Welcome to Your Texas A&M System Dental Benefits Program

Texas A&M Dental PPO

Texas A&M Dental PPO Plan Highlights Freedom of choice – patient can visit any dentist Reduced fee-for-service: Maximize savings by utilizing PPO dentists Nationwide coverage – visit any licensed dentist anywhere in the world Visiting a Delta Dental PPOSM dentist usually saves patients almost 30% on average out-of-pocket costs The A & M Dental PPO is a reduced fee-for service plan. This plan covers services received from a licensed dentist anywhere in the world. Although you may visit any dentist, you will usually pay the least out-of-pocket when you visit a Delta Dental PPO dentist.

Non-Delta Dental Dentist Texas A & M Dental PPO Plan Highlights Benefits And Covered Services Delta Dental PPO Dentist Premier Dentist Non-Delta Dental Dentist WHO’S ELIGIBLE Primary enrollee, spouse and eligible dependent children DEDUCTIBLES $ 75 per person, $225 per family, per plan year DEDUCTIBLE WAIVED FOR DIAGNOSTIC & PREVENTIVE? Yes ANNUAL MAXIMUM The maximum benefit paid per plan year is $1,500 per person DIAGNOSTIC & PREVENTIVE BENEFITS -- Oral examinations, cleanings, x-rays, fluoride treatment, space maintainers, sealants 100%* (3 times per plan year) (3 times per plan year) BASIC BENEFITS --Fillings, denture repairs, Endodontics (root canals), Periodontics (gum treatment) , Oral Surgery 80%* MAJOR BENEFITS -- Crowns, jackets and cast restorations and prosthodontics (bridges, partial dentures, full dentures), implants 50%* 50% * ORTHODONTICS (adult and child) ORTHODONTIC MAXIMUMS $1,500 Lifetime COVERED PROCEDURES REIMBURSED BASED ON Contract allowance Contract allowance Delta Dental’s Allowed mount The PPO program, available to you, your spouse and your dependents, has a deductible of $75 per person and $225 per family each calendar year. You must satisfy you portion of the deductible each year before Delta Dental’s portion of the coinsurance will be paid. However, diagnostic and preventive benefits such as regular exams and cleanings are not subject to the deductible, and are paid at 100%. Basic benefits such as fillings and periodontic treatment are covered at 80%. Major benefits are covered at 50%, and your plan also covers orthodontics both for children AND adults at 50%, up to a lifetime maximum of $1500 per person. *of Delta Dental’s allowed amount Benefits illustrated above are not intended for use as a comprehensive description of the Plan. Please consult your benefit booklet for complete details, including limitations and exclusions.

Texas A&M PPO Customer Service Helpful, Accessible, Dependable Call Delta Dental at (800) 521-2651, seven days a week Choose from automated voice recordings, automated fax back or live operators to obtain information from 6:15 a.m. – 6:30 p.m. (central time). Visit us on our website at deltadentalins.com/tamus to: Find a dentist & map directions Check eligibility & benefits View claims information Recommend your dentist Print an ID card and claim form Read dental health tips and articles Visit SmileKids, a fun way for children to learn about oral health Delta Dental PPO also provides you with a myriad of ways to make your dental benefits plan hassle-free by providing toll-free numbers, internet tools and personal assistance.

DeltaCare® USA DHMO

DeltaCare® USA Dental HMO Plan Highlights Patient pays pre-specified copayment for each covered procedure. Patient selects, or is assigned, a dentist at enrollment. Specialty care provided by specialists requires preauthorization. Specialty care usually processed as a claim. If you do not wish to visit a PPO dentist, visiting a Premier dentist is your next best option, because you can still enjoy cost protections and balance billing protection with a Premier dentist. Delta dentists also agree to file all claim forms for you, and to accept payment directly from Delta Dental. With a Delta dentist, you will never have to pay the entire cost of service up front, then file the claim and wait for reimbursement. You will only be responsible for your percentage of the coinsurance, as well as any deductibles and amounts in excess of maximums.

