Your Two Plan Options - St. Francis Episcopal School

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Your Two Plan OptionsChoosing between the Delta Dental PPOSM and DeltaCare USA plansWe’ll do whatever it takes and then some.Plan FeaturesDelta Dental PPODeltaCare USACoinsurance/copaymentsCovered services paid at applicable percentage — for example, Covered procedures have predetermined dollar copaymentsfillings are covered at 80% of allowed amount — you pay the for services provided by network dentists (this means out-ofremaining 20%pocket costs are predictable)CoverageWide range of covered servicesPlan covers nearly 300 proceduresNo exclusions for most pre-existing conditionsNo or low copayments for most diagnostic and preventiveservicesNo exclusions for pre-existing conditions or missing teethDentist networkFreedom to choose any licensed dentist; selecting a PPOdentist will usually result in the lowest out-of-pocket costsYou select a dentist from a list of network dental facilities,and you must visit this dentist to receive benefitsChanging yourdentistChange dentists any time without contacting Delta DentalYou must contact Delta Dental to change your selected dentist,and can do so via telephone or internetTransitions fromprevious planCoverage is provided only for treatment started after youreffective date of coverage under the Delta Dental planCoverage is provided only for treatment started after youreffective date of coverage under the Delta Dental planOrthodontictreatment inprogress (whencovered underprior plan)Plan will pay the amount of the total case fee calculatedto be Delta Dental's liability, subject to lifetime and annualmaximum benefits (when plan includes orthodonticcoverage)Covers new enrollees who, on the effective date of theircoverage, are in active treatment started under their previousemployer-sponsored dental planAuthorizationfor specialtycare treatmentPreauthorization for treatment is not requiredWritten or verbal preauthorization may be required fortreatment from a specialist; your DeltaCare USA dentist willcoordinate your specialty care treatment authorization for youOut-of-areacoverageVisit any licensed dentistLimited to emergency care allowanceDeductibles andmaximumsDeductibles and annual maximums apply to most plandesignsNo annual deductible or annual dollar maximumsClaimsNo claim forms required when treatment is received from aDelta Dental dentist; Delta Dental dentists file claim formsand accept payment directly from Delta DentalNo claim forms requiredYou will never have to pay more than the patient's share atthe time of treatment when you visit a Delta Dental dentistEnrollees are responsible for all copayments and fees subjectto the provisions of their prior dental planYou only need to pay the specified copayment for coveredservices provided at the time of your visitWE KEEP YOU SMILING Page 1 of 2

WE KEEP YOU SMILING Why do 54 million enrollees trusttheir smiles to Delta Dental? More dentists Simpler process Less out-of-pocketThe Value of ChoiceWhen it comes to choosing a dental plan, you want benefits that fit theneeds of you and your family. Delta Dental PPO and DeltaCare USA both offercomprehensive dental coverage, quality care and excellent customer service.Delta Dental PPOFree NewsletterGet the latest in oral healthwith Dental Wire, our bi-monthlye-mail newsletter. Sign up at:deltadentalins.com/oral healthDelta Dental PPO, our preferred provider organization (PPO) plan, providesaccess to the largest PPO dentist network in the U.S. Delta Dental PPO dentistsagree to accept reduced fees for covered procedures when treating PPOpatients. This means your out-of-pocket costs are usually lower when you visita PPO dentist than when you visit a non-Delta Dental dentist, but you have thefreedom to visit any licensed dentist, anywhere in the world.DeltaCare USAdeltadentalins.comDelta Dental PPOSM is underwritten byDelta Dental Insurance Company in AL,DC. FL, GA, LA, MS, MT, NV and UT and bynot-for-profit dental service companiesin these states: CA – Delta Dental ofCalifornia, PA, MD – Delta Dental ofPennsylvania, NY – Delta Dental of NewYork, DE – Delta Dental of Delaware,WV – Delta Dental of West Virginia. InTexas, Delta Dental Insurance Companyprovides a Dental Provider Organization(DPO) plan.DeltaCare USA is our prepaid plan that features set copayments, no annualdeductibles and no maximums for covered benefits. In most states, enrolleesmust select a primary care dentist in the DeltaCare USA network from whomthey receive treatment as in a traditional dental HMO.Visit us at deltadentalins.comDeltaCare USA is underwritten in thesestates by these entities: AL — AlphaDental of Alabama, Inc.; AZ — AlphaDental of Arizona, Inc.; CA — DeltaDental of California; AR, CO, IA, ME, MI,NC, OK, OR, RI, SC, SD, WA, WI, WY —Dentegra Insurance Company; NH andVT — Dentegra Insurance Company of NewEngland; AK, CT, DE, FL, GA, KS, LA, MS,MT, TN, WV and Washington, D.C. — DeltaDental Insurance Company; HI, ID, IL, IN,KY, MD, MO, NJ, OH, TX — Alpha DentalPrograms, Inc.; NV — Alpha Dental ofNevada, 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. DeltaDental Insurance Company acts as theDeltaCare USA administrator in all thesestates. These companies are financiallyresponsible for their own products.Please refer to your plan booklet forwaiting periods and a list of benefits,limitations and exclusions.Page 2 of 2E EF3 PPO USA #62465 (rev. 2/11)

