Minnesota Statutes Insurance (Ch. 59A-79a) § 62Q.77. Terms of coverage disclosure

(1) the dental care services and other benefits to which the enrollee is entitled under the dental plan;

(2) any exclusions or limitation on the services, kind of services, benefits, or kind of benefits to be provided, including any deductible or co-payment features and any requirements for referrals to specialists;

(3) a description as to how services, including emergency dental care and out-of-area service, may be obtained;

(4) a general description of payment and co-payment amounts, if any, for dental care services, which the enrollee is obligated to pay; and

(5) a telephone number by which the enrollee may obtain additional information regarding coverage.