Voluntary Dental Plan for Students – Benefit Highlights, 21-22 Plan Year
These highlights are a brief description of the new Delta Dental Student Plan.
Plan Maximum: $1,200/patient/contract year
Annual Deductible: $50 per person not to exceed $150 per family
Delta Dental will pay for a portion of eligible expenses. You pay the amount per the Plan’s Table of Copayments when treated by in-network dentists, Delta Dental pays the remainder of the discounted fees. The Plan’s national networks are:
- the Delta Dental PPO and
- the Delta Dental Premier network.
The 21-22 benefits are the same as the 20-21 benefits, Exclusions and Limitations apply, refer to Schedule B in the Evidence of Coverage.
Out of Network:
Eligible dental expenses and services are listed below with the corresponding out of network co-insurance that Delta Dental will pay. Exclusions and Limitation apply, refer to Schedule B in the Evidence of Coverage.
- Diagnostic and Preventive, 60%
- Sealants, 40%
- Space Maintainers, 60%
- Basic Restorative, 40%
- Oral Surgery, 40%
- Simple Extractions, 40%
- Endodontics, 40%
- Surgical Periodontics, 40%
- Non-Surgical Periodontics, 40%
- Major Restorative, 25%
- Prosthodontics-Fixed & removable, 25%
- Denture Repair and Relining, 40%
- Implants, 25%