Student Dental Insurance Plan


Benefits Summary

Below is a summary of your benefit coverage for services received within the Delta Dental network. To maximize your dental benefits, we encourage you to visit a participating dentist. Your out-of-pocket costs will be higher when you visit a non-participating dentist. Please refer to your Certificate of Coverage for further details.


Individual Deductible: $50.00
Family Deductible: $150.00

Maximums

Below is a summary of all maximums associated with your group and policy.

Annual Maximum $1,750.00
Maximum Lifetime Cap Unlimited

Indicates Prior Authorization Required
Indicates Pre-Treatment Estimate is Recommended
Indicates Deductible Applies

  Procedure
Covered
At
Waiting Period Frequency/Limitations *
DIAGNOSTIC
  Oral exam 100% None Twice per policy year
  Bitewing x-rays 100% None One set per policy year
  Complete x-ray series or panoramic film 100% None Once every 60 months. A panoramic film is a benefit for individuals ages 6 and older.
  Single x-rays 100% None As required
PREVENTIVE
  Cleaning 100% None Three per calendar year, more frequent cleanings may be allowed for pregnant women or patients with diabetes or compromised immune systems. Documentation is required.
  Fluoride treatment 100% None For children under age 19 twice per policy year
  Sealants 100% None For children under age 16, once every 24 months on unrestored permanent molars
  Space maintainers 100% None Once per lifetime for lost deciduous (baby) teeth
RESTORATIVE
  Amalgam (silver) fillings and composite (white) fillings 80% Deductible Applies None
Crowns over natural teeth, build ups, posts and cores 50% Deductible Applies None Replacement limited to once every 60 months
  Recementing crowns or bridges 80% Deductible Applies None Once every 60 months
ENDODONTICS
  Root canal therapy on permanent teeth 80% Deductible Applies None One procedure per tooth per lifetime.
PERIODONTICS
Root planing and scaling 50% Deductible Applies None Once per quadrant every 24 months
Osseous (bone) surgery 50% Deductible Applies None Once per quadrant every 36 months
Gingivectomies 50% Deductible Applies None Once per site every 36 months
Soft tissue grafts 50% Deductible Applies None Once per site every 60 months
Crown lengthening 50% Deductible Applies None Once per site every 60 months
Guided tissue regeneration and bone replacement graft 50% Deductible Applies None Once per site every 24 months
  Periodontal maintenance following active therapy 100% None Two per year
PROSTHODONTICS
Bridges and crowns over implants 50% Deductible Applies None Replacement limited to once every 60 months
Partial and complete dentures 50% Deductible Applies None Replacement limited to once every 60 months
  Repairs to existing partial or complete dentures 80% Deductible Applies None Once per policy year
  Rebasing or relining of partial or complete dentures 80% Deductible Applies None Once every 60 months
IMPLANT SERVICES
Surgical placement of endosteal implant and abutment 50% Deductible Applies None Once per tooth site per lifetime
EXTRACTIONS AND ORAL SURGERY
  Extractions and other routine oral surgery when not covered by a patient's medical plan 80% Deductible Applies None
OTHER SERVICES
  Palliative treatment (minor procedures necessary to relieve acute pain) 80% Deductible Applies None Twice per policy year
  General anesthesia or intravenous (I.V.) sedation for certain complex surgical procedures 80% Deductible Applies None
  Occlusal guards 50% Deductible Applies None

Dependent children are covered under these benefits up until the end of the month that they turn 26.
To review the list of exclusions and limitations  Click Here
This is a summary of benefits. The information shown here is not a guarantee of payment. Refer to the Certificate of Coverage for the full plan terms. The Certificate includes any limitations or exclusions not seen here. To be covered, services must be dentally necessary and appropriate as per our review guidelines.

* Time limits on services (e.g. 6, 12, 24, 36, or 60 months) are figured to the exact day. Services are then covered the following day. For example, when a service is covered once every 12 months, if the service was done on July 1, it will not be covered again until the following year on July 2 or after.