Copyright © 2018 Delta Dental. All rights reserved. HL_PPO #112725A (rev. 4/18)

1 In Texas, Delta Dental Insurance Company provides a dental provider organization (DPO) plan.

2 You can still visit any licensed dentist, but your out-of-pocket costs may be higher if you choose a non-PPO dentist. Network dentists are paid contracted fees.

3 You are responsible for any applicable deductibles, coinsurance, amounts over annual or lifetime maximums and charges for non-covered services. Out-of-network dentists may bill the difference between their usual fee and Delta Dental’s maximum contract allowance.

4 Applies only to procedures covered under your plan. If you began treatment prior to your effective date of coverage, you or your prior carrier is responsible for any costs. Group- and state-specific exceptions may apply. If you are currently undergoing active orthodontic treatment, you may be eligible to continue treatment under Delta Dental PPO. Review your Evidence of Coverage, Summary Plan Description or Group Dental Service Contract for specific details about your plan.

LEGAL NOTICES: Access federal and state legal notices related to your plan at deltadentalins.com/about/legal/index-enrollee.html.

Save with PPOVisit a dentist in the PPO1 network to maximize your savings.2 These dentists have agreed to reduced fees, and you won’t get charged more than your expected share of the bill.3 Find a PPO dentist at deltadentalins.com.

Set up an online accountGet information about your plan anytime, anywhere by signing up for an online account at deltadentalins.com. This free service, available once your coverage kicks in, lets you check benefits and eligibility information, find a network dentist and more.

Check in without an ID cardYou don’t need a Delta Dental ID card when you visit the dentist. Just provide your name, birth date and enrollee ID or social security number. If your family members are covered under your

plan, they will need your information. Prefer to take a paper or electronic ID card with you? Simply log in to your account, where you can view or print your card with the click of a button.

Coordinate dual coverage If you’re covered under two plans, ask your dental office to include information about both plans with your claim, and we’ll handle the rest.

Understand transition of careDid you start on a dental treatment plan before your PPO coverage kicked in? Generally, multi-stage procedures are only covered under your current plan if treatment began after your plan’s effective date of coverage.4 You can find this date by logging in to your online account.

Newly covered?Visit deltadentalins.com/welcome.

Save with a PPO dentist

PPO NON–PPO

Keep Smiling Delta Dental PPOTM

In this incentive plan, Delta Dental pays 70% of the PPO contract allowance for covered diagnostic, preventive and basic services and 70% of the PPO contract allowance for major services during the first year of eligibility. The coinsurance percentage will increase by 10% each year (to a maximum of 100%) for each enrollee if that person visits the dentist at least once during the year. If an enrollee does not use the plan during the calendar year, the percentage remains at the level attained the previous year. If an enrollee becomes ineligible for benefits and later regains eligibility, the percentage will drop back to 70%.

Eligibility Primary enrollee, spouse (includes domestic partner) and eligible dependent children to age 26

Deductibles None

Maximums

D & P counts toward maximum?

Delta Dental PPO dentists: $2,200 per person each calendar year Non-Delta Dental PPO dentists: $2,000 per person each calendar year Yes

Waiting Period(s) Basic Benefits None

Major Benefits None

Prosthodontics None

Orthodontics None

* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist’s actual fees.

** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for non-Delta Dental dentists.

Delta Dental of California 560 Mission St., Suite 1300 San Francisco, CA 94105

Customer Service 866-499-3001

Claims Address P.O. Box 997330 Sacramento, CA 95899-7330

deltadentalins.com This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative.

HLT_PPO_INCEN_DDC (Rev. 3/8/2019)

Plan Benefit Highlights for: School Insurance Group (Plan IB)

Group No: 07005

Benefits and Covered Services*

Delta Dental PPO dentists**

Non-Delta Dental PPO dentists**

Diagnostic & Preventive Services (D & P)

Exams, cleanings and x-rays 70 - 100 % 70 - 100 %

Basic Services Fillings, sealants and posterior composites

70 - 100 % 70 - 100 %

Endodontics (root canals) Covered Under Basic Services 70 - 100 % 70 - 100 %

Periodontics (gum treatment) Covered Under Basic Services 70 - 100 % 70 - 100 %

Oral Surgery Covered Under Basic Services 70 - 100 % 70 - 100 %

Major Services Crowns, inlays, onlays and cast restorations

70 - 100 % 70 - 100 %

Prosthodontics Bridges and dentures 50 % 50 %

Orthodontic Benefits Dependent children 50 % 50 %

Orthodontic Maximums $1,000 Lifetime $1,000 Lifetime

Dental Accident Benefits 100 %

(separate $1,000 maximum per person per calendar year)

Estimate Your CostsLooking to budget your dental costs? Try the Cost Estimator. This feature of Delta Dental’s Online Services gives you a personalized estimate of how much you’ll pay for your next dentist visit.