Delta Dental PPO – Easy, Friendly, AccessibleSMWe’ll do whatever it takes and then some.Greatest potential savingswhen you visit a Delta DentalPPO dentistOUT-OF-POCKET COSTSSAVE LESSNON-NETWORKDENTISTSAVE MOREPPODENTISTAMOUNT YOU SAVEAMOUNT YOU PAYIllustration showing sample enrolleeshare of cost for information purposesonly. Actual dentist fees and contractallowances will vary by region,procedure and by group contract.We’re pleased to be your partner in maintaining great oral health. The Delta Dental PPO*plan makes it easy for you to find a dentist, and easy to control your costs when you visit anetwork dentist. Here are some of the great things you’ll need to know about enrolling withDelta Dental: Save money with a Delta Dental PPOdentist. Our PPO network dentistsaccept reduced fees for coveredservices they provide you, so you’llusually pay the least when youvisit a PPO network dentist. Thisalso ensures Delta Dental dentistswon’t balance bill you the differencebetween the contracted amount andtheir usual fee. Visit the dentist of your choice.Want to visit a non-Delta Dentaldentist? No problem. You can visitany licensed dentist, but your costsare usually lowest when you see aPPO dentist. Many network dentists to choosefrom. Since Delta Dental offersaccess to some of the largest dentistnetworks in the U.S., chances arethere’s a wide choice of networkdentists near your home or office.Four out of five dentists nationwideare contracted Delta Dental dentists,giving more enrollees convenientaccess to more dentists. Visit us atwww.deltadentalins.com to searchour dentist directory by locationor specialty. Easy to use your benefits.When you visit a Delta Dental dentist,pay only your portion for services.Delta Dental dentists will file claimforms for you and receive paymentdirectly from us. Many non-DeltaDental dentists ask that you paythe entire cost up front and waitfor reimbursement. Delta Dental’s Online Services makegetting information quick and easy.Access your benefits and eligibility,print ID cards and get informationabout your claims. And check outDelta Dental’s oral health resourcestoo for tips and information that canhelp keep your smile healthy.* In Texas, Delta Dental Insurance Company offers a Dental Provider Organization (DPO) plan.WE KEEP YOU SMILING E HL PPO ENG 2col BWL #60482 (9/10)

