A REGISTERED MARK OF DELTA DENTAL PLANS ASSOCIATION

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¥ Please refer to your plan booklet for benefits, limitations and exclusions, any waiting periods and other coverage details.† In Texas, Delta Dental Insurance Company offers a Dental Provider Organization (DPO) plan.ß Except in Texas; please refer to your plan booklet for details.

Delta Dental PPO† DeltaCare USAPlan features¥

Coinsurance/ copayments

Covered services are paid based on a percentage — if, for example, fillings are covered at 80%, you pay the remaining 20%

Covered services provided by your DeltaCare USA dentist have predetermined dollar copayments, making your costs predictable

Coverage Wide range of covered services

No exclusions for most pre-existing conditions

Diagnostic and preventive services have little or no coinsurance

Covers nearly 300 procedures

No exclusions for pre-existing conditions or missing teeth

No or low copayments for most diagnostic and preventive services

Dentist network Freedom to choose any licensed dentist

No referral required for specialty care

You select a primary care dentist from the list of DeltaCare USA dental facilities, and you must visit this dentist in order to receive benefits.

This dentist will refer you to a specialist when necessary.

Changing your dentist Change your dentist at any time without contacting us. Change your selected or assigned dentist online or by telephone.

Transitions from previous plan

Coverage is provided only for treatment started and completed after your effective date.

Coverage is provided only for treatment started and completed after your effective date.ß

Orthodontic treatment- in-progress

Typically, we will pay the remaining amount of the total case fee not paid by your prior dental plan.

You are responsible for the copayments and fees subject to the provisions of your prior dental plan.

Authorization for specialty care treatment

Preauthorization is not required. Authorization may be required.

Your DeltaCare USA dentist will coordinate your referral.

Out-of-area coverage Visit any licensed dentist. Emergency care provision allows you to go out of network.

Deductibles and maximums

Annual deductibles and maximums apply to most plans.

No annual deductibles or maximums

Claims Delta Dental dentists file claim forms and receive payment directly from us.

You never have to pay more than the patient’s share of the bill when you visit a Delta Dental dentist.

No claim forms

You pay only the specified copayment for covered services at the time of your visit.

When ortho was covered under your prior group-sponsored plan and you are in active treatment on your new effective date

Your two plan optionsChoosing between the Delta Dental PPOSM and DeltaCare® USA dental plans

E EF3_PPO #75086 (rev. 11/13)

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deltadentalins.com/enrollees

This flyer can help you select a dental plan based on your specific needs. Both plans provide an excellent balance of value and coverage. They focus on preventive care to help you catch any dental problems early. Because oral and overall health are linked,§ we want to make sure your dental care needs are taken care of so you can achieve optimal health.

Whichever plan you choose, we look forward to providing you with quality dental care, a broad range of coverage and helpful customer service.

The choice is yours

Delta Dental PPOOur preferred provider plan, also referred to as PPO, allows you to visit any licensed dentist. Because PPO network dentists agree to accept contracted fees as full payment, your costs are usually lowest when you visit a PPO dentist. Our PPO plan provides access to one of the largest dentist networks nationwide.‡

DeltaCare USADeltaCare USA is a closed network plan that features set copayments, no annual deductibles and no maximums for covered benefits. You select a primary care dentist in the DeltaCare USA network from whom you receive treatment, as in a traditional dental HMO. If you need specialty care, this dentist will coordinate a referral. Family members may select different dentists for treatment within the covered service area.Ÿ

Why do 60 million enrollees trust their smiles to Delta Dental?*

• Moredentists• Simplerprocess• Lessout-of-pocket

WE KEEP YOU SMILING®

Delta Dental PPOSM is underwritten by Delta Dental InsuranceCompanyinAL,DC,FL,GA,LA,MS,MT,NVandUTandby not-for-profit dental service companies in these states: CA – Delta Dental of California, PA, MD – Delta Dental of Pennsylvania, NY – Delta Dental of New York, Inc., DE – Delta Dental of Delaware, Inc., WV – Delta Dental of West Virginia. In Texas, Delta Dental Insurance Company provides a Dental Provider Organization (DPO) plan.

DeltaCare® USA is underwritten in these states by these entities: AL—AlphaDentalofAlabama,Inc.; AZ — Alpha Dental of Arizona, Inc.; CA — Delta Dental of California; AR, CO, IA, ME, MI, NC, NE, NH, OK, OR, RI, SC, SD, VT, WA, WI, WY — Dentegra Insurance Company; AK, CT, DE, FL,GA,KS,LA,MS,MT,TN,WVand the District of Columbia — Delta Dental Insurance Company; HI,ID,IL,IN,KY,MD,MO,NJ,OH,TX — Alpha Dental Programs, Inc.; NV — Alpha Dental of Nevada, Inc.; UT — Alpha Dental of Utah, Inc.; NM — Alpha Dental of New Mexico, Inc.; NY — Delta Dental of New York; PA — Delta Dental of Pennsylvania; VA – Delta Dental of Virginia. Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these states. These companies are financially responsible for their own products.

* Delta Dental of California, Delta Dental of Pennsylvania and Delta Dental Insurance Company, together with our affiliate companies and Delta Dental of New York, are members, or affiliates of members, of the Delta Dental Plans Association, a network of 39 Delta Dental companies that together provide dental coverage to more than 60 million people in the U.S.

Product administration

Check out our new wellness resource

The SmileWay Wellness Challenge provides recommendations for how to participate in the program by taking advantage of the extensive resources available on our SmileWay Wellness site.

1. Review your habitsTake one or both of our interactive quizzes to see if you are at risk for cavities or gum (periodontal) disease. When you receive your quiz results, you can sign up to receive customized emails based on your risk level.

2. Get educatedRead any of the 100+ articles on dental health–related topics — everything from acid reflux to x-rays. We also have a variety of short videos on specific topics.

3. Stay informedReceive regular dental health tips and information from us by:

a. signing up for the Grin! newsletter (emailed quarterly)

b. connecting with us on Facebook

c. following us on Twitter

All of this is accessible from our SmileWay Wellness site at mysmileway.com. Bookmark the page so you can refer to it frequently.

§ U.S. Department of Health and Human Services. “Oral Health in America: A Report of the Surgeon General,” 2000.

‡ NetMinder Dental Network Trend Report, March 2013Ÿ In some states, DeltaCare USA is offered as an open access plan where you can obtain treatment

from any licensed dentist; however, deductibles and maximums may be applied for services provided by an out-of-network dentist.

Copyright © 2013 Delta Dental. All rights reserved.