ben: Two per year
Routine & Restorative Care

Emergency Treatment for Pain, General Anesthesia/Sedation Anesthesia or Analgesia, Restoration of Decayed or Fractured Teeth,
Limited Occlusal Adjustment, Routine Oral Surgery, Consultations,
Antibiotic Drug Injections

Deductible (single/family):

PPO - $15 / $45
PREMIER - $25 / $75
NON-PAR -  $25 / $75

Coinsurance:

PPO - 10%
PREMIER - 20% 
NON-PAR - 20%

Deductible (single/family):

PPO - None
PREMIER - None
NON-PAR -  None

Coinsurance:

PPO - 0%
PREMIER - 20% 
NON-PAR - 20%

Endodontic & Periodontal Services
Root Canals, Apicoectomy, Direct Pulp Cap
Pulpotomy, Retrograde Fillings, Root Canal Therapy
Gum and Bone Diseases, Conservative Procedures
Complex Procedures


 

Deductible (single/family):

PPO - $15 / $45
PREMIER - $25 / $75
NON-PAR -  $25 / $75

Coinsurance:

PPO - 20%
PREMIER - 20% 
NON-PAR - 20%

Deductible (single/family):

PPO - None
PREMIER - None
NON-PAR -  None

Coinsurance:

PPO - 10%
PREMIER - 20% 
NON-PAR - 20%
High Cost Restorations & Prosthetics
Crowns, Inlays, Onlays, Posts and Cores
Bridges, Dentures, Denture Relining, Implants

 

Deductible (single/family):

PPO - $15 / $45
PREMIER - $25 / $75
NON-PAR -  $25 / $75

Coinsurance:

PPO - 50%
PREMIER - 50% 
NON-PAR - 50%

Deductible (single/family):

PPO - None
PREMIER - None
NON-PAR -  None

Coinsurance:

PPO - 10%
PREMIER - 20% 
NON-PAR - 20%
Orthodontic Care

Treatment necessary for the proper alignment of teeth


 		 Not Covered

Deductible: $0

Coinsurance: 50%

Orthodontic benefits are paid quarterly

*Maximum Annual Benefit (per member):

$2,000 includes all covered services per member. The annual benefit maximum for Dental II includes a carryover feature from one calendar year to the next.  If you do not use all of your $2,000 maximum, have been covered the full year, and submitted at least one claim, what remains will carryover and be added to your annual maximum in the following year up to $4,000.

ABOUT OUR SITE: The information presented on our website describes only the highlights of the plans and does not constitute official plan documents. Additional terms and conditions apply. If there are any discrepancies between the information contained herein and the official plan documents, the plan documents will govern.