Plan Benefit Highlights for: ISAS Group Benefits TrustPrimary enrollee, spouse and eligible dependent children to age 26Deductibles 100 per person / 300 per family each plan yearDeductibles waived for D & P?MaximumsD & P counts toward maximum?Yes 2,000 per person each plan yearNoBasic Benefits0 MonthsWaiting Period(s)Benefits andCovered Services*Major Benefits0 MonthsOrthodontics0 MonthsDelta Dental PPO dentists**Non-Delta Dental dentists**100 %100 %80 %80 %80 %80 %80 %80 %80 %80 %50 %50 %50 %50 % 2,000 Lifetime 2,000 LifetimeDiagnostic & PreventiveServices (D & P)Exams, cleanings, x-rays, sealantsBasic ServicesFillings, simple tooth extractionsEndodontics (root canals)Covered Under Basic ServicesPeriodontics (gum treatment)Covered Under Basic ServicesOral SurgeryCovered Under Basic ServicesMajor ServicesCrowns, inlays, onlays and castrestorations, bridges and dentures,implantsOrthodontic Benefitsdependent childrenOrthodontic MaximumsLifetime*Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’ssubmitted fees.** Reimbursement is based on PPO contracted fees for PPO dentists, program allowance for Premier dentistsand 90th percentile for non-Delta Dental dentists.Delta Dental Insurance CompanyCustomer ServiceClaims Address1130 Sanctuary Parkway, Suite 600Alpharetta, GA 30009800-521-2651P.O. Box 1809Alpharetta, GA 30023-1809www.deltadentalins.comThis benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage orSummary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for yourplan, please consult your company’s benefits representative.HLT PPO 2COL DDIC (Rev. 1 6/10)Benefit HighlightsEligibilityDelta Dental PPOSMEffective Date: 9/1/2011Group No: 15447

DeltaCare USA — Getting the most from your plan We’ll do whatever it takes and then some.W ith DeltaCare USA, thereare no claim forms to submit.Select aDeltaCare USAdentistReceive yourwelcome kitSchedule anappointmentReceivedentalcarePay only yourcopaymentdirectly todentistSave money with a DeltaCare USA dentistDeltaCare USA plans feature: Set copayments. No annual deductibles and nomaximums for covered benefits. Low out-of-pocket costs for manydiagnostic and preventive services(such as professional cleaningsand regular dental exams).Choosing your DeltaCare USA dentistWhen you enroll, you choose from manyconveniently located DeltaCare USAcontracted general dentists to receivebenefits under your plan. To find the mostcurrent listing of DeltaCare USA networkdental offices: Visit our website and click on“Find a Dentist” on our home page. Select “DeltaCare USA” as yourplan network.You can also call Customer Servicefor help in finding a dentist.Visit your DeltaCare USA dentistYou must visit your selected DeltaCareUSA dentist to receive benefits underyour plan.* If you do not select a dentist, we willselect a dentist for you. Family members may select a differentdentist for treatment within the coveredservice area. Refer to your plan bookletfor details. You can change your selected networkdentist by telephone or through ourwebsite. Changes received by the 21st of themonth will be effective the first dayof the following month.Easy to use We will notify your DeltaCare USAdentist about your enrollment in theplan, and other important details aboutyour coverage such as dependentinformation, group number andenrollee ID number. No ID card is required to receiveservices; simply provide the dentaloffice with your name, date of birth andsocial security or enrollee ID number. With DeltaCare USA, there are no claimforms to submit. And, since you areresponsible only for the copaymentat the time of treatment, you will notreceive a claims statement. Predictable costs: you’ll finda complete list of covered procedures,copayments, plan limitations andexclusions in your plan booklet.*State-specific exceptions may apply. Please review your plan booklet for specific details about your plan.WE KEEP YOU SMILING Page 1 of 2