Whether you’re getting braces or need a cavity filled, you’ll choose from the top reasons for visiting the dentist, written in everyday language. The Cost Estimator organizes information logically, so you don’t need to be concerned whether the service involves multiple procedure codes or visits.

We keep you smiling® deltadentalins.com/enrollees

Advantages• Easy to use. Questions guide you

through the process, letting you add services to your visit, like getting x-rays or a cleaning alongside your dental exam.

• Based on real data. Your cost estimate is calculated from actual claims Delta Dental has processed, updated daily.

• Personalized. You’ll get a customized cost based on your actual benefits, taking into account any maximums and remaining deductible.

• Available on desktop and mobile. Get an estimate on your computer, tablet or phone.

Features• Change your dentist. Want to know

if you’d save by switching to another dentist? Test it out by comparing up to five dentists.

• Personalize your procedure. Specify which tooth is being treated, the type of filling you need or whether you’re going to a specialist. The price will be calculated accordingly.

• Keep track of your benefits. A handy sidebar shows the current status of any deductibles and annual and lifetime maximums.

Copyright © 2016 Delta Dental. All rights reserved. EF88A #102540 (rev. 11/16)

Our Delta Dental enterprise includes these companies in these states: Delta Dental of California — CA, Delta Dental of the District of Columbia — DC, Delta Dental of Pennsylvania — PA & MD, Delta Dental of West Virginia, Inc. — WV, Delta Dental of Delaware, Inc. — DE, Delta Dental of New York, Inc. — NY, Delta Dental Insurance Company — AL, DC, FL, GA, LA, MS, MT, NV, TX and UT.

Delta Dental PPOSM is underwritten by Delta Dental Insurance Company in AL, DC, FL, GA, LA, MS, MT, NV and UT and by 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, Inc. In Texas, Delta Dental Insurance Company provides a Dental Provider Organization (DPO) plan.

Try it outReady to get an estimate?

1. Log in to your account at deltadentalins.com. (If you don’t have one yet, click on Register.)

2. Click on the Cost Estimator link by your name.

How to navigateStart by selecting the service you need. As you explore, you can answer additional questions (like “Which tooth?” or “Are you a new patient?”) to further customize your results. If you’ve been using your dental benefits, your current dentist will show up by default, but if you want to see other options, just click on Select dentists to compare. Whenever you’re ready, click See cost.

Click on I need to go back to the full list of procedures.

The benefits sidebar will show the current status of your maximums and deductibles, if applicable.

Clicking on Explain cost details will expand the breakdown of how your estimate was calculated.

To change the dentists shown, click on Change compared dentists. Select your options, then click on Show cost.

This section summarizes the type of visit or procedure selected.

Looking for a procedure not listed? Scroll to the bottom of the page for a link to a longer list.

Why go paperless?

• It’s convenient. Get your claim statements, pre-treatment estimates and other important plan documents online. You’ll get an email alert every time a new document is available.

• It saves paper. You’ll reduce your ecological footprint.

• It’s faster. No need to wait for “snail mail.”

• It’s easy. Updating your settings takes only a few moments.

How do I change my settings?

Visit deltadentalins.com. Log in to your account. (If you don’t already have one, click Register Today to sign up.)

1. Click on the My Profile tab.

2. Go to the Go Paperless section

3. Select Online and click Save.

We keep you smiling® deltadentalins.com/enrollees

Go PaperlessView your documents online

1

2

3

Delta Dental PPOTM

Delta Dental Premier®

Turn the page to learn how to download and read your electronic claims statements.

Where can I find my claims?

To view your claim statements as PDFs, simply log in to your online account.

