Your Benefits - Three Options

Basic Basic Plus Flex

Who provides services?

Delta Dental PPO Dentists

Delta Dental PPO Dentists

Delta Dental PPO Dentists or any other dentist you choose

What services are covered?

Preventive and basic care including cleanings, x-rays, fluoride treatments, sealants, fillings and extractions.

All of the benefits provided under the Basic Option plus major services including bridges, dentures, crowns, periodontics, endodontics and orthodontics for children (up to age 19 only).

All of the benefits provided under the Basic Plus option plus the availability to use ANY dentist.The Flex Option also includes a higher level of benefits on many services and adult orthodontic benefits.

Delta Networks

800 Local PPO dental offices

1700 Local Premier dental offices

Basic and Basic Plus members use the PPO network exclusively while Flex Option members can choose

Premier and non-participating dentists as well.

Delta Dental PPO Network• No balance billing• Dentist submits claim paperwork• Minimal out of pocket expenses• Over 600 general dentists to

choose from in the St. Louis area

Your Benefits – Basic & Basic Plus OptionsNetwork Delta Dental

PPOBasic Option

Delta Dental PPOBasic Plus Option

Calendar Year Deductible (does not apply to preventive care)

$25 per person$75 per family

$25 per person$75 per family

Preventive Care including routine exams, cleanings, fluoride treatment, space maintainers and emergency treatment for pain.

100% 100%

Basic Services including x-rays (bite-wings, full mouth and periapical), fillings (amalgam, synthetic porcelain and plastic), simple extractions and sealants. 70% 70%

Major Services such as bridges, dentures, crowns, oral surgery, periodontics & endodontics

Not covered 35%

Orthodontics for Children (under age 19) Not covered 50%$1000 lifetime

maximum

Annual Maximum $750 $1000

Your Benefits – Flex OptionNetwork Delta Dental PPO Out of PPO

network dentists (including Delta Premier dentists)

Calendar Year Deductible (does not apply to preventive care)

$50 per person$150 per family

$50 per person$150 per family

Preventive Care including routine exams, x-rays, cleanings, fluoride treatment, space maintainers and emergency treatment for pain.

100% 100%

Basic Services including , fillings, sealants, simple and surgical extractions, oral surgery, periodontics and endodontics. 90% 80%

Major Services such as bridges, dentures, and crowns.

60% 50%

Orthodontics for Adults and Children 50%; $1000 lifetime maximum

50%; $1000 lifetime maximum

Annual Maximum $1000 $1000

• Claims finalized in 3.3 days (average)

• 99.9% accuracy

Outstanding Speed and Accuracy

Procedure code 2150 – two surface amalgam filling

Submitted DPO scheduled Delta Dental pays Patient paysamount amount (70% of $65) (30% of $65)

$136.00 $65.00 $45.50 $19.50

Example: a Delta Dental PPO dentist installs a two surface amalgam filling on a patient. Patient has 70% coverage for basic services.

Delta Dental PPO Network – Basic Options

This calculation is for illustration purposes only, it does not reflect actual fees.

Procedure code 2150 – two surface amalgam filling

Submitted DPO scheduled Delta Dental pays Patient paysamount amount (90% of $65) (10% of $65)

$136.00 $65.00 $58.50 $6.50

Example: a Delta Dental PPO dentist installs a two surface amalgam filling on a patient. Patient has 90% coverage for basic services.

Delta Dental PPO Network – Flex Option

This calculation is for illustration purposes only, it does not reflect actual fees.

Procedure code 2150 – two surface amalgam filling

Submitted Approved Delta Dental pays Patient paysamount amount (80% of $125) (20% of

$125)

$136 $125 $100 $25

Example: a Delta Dental Premier dentist installs a two surface amalgam filling on a patient. Patient has 80% coverage for basic services.

Members in Basic and Basic Plus Options have no benefits for Premier or non-participating providers.

This calculation is for illustration purposes only, it does not reflect actual fees.

Delta Dental Premier Network – Flex Option Only

Procedure code 2150 – two surface amalgam filling

Submitted Approved Delta Dental pays Patient pays

amount amount (80% of $128) *$136 $128 $102.40 $33.60

* 20% of $128 ($25.60) - plus the difference between the approved amount and the dentist’s charges ($8)

Example: a nonparticipating dentist installs a two surface amalgam filling on a patient. Patient has 80% coverage for basic services.

Members in Basic and Basic Plus Options have no benefits for Premier or non-participating providers.

This calculation is for illustration purposes only, it does not reflect actual fees.

Delta Dental Nonparticipating – Flex Option Only

Filling Submitted

Amount

Approved

Amount

Delta Pays

You Pay

Delta PPO(Basic Options)

$136.00 $65.00 $45.50 $19.50

Delta PPO(Flex Option)

$136.00 $65.00 $58.50 $6.50

Delta Premier(Flex Option Only)

$136.00 $125.00 $100.00 $25.00

Out of Network(Flex Option Only)

$16.00 $128.00 $102.40 $33.60

• 99.8% - solutions on first call

• Over 98% of customers satisfied with service

• Average speed of answer: 8 seconds

• 96% answered in 30 seconds

• Abandon rate: 0.6%

• Average 14 years experience

• Minimal turnover

Unrivaled Customer Service

1-800-335-8266

• 24/7 access to benefit and claims information:

– Benefit24 online at www.deltadentalmo.com

– Benefit24 VRU • Faxback – summary of benefits

Ease and Convenience

For members and dentists:

–Participating dentists–Claims status and history–Copy of EOB–Benefit design–Track use of maximums–Print ID cards

State-of-the-art Web-based Service

Find a Dentist . . .

Benefits OPTION 1Flex Option

OPTION 2Basic Plus Option

OPTION 3Basic Option

Type of Plan Delta Dental PPO Delta Dental PPO(with no out of

network benefit)

Delta Dental PPO(with no out of

network benefit)

Network Considerations In PPO Network

Out of PPO Network

(Delta Premier Network or Non-participating providers)

In Delta Dental PPO Network Only

In Delta Dental PPO Network Only

Co-Insurance (Plan Pays)

Type A: Preventive Care 100% 100% 100% 100%

Type B: Basic Restorative Services

90% 80% 70% 70%

Type C: Major Restorative Services

60% 50% 35% Not Covered

Type D: Orthodontics 50% 50% 50% Not Covered

Deductible

Applies to: B & C Services B & C Services B & C Services B Services

Per Person $50 $50 $25 $25

Per Family $150 $150 $75 $75

Annual Maximum Per Person $1000 $1000 $1000 $750

Lifetime Orthodontia Maximum

$1000Adult & Child

$1000Adult & Child

$1000Child Only

Not Covered

Rates:

Employee $25.14 $16.41 $11.63

Employee + 1 $49.21 $31.15 $22.76

Family $84.24 $52.98 $40.72

Questions?