WE KEEP YOU SMILING Why do 1.3 million enrollees trusttheir smiles to DeltaCare USA? Large dentist network Easy to use Affordable costs Extensive coverage,including orthodonticsWith DeltaCare USA, you and your family will enjoy many new features including:Expanded businesshours/toll-freecustomer serviceOut-of-areaemergency coverageOrthodontictreatment in progressprovisionSmileWay Wellness ProgramFind all of our dental healthresources, including riskassessment quizzes, articles,videos and a free newslettersubscription, at: mysmileway.com.Connect with talinsyoutube.com/deltadentalinsDeltaCare USA Customer Service800-422-4234DeltaCare USA is underwritten inthese states by these entities: AL— Alpha Dental of Alabama, Inc.;AZ — Alpha Dental of Arizona, Inc.;CA — Delta Dental of California; AR,CO, IA, MI, NC, OR, RI, SC, WA, WI— Dentegra Insurance Company;DE, FL, GA, KS, TN, WV and Districtof Columbia — Delta DentalInsurance Company; HI, ID, IL, IN,KY, MD, MO, NJ, OH, TX — AlphaDental Programs, Inc.; NV — AlphaDental of Nevada, Inc.; UT — AlphaDental of Utah, Inc.; NM — AlphaDental of New Mexico, Inc.; NY— Delta Dental of New York, Inc.;PA — Delta Dental of Pennsylvania.Delta Dental Insurance Companyacts as the DeltaCare USAadministrator in all these states.These companies are financiallyresponsible for their own products. Specialty care and authorizationsIf you require treatment from a specialist,your DeltaCare USA general dentist willcoordinate any referrals for you.In some states, Delta Dental mustpre-authorize any dental services, withthe exception of emergency treatment,that are not performed by yourDeltaCare USA general dentist. Pleaserefer to your plan booklet for specificdetails about your plan.Dual coverage/Coordination of benefitsIf your spouse has coverage with anotherdental plan, you or your family membersmay be covered by both dental plans.* We do not coordinate benefits withthe other plan when you receivetreatment from your DeltaCare USAgeneral dentist. However, if youreceive authorized treatment from aspecialist (such as an oral surgeon),we will coordinate benefits with theother carrier. Ask your specialist to submit the otherplan’s explanation of benefits with theDeltaCare USA claim form and we’lltake it from there.Orthodontic treatment in progressDeltaCare USA has an orthodontictreatment-in-progress provision thatallows new enrollees to continuetreatment with their currentorthodontist, as long as the enrollee isin active treatment started under his orher previous employer-sponsored dentalplan. Enrollees are responsible for allcopayments and fees subject to theprovisions of their prior dental plan.**Transitioning from another plan?Your DeltaCare USA plan coverstreatment started and completedonly after your plan’s effective dateof coverage. If you have any dentaltreatment in progress when yourcoverage begins — root canals inprogress, teeth prepared for crowns anddentures for which an impression hasbeen taken — those expenses are notcovered by your DeltaCare USA plan.However, DeltaCare USA plans haveno exclusion for pre-existing dentalconditions or missing teeth.Visit our website: deltadentalins.comOn our website, you can: Find a dentist in our online directory Review benefits Verify eligibility Print an ID card and much moreTo access some services, you’ll need tolog in: simply enter your username andpassword in the designated boxes andsubmit. If you are visiting our website forthe first time, you’ll need to complete aquick one-time registration process byclicking the “Register Today” link.Questions about your plan?If you have questions, you can checkyour benefits and eligibility informationon our website or on our interactivevoice response telephone line. Formore information, you may also contactus through our website or call oneof our helpful multilingual CustomerService representatives toll-free duringbusiness hours.* Group-specific exceptions may apply. Please review your plan booklet for specific details about your plan’scoordination of benefits, including rules for determining primary and secondary coverage.** This provision may not apply to all plans. Please refer to your plan booklet for specific coverage details.deltadentalins.comPage 2 of 2E EF17 DCU USA #63500 (5/11)

comprehensive dental coverage, quality care and excellent customer service. Delta Dental PPO: Delta Dental PPO, our preferred provider organization (PPO) plan, provides : access to the largest PPO dentist network in the U.S. Delta Dental PPO dentists