1. Go to deltadentalins.com. Log in.

2. Click on Documents tab at the top.

3. Choose the claim you want to view. A new window will pop up with the PDF, which you can save to your desktop for reference. (If the window does not pop up, make sure your browser has not disabled pop-ups.)

What’s in my claim statement?

Note: You can also see claim information listed under the Claims tab, although this feature does not allow you to download the full statement in PDF form.

A. Submitted fee: The amount charged by the dental office.

B. Accepted fee: The total owed to the dentist, including your share and the amount paid by insurance.

C. Maximum contract allowance: The total on which Delta Dental bases its payment portion.

Note: If you go to an out-of-network dentist, this amount may be lower than the accepted fee.

D. Amount applied to deductible: How much of your deductible you have fulfilled with the given procedure(s).

Note: Not all plans include a deductible (a fixed dollar amount you are required to pay before your coverage applies).

E. Paid by another plan: The amount covered by your primary plan, if you have dual coverage.

Note: This column only applies if Delta Dental is your secondary plan (such as coverage through your spouse or second job).

F. Contract benefit level: The percent of the maximum contract allowance that’s paid by your dental plan.

G. Delta Dental pays: The amount your dentist is paid through your current dental plan.

H. Patient pays: How much you owe the dentist: This is what’s left over from the accepted fee after your insurance covers its portion(s).

A B C D E F G H

Copyright © 2018 Delta Dental. All rights reserved EF44 #112725N (rev. 5/18)

Delta Dental PPO and Delta Dental Premier are underwritten by Delta Dental Insurance Company in AL, DC, FL, GA, LA, MS, MT, NV, TX and UT and by 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, Inc. In Texas, Delta Dental Insurance Company provides a dental provider organization (DPO) plan.

Makingthe Switch

1 NetMinder Dental Network Trend Report, September 2017. Based on total unique dentists nationwide.

We keep you smiling® deltadentalins.com/enrollees

What are the advantages of the PPO plan?

• Save on out-of-pocket costs. PPO dentists have agreed to reduced fees that are often lower than Premier fees. This helps you cover more services under your annual maximum. As with your Premier plan, you won’t get charged more than your expected share of the bill when you visit a PPO dentist.

• Maintain access to the same large network. You can still visit any dentist in the Premier network, which is the largest dentist network nationwide.1 That means you don’t have to change your dentist if you don’t want to.

• No claims. Just like under your previous plan, you won’t have to submit any claim paperwork when you visit a Delta Dental dentist.

Moving from Delta Dental Premier® to Delta Dental PPOSM

Save with aPPO dentist

PPO PREMIER NON–DELTA DENTAL

Can I still visit a Premier dentist?

Yes. Check your plan details to see if Premier dentists are considered in-network or out-of-network under your plan. This can affect what percent of the fee will be covered. Even if Premier is considered out-of-network under your plan, you’ll usually save more by visiting a Premier dentist than choosing a non–Delta Dental dentist.

What’s the difference between a Premier dentist and a PPO dentist?

PPO dentists are part of a smaller network and typically charge lower fees than dentists in the Premier network.

Can I ask my dentist join the PPO network?

Visit deltadentalins.com/recommend to recommend your dentist for the PPO network. Although the final decision is still up to your dentist, your encouragement may be just what he or she needs to make the leap. You can also ask about PPO network participation at your next appointment.

How can I tell if my dentist is Premier or PPO?

Your dentist might already be a PPO dentist. To find out, enter your dentist’s name in the Find a Dentist search at deltadentalins.com. You can also call your dental office to confirm. Ask whether your dentist is a “contracted Delta Dental PPO dentist.”

Delta Dental Premier® and Delta Dental PPOSM are underwritten by Delta Dental Insurance Company in AL, DC, FL, GA, LA, MS, MT, NV, TX and UT and by 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, Inc. In Texas, Delta Dental Insurance Company provides a Dental Provider Organization (DPO) plan.

