C2MB

Plan Name	Dental
Description	All Employees
Carrier	Delta Dental of Minnesota
Policy Type	Dental PPO
Effective Dates	8/1/2021 to 8/1/2022
Benefit Attributes - All Employees	In-Network	Out-of-Network
Covered Services
Basic	90%	80%
Diagnostic and Preventive	100%	100%
Periodontic Treatment	90%	80%
Endodontic Treatment	90%	80%
Major	70%	50%
Orthodontia	Not Covered	Not Covered
Dependent Children	N/A	N/A
Adults (and Covered Full-Time Students, if Eligible)	N/A	N/A
Adult Lifetime Maximum	N/A	N/A
General Plan Information
Annual Deductible/Family	$75 (Applies to Basic & Major Services)	$75 (Applies to Basic & Major Services)
Annual Deductible/Individual	$25 (Applies to Basic & Major Services)	$25 (Applies to Basic & Major Services)
Annual Plan Maximum	$1,250	$1,250
Lifetime Orthodontia Plan Maximum	N/A	N/A