Student Dental Plan Details

How Much an Individual Pays for Dental Services

Check Ups and Teeth Cleaning (Diagnostic and Preventative Services)

  • Dental Cleaning
  • Oral Evaluations
  • Fluoride Applications
  • X-rays
  • Sealant Applications
  • Space Maintainers
  • Diagnostic Tests
  • Biopsy of Oral Tissue
  • Maintenance Therapy
*Deductible is waived for all providers in this category
  PPO PREMIER NON-PARTICIPATING
Deductible* $0 $0 $0
Co-Insurance 0% 0% 0%
Annual Maximum $1,000 $1,000 $1,000

Cavity Repair and Tooth Extractions (Routine and Restorative Services)

  • 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
  PPO PREMIER NON-PARTICIPATING
Deductible (Single / Family) $15 / $45 $25 / $75 $25 / $75
Co-Insurance 10% 20% 20%
Annual Maximum $1,000 $1,000 $1,000

Root Canals (Endodontic Services)

  • Apicoectomy
  • Direct Pulp Cap
  • Pulpotomy
  • Retrograde Fillings
  • Root Canal Therapy
  PPO PREMIER NON-PARTICIPATING
Deductible (Single / Family) $15 / $45 $25 / $75 $25 / $75
Co-Insurance 20% 20% 20%
Annual Maximum $1,000 $1,000 $1,000

Gum and Bone Diseases (Periodontal Services)

  • Conservative Procedures
  • Complex Procedures
  PPO PREMIER NON-PARTICIPATING
Deductible (Single / Family) $15 / $45 $25 / $75 $25 / $75
Co-Insurance 20% 20% 20%
Annual Maximum $1,000 $1,000 $1,000

High Cost Restorations (Cast Restorations)

  • Crowns
  • Inlays
  • Onlays
  • Posts and Cores
  PPO PREMIER NON-PARTICIPATING
Deductible (Single / Family) $15 / $45 $25 / $75 $25 / $75
Co-Insurance 50% 50% 50%
Annual Maximum $1,000 $1,000 $1,000

Dentures and Bridges (Prosthetics)

  • Bridges
  • Dentures
  • Denture Relining
  • Implants
  PPO PREMIER NON-PARTICIPATING
Deductible (Single / Family) $15 / $45 $25 / $75 $25 / $75
Co-Insurance 50% 50% 50%
Annual Maximum $1,000 $1,000 $1,000

The benefit period is the same as a calendar year.  It begins the day your coverage goes into effect and starts over each January 1. This is true for as long as you have coverage.

Contact Information

University Benefits Student Insurance

Fax
319-335-2776
Campus Address
120 USB
Mailing Address

120 University Services Building
Iowa City, IA 52242-1911
United States

Hours
Monday-Friday, 8 a.m.-5 p.m.