GoodHealthStartshere.org | DeltaDentalMO.com Odessa School District 2015 Open Enrollment

2 Broad Network Protection with Delta Dental Selecting a Dentist Delta Dental PPO & Delta Dental Premier Dentists - Delta Dental Contracted Providers - Discounted Fees In-Network** - No Balance Billing - No Claim Forms - Delta Pays Dentist Directly Non-Participating Dentists - Not Under Contract With Delta Dental - No Discounted Fees - Balance Billing is Possible - Dentists May Not File Claims - Delta Dental Pays Patient **Delta Dental PPO providers typically offer the greatest discounts. **Plan coverage is higher when you use a Delta Dental PPO provider.

3 Delta Dental PPO ← Greatest Patient Savings Least Patient Savings → Delta Dental PPO Network Dentist Delta Dental Premier Network Dentist Non-Participating Dentist Co-Insurance (Plan Pays) Type A: Diagnostic and Preventive Services (exams, cleanings, x-rays, fluoride, sealants) 100%80% Type B: Basic Restorative Services (fillings, extractions, periodontal maintenance) 80% Type C: Major Restorative Services (periodontics, endodontics, crowns, dentures, bridges) 50% Type D: Child Orthodontic Services (to age 19) 50% Calendar Year Deductible$50 per person / $150 family limit Applies to:B & C Services Calendar Year Benefit Maximum$1,000 per person Separate Lifetime Orthodontic Maximum$1,000 per eligible dependent child Dependent Age LimitEnd of the calendar year in which your dependent turns 26 Benefit Overview – BASE PLAN This is intended to be a summary. For more detailed information regarding covered services, limitations and exclusions consult your Summary Plan Description.

4 Delta Dental PPO ← Greatest Patient Savings Least Patient Savings → Delta Dental PPO Network Dentist Delta Dental Premier Network Dentist Non-Participating Dentist Co-Insurance (Plan Pays) Type A: Diagnostic and Preventive Services (exams, cleanings, x-rays, fluoride, sealants) 100% Type B: Basic Restorative Services (fillings, extractions, periodontal maintenance) 90%80% Type C: Major Restorative Services (periodontics, endodontics, crowns, dentures, bridges) 60%50% Type D: Child Orthodontic Services (to age 19) 50% Calendar Year Deductible$50 per person / $150 family limit Applies to:B & C Services Calendar Year Benefit Maximum$1,500 per person Separate Lifetime Orthodontic Maximum$1,000 per eligible dependent child Dependent Age LimitEnd of the calendar year in which your dependent turns 26 Benefit Overview – BUY UP PLAN This is intended to be a summary. For more detailed information regarding covered services, limitations and exclusions consult your Summary Plan Description.

5 Questions? Customer Service and Benefit Information Call: Live reps from 7am to 5pm Monday through Friday Benefit24 VRU (Virtual Response Unit) -Faxback – summary of benefits Go online: Self-serve Subscriber features: Online access 24/7 Search for a Network Provider Track Use of Annual Maximum Print/Request ID Cards Claim Status and History Copies of EOBs