Copyright © 2017 Delta Dental. All rights reserved. EF16 #110273A (rev. 11/17)

Get a pre-treatment estimate

Plan for a Healthy Smile

You might benefit from a pre-treatment estimate if you are:

• Planning dental work that will likely exceed $300, like a crown, wisdom tooth extraction, bridge, dentures or periodontal surgery

• Wondering if a procedure is covered by your plan

• Worried a procedure might exceed your annual plan maximum

• On a budget and need to plan your payment in advance

The pre-treatment estimate includes:

• An overview of services covered by your dental plan, as well as those that are limited or excluded

• How coinsurance, deductibles and dollar maximum limits might affect your share of the cost

Even if you’re savvy about your dental benefits, you might like a bit of help clarifying the cost of a treatment. That’s why Delta Dental offers free pre-treatment estimates. This is an easy way to help you predict your out-of-pocket cost for a specific procedure.1

1 Pre-treatment estimates are available to Delta Dental PPOSM and Delta Dental Premier® enrollees.

We keep you smiling® deltadentalins.com/enrollees

Delta Dental PPOSM and Delta Dental Premier® are underwritten by Delta Dental Insurance Company in AL, DC, FL, GA, LA, MS, MT, NV, TX and UT and by 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, Inc. In Texas, Delta Dental PPO is underwritten as a Dental Provider Organization (DPO) plan.

2 A pre-treatment estimate is not a guarantee of Delta Dental’s final payment. When the treatment is complete and a claim is received for payment, Delta Dental will calculate its payment based on your current eligibility, amount remaining in your annual maximum and any deductible requirements or dual coverage. Please review your Evidence of Coverage, Summary Plan Description or Group Dental Service Contract for specific details about your plan.

3 Generally, pre-treatment estimates process in two to three weeks. However, dentists using our online Provider Tools can have some pre-treatment estimates completed while you are in the office.

The pre-treatment estimate process

Step by step

Have more questions about your plan? Visit “Your Dental Plan Support Guide” online at deltadentalins.com/enrollees.

You request a pre-treatment estimate from your dentist.

Your dentist sends us a proposed treatment plan and x-rays, if necessary.

We review the treatment plan against your benefits to determine covered services and estimated costs.

We send you and your dentist a copy of your pre-treatment estimate.2 The amount of time it takes to receive your pre-treatment estimate varies, depending on your dentist and treatment plan.3

You and your dentist discuss any questions you may have about the treatment and determine whether to proceed with the treatment plan.

1 2 3 4 5

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Copyright © 2017 Delta Dental. All rights reserved. EF19 #104477B (rev. 3/17)

Stay Connected

Create an account1. Go to deltadentalins.com.

2. Click on Register Today in the Online Services section.

With an online account, you can:

• Check your plan details and eligibility

• Review claim statements and plan documents

• View or print your ID card

Find a dentist1. Go to deltadentalins.com.

2. In the Find a Dentist section, enter your address and select your network from the drop-down menu.

3. Click Search.

Browse Yelp reviews, check offi ce hours and see the address on a map.

At deltadentalins.com, all the information you need is at your fi ngertips. You can check your plan details, fi nd an in-network dentist and more.

For more online resources, turn the page.

We keep you smiling® deltadentalins.com/enrollees

Download the app1. Open the App Store or Google Play.

2. Search for “Delta Dental.”

3. Download the free app titled Delta Dental by Delta Dental Plans Association.

Review your plan details, pull up your ID card and try out the musical toothbrush timer.

Get answersGot a question? We’ve got answers.

Learn how your dental plan works:Visit deltadentalins.com/enrollees for the 101 on dental benefits.

Improve your dental health:Check out mysmileway.com for the latest recipes, articles and videos.

Contact Customer Service:Submit an online question at deltadentalins.com/contact.

Our Delta Dental enterprise includes these companies in these states: Delta Dental of California — CA, Delta Dental of the District of Columbia — DC, Delta Dental of Pennsylvania — PA & MD, Delta Dental of West Virginia, Inc. — WV, Delta Dental of Delaware, Inc. — DE, Delta Dental of New York, Inc. — NY, Delta Dental Insurance Company — AL, DC, FL, GA, LA, MS, MT, NV, TX and UT. These enterprise companies 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 78 million people in the U.S. The website deltadentalins.com is the home of the Delta Dental companies listed above. For other Delta Dental companies, visit the Delta Dental Plans Association website at deltadental.com.

Copyright © 2018 Delta Dental. All rights reserved. EF30 #112725U (rev. 09/18)

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