DeltaCare® USA Dental HMO Plan Highlights Enrollees must use their designated dental provider in order to receive benefits. No deductibles or annual maximums. No (or very low) copayments for diagnostic and preventive services. Fixed copayments for basic and major services. If you do not wish to visit a PPO dentist, visiting a Premier dentist is your next best option, because you can still enjoy cost protections and balance billing protection with a Premier dentist. Delta dentists also agree to file all claim forms for you, and to accept payment directly from Delta Dental. With a Delta dentist, you will never have to pay the entire cost of service up front, then file the claim and wait for reimbursement. You will only be responsible for your percentage of the coinsurance, as well as any deductibles and amounts in excess of maximums.

DeltaCare ® USA Dental HMO Plan Highlights DeltaCare® USA Plan 15B WHO’S ELIGIBLE Primary enrollee, spouse and eligible dependent children DEDUCTIBLES None MAXIMUMS DIAGNOSTIC & PREVENTIVE BENEFITS* Comprehensive oral exam: $0 Cleaning (once each six months): $5 Panoramic X-rays (once every three years): $0 BASIC BENEFITS* Amalgam fillings – one surface: $8 Resin-based composite filling; two surfaces, posterior; permanent: $75 Anterior root canal, excluding final restoration: $125 Periodontic scaling and root planing; per quadrant, limited to 4 quadrants per 12 consecutive months: $60 MAJOR BENEFITS* Crown; porcelain/ceramic substrate: $395 Complete denture; maxillary: $365 ORTHODONTICS* Orthodontic treatment plan and records: $200 Comprehensive treatment; permanent teeth (children up to age 19; higher copayment for adults): $1,900 ORTHODONTIC TAKEOVER PROVISION Available in Texas, California, District of Columbia, Florida, Georgia, Maryland, Nevada, New York, Pennsylvania, Utah and West Virginia to covered enrollees where banding has already occurred * Copayments specified above are representative samples only, and are not intended to apply to each procedure. For a full copayment schedule, including plan limitations and exclusions, please refer to your plan booklet. One of the advantages of Delta Dental is the added protection that our Premier dentists provide. PPO enrollees who choose not to visit a PPO dentist still retain some meaningful cost protections when visiting a Delta Dental Premier dentist. This chart provides an illustration of your out-of-pocket costs depending on the dentist you visit.

Continuous Orthodontic Coverage from DeltaCare® USA DeltaCare® USA provides continuous orthodontic coverage provisions that allow enrollees to enjoy the same coverage and convenience as their previous program Provision available to initial enrollees where banding has already occurred To sign up for this feature, go to the Texas A&M System HR website at http://tamus.edu/benefits/programs to obtain the form & follow instructions on how to submit the application One of the great things about enrolling in DeltaCare USA is our orthodontic treatment-in-progress provision. This benefit allows you to continue orthodontic treatment you started under your previous plan. If you were covered by a dental plan with your current orthodontist, and banding has already been completed, you may continue to visit the same orthodontist and enjoy the same coverage and copayments that you had under your previous program. However, to be eligible for this coverage, you must remain enrolled in the DeltaCare USA plan until your orthodontic treatment is completed. You can obtain more details on this feature by visiting the System HR website.

DeltaCare® USA Customer Service The Experts You Can Turn To Toll-free number - (800) 422-4234 is available seven days a week Choose from automated voice recordings, automated fax back or live operators to obtain information from 7:00 a.m. – 8:00 p.m. (central time). Visit our website at deltadentalins.com/tamus to: Find a dentist & map directions Check eligibility & benefits View claims information Recommend your dentist Print an ID card Read dental health tips and articles Visit SmileKids, a fun way for children to learn about oral health DeltaCare USA provides you many ways to obtain information. These include automated voice lines, fax-back capabilities, internet tools, and of course, our friendly and helpful service representatives. You can use these tools to find a dentist, request a change in your assigned dentist, obtain an ID card, view eligibility and benefits for you and your dependents or obtain dental health information. (Don’t forget you can also check the Texas A&M System Benefits website at tamus.edu/offices/benefits/programs/#dental to find an additional list of dentists that are exclusive to the Texas A&M System Dental HMO plan)

We’ve got a plan that will keep you smiling. Thank you for taking the time to learn more about Delta Dental and your dental benefits program. We hope that this information is helpful to you, and that you’ll find the plan that keeps you and your family smiling. The Texas A & M System PPO plan is administered by Delta Dental Insurance Company. DeltaCare USA is underwritten by Delta Dental affiliate Alpha Dental Programs, Inc. and administered by Delta Dental Insurance Company.