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Enrollment instructionsEnroll in dental and vision coverage online at: myOhio.gov or byusing a paper enrollment formavailable online atbenefitstrust.org, under theForms & Info Tab, from your agencybenefits representative or bycalling UBT at 800-228-5088 or614-508-2255.A. ONLINE You may enroll on-line atmyOhio.gov beginning thesecond business day followingyour one-year anniversary date. Enter your State of OhioUser ID and password,click “SIGN IN;” On toolbar clickHEALTH & BENEFITS Tab Select BENEFITS SUMMARYfrom drop down menuThe Benefits Summary pagewill open; Click on “Enroll in Benefits” Click the “SELECT” button onthe benefit enrollment pageSubmit your selections throughmyOhio.gov within 31 days ofyour anniversary date. Make sureyour online elections are correctlysubmitted and that you receive aconfirmation message. Print andkeep a copy for your records.OnlineAccess hoursNon-Payday WeekMon. - Thurs.Available 24 hours/dayFriday.All day until 7 pmSat. and Sun.UnavailablePayday WeekMon. - Fri. .Available 24 hours/daySaturday.All day except 4-6 pmSunday.UnavailableB. paperObtain a paper dental andvision enrollment form online at benefitstrust.org, from your agency’s humanresource office, or call UBT at 800-228-5088 tohave one mailed to your home.Give the completed, signed anddated form to your agency’shuman resource office within 31days of your anniversary date.ENROLLING DEPENDENTSIf you are enrolling yourdependent(s) in your dental andvision coverage, you are requiredto provide the required eligibilitydocumentation for your dependents. A listing of the requireddocuments can be found at:das.ohio.gov/eligibilityrequirement. Coverage will not be provided for dependents until theeligibility documents are receivedand approved by your agency’s human resource office. If the requireddocumentation is on file with youragency’s human resource office asa result of enrolling in a medical7plan, you may not need to resubmit.Be sure you have a valid mailingaddress on file at myOhio.gov.Information regarding your benefits is mailed to that address fromDAS and UBT. It is your responsibility to ensure that your currentaddress is on file. You may list a P.O.Box as a mailing address but not asa home address.BenefitReference Cardsfor dental andvisionA card is not required to receiveservices at your dental or visionprovider’s office for yourconvenience.You have an option to printreference cards for you and yourfamily’s dental and vision benefitvisits. Simply1. link from UBT’s websitebenefitstrust.org toDelta Dental & VSP.2. register and create a password fora secure login.3. print a card with your name andgroup number (which can beused for all familymembers).4. for Eyemed, print reference cardat benefitstrust.org under theVISION tab.

Your DENTAL & VISION coverageWhen you are onleaveIn some cases your dental andvision coverage may continue whenyou are not actively at work for thelength of your authorized Stateleave. See your HR Representativefor details.WHEN YourCoverage ENDSGenerally, coverage is extendedthrough the end of the monthfollowing the month state serviceterminates. For example, typically,if you leave State employment inJuly, and UBT receives a contributionin July, UBT will pay your last dentalor vision premium for August. Yourcoverage would end August 31.However in certain circumstances,you may be able to continue yourdental and vision benefits throughCOBRA. See page 21 for more information.When yourdependent(s)coverage endsYour dependent benefits will endon the last day of the month inwhich your dependent no longermeets the definition of an eligibledependent or the date your benefits end. See page 5 for dependenteligibility.CoBRAYou are responsible for notifyingUBT when your dependent(s)is no longer eligible to receivedental and vision coverage underyour benefits. At no time is youroverage dependent automaticallyenrolled in COBRA for dental andvision, even if they have enrolledin COBRA for the state’s medicalplan. See page 21 for more information.Contact UBT at 800-228-5088 or614-508-2255 or email tocustomerservice@benefitstrust.org.8Access your member-specificbenefits at benefitstrust.org.Click MyUBT to register andcreate a password for a securelogin. Check you plan coveragesfor dental, vision, lifeand legal Check what dependentsyou have covered Find out how muchlife insurance youhave for you and yourdependentsTo access network providersyou do not need to create apersonal account. Link to all plannetworks via the PLANS tab.Find forms and booklets via theFORMS & INFO tab.View Frequently AskedQuestions via the FAQ tab.

DENTAL BENEFITSUBT Dental PlanYour UBT Trustees have selectedDelta Dental of Ohio as your dentalcarrier effective July 1, 2010.The UBT Dental Plan coversdiagnostic and preventativeservices at 100% and no annualdeductible is required forClass 1 or 4 services. You mustmeet the annual deductible of 25 per person, for Class 2 and 3services, before benefits are paid.Benefits will be paid up to themaximum annual benefit amountof 1500 per person per plan year.Out-of-pocket costs may varydepending on the provider youchoose. You will be covered byone plan, but your savings aredetermined by the dentist youchoose.One plan, three levels of coverage elta Dental PPO providersDoffer the highest level of savings and cannot balance-billyou for additional payment forthe services you received. Thatmeans no additional out ofpocket expenses. elta Dental PremierDproviders are in the secondarynetwork. While you receive amore modest savings compared to the PPO dentist, youwill have many more dentiststo choose from than the PPO.You cannot be balance-billedfor the difference between thedental charge and the allowedamount. on-participating providersNwill balance-bill you for anyamount that exceeds DeltaDental’s allowed amount.They may ask you to pay thefull amount up front and mayhave you submit your claiminformation to receivereimbursement.PLAN ADMINISTRATIONThe UBT Dental Plan is administered by Delta Dental of Ohio, aThird Party Administrator (TPA) withtwo dental provider networks: theDelta Dental PPO and Delta DentalPremier. With two networks available the UBT Dental Plan offersaccess to more in-network providers and thus greater savings to itsmembers.The UBT DENTAL Plan also has anout of network benefit. So you cansee any dentist you choose and theplan will pay, however benefits arebetter in one of Delta Dental’s twonetworks.For a summary of benefits and thepercentages of dentists’ fees theplan pays in the PPO, Premier or outof network, see the chart on pages10 and 11. See Page 12 for plan payment examples by network.You must meet a deductible of 25 per person each plan yearbefore benefits are payable forrestorative services, oral surgery,endodontic, periodontic andprosthodontic services (Class 2and 3 services combined).Finding a ParticipatingDentistTo find the names of participating dentists near you, callDelta Dental’s customer servicedepartment toll-free at 877334-5008. The DASI (Delta’sAutomated Service Inquiry)system is available 24 hours aday, seven days a week, and canprovide you with the names ofparticipating dentists. You canalso check the Delta Dentallink under the PLANS tab, or godirectly to deltadentaloh.com.Pre-treatmentestimateA pre-treatment estimate isrecommended for services over 300. It outlines what the plan willpay, giving you an idea as to theportion of the cost that will beyour responsibility. See page 13 forclaims information.Network feeA discounted fee negotiated byDelta Dental for services fromnetwork providers.9

UBT DENTAL PLANThis chart presents a summary of benefits and reflects the amount that the plan pays for your treatment orservices. Please read the sections that follow for details on plan benefits and limitations. Benefit Classes 2 and3 are subject to the annual plan deductible of 25 per person. Benefit Classes 1 and 4 have no deductible.PPODentistAnnual Maximum 1500 per person per benefit yearCLASS 1 SERVICESDiagnostic and Preventive ServicesOral Exams twice per plan yearCleanings (prophylaxes) twice per plan yearFull mouth x-rays once in any three year periodBitewing X-rays twice per plan yearTopical fluoride treatment for age 18 and under or age 55or older, twice per plan yearSpace maintainers, age 18 and under, once per lifetimeEmergency palliative treatment (temporary pain relief)Sealants for unblemished permanent molars for age 18and under, once per tooth, per three year periodBrush t*Plan Pays Plan 00%65%65%*100%100%65%65%65%*65%*CLASS 2 SERVICES (annual 25 deductible applies)Restorative ServicesFilingsRoutine extractionsRelining and rebasing of existing removable dentures,once in any three year periodRepair or re-cementing of crowns, inlays, onlays,dentures or bridgeworkOral SurgeryComplex extractions or removal of tooth or rootGeneral anesthesia when medically necessary inconnection with a covered dental serviceAntibiotic injectionsEndodonticRoot canal, pulp capping, pulpotomy or therapy fordiseases of the soft tissuePeriodonticsTreatment of diseases of the gums and tissuePeriodontal maintenance cleanings following some formof periodontal treatment10

PPODentistAnnual Maximum 1500 per person per entist*Plan Pays Plan Pays*CLASS 3 SERVICES (annual 25 deductible applies)Prosthodontics (crowns, implants, bridges,dentures)Installation of fixed bridgeworkInstallation of implants and implant relatedservices, once per tooth in any five year periodInstallation of a partial removable or fullremovable dentureCrowns, inlays, and onlays up to one suchrestoration to the same tooth surface, oncein any five year periodReplacement of an existing removable denture orfixed bridgework. Must be due to the loss of oneor more natural teeth after the existing denturewas installed or if the existing denture or bridgework is at least five years old and unserviceableReplacement of an existing immediate temporaryfull denture by a new permanent full denture.Must be necessary because the existing denturecannot be made permanent and the permanentdenture is installed with 12 months after theexisting denture was installed.Addition of teeth to an existing partial removabledenture. Must be needed to replace one or morenatural teeth removed after the existing denturewas 60%50%50%*60%50%50%*60%50%50%*CLASS 4 SERVICESOrthodontia (children only)Lifetime Orthodