Delta Dental PPO and Delta Dental Premier Networks

Group #0088 - Option 4


A Snapshot of Your Coverage*  

Service & Description

Delta Dental


Diagnostic & Preventive Services

Exams and cleanings, x-rays, fluoride treatment, space maintainers
 100%  100% of maximum 
 allowable fee**

Basic Services

Emergency treatment for relief of pain, sealants, amalgam restorations (silver fillings) and composite resin restorations (white fillings) on anterior (front) teeth

 80%   80% of maximum 
 allowable fee**


Pulpotomies on primary teeth for dependent children, root canal therapy on permanent teeth
 80%   80% of maximum 
 allowable fee**


Surgical/Nonsurgical periodontics

80% 80% of maximum 

 allowable fee**

Oral Surgery

Surgical/Nonsurgical extractions, all other oral surgery
 80%   80% of maximum 
 allowable fee**

Major Restorative

Crowns and composite resin restorations (white fillings) on posterior (back) teeth
 80%   80% of maximum 
 allowable fee**

Prosthetic Repairs and Adjustments

Denture adjustments and repairs, bridge repair  
 50%  50% of maximum 
 allowable fee**


Dentures (full and partial), bridges
 50% of maximum 
 allowable fee**


Per person/per family per coverage year (from 1/1 through 12/31)
Deductibles do not apply to Diagnostic and Preventive Services
 None None

Coverage Year Plan Maximum

Per person per coverage year (from 1/1 through 12/31)
 $1500  $1500
Eligible Dependents  Spouse and dependent
 children up to age 26.
*    This is a summary of benefits only and does not guarantee coverage. For a complete list of covered services
      and limitations/exclusions, please refer to the Dental Benefit Plan Summary.

**   Dentists who have signed a participating network agreement with Delta Dental have agreed to accept
      the maximum allowable fee as payment in full. Non-participating dentists have not signed an agreement
      and are not obligated to limit the amount they charge; the member is responsible for paying any difference
      to the non-participating dentists.

Welcome to Delta Dental  

Welcome to Delta Dental of Minnesota. We’ve designed your dental plan so it is easy to use and gives you and your family maximum flexibility, network savings, an unparalleled commitment to service and peace of mind. Together with your employer, our goal is to help you maintain healthy, happy smiles all year round.

Prevention is the key to good long-term oral health

Our plans are designed to encourage you to visit the dentist and help ensure your basic dental needs are met in a timely, cost effective manner.

Access to regular checkups and sound preventive care are key to long-term oral health. Furthermore, new research suggests that good oral health can positively impact the burden of illness caused by cardiovascular disease and diabetes.

In addition to visiting your dentist for regular preventive care, talk to your dentist about your specific oral health needs. Your dental plan is intended only to help you pay for care - your dentist is the one who will help you determine your actual care needs.

Helpful Online Tools

As part of our commitment to your long term oral health, we provide members free access to valuable oral health information and dental benefit tools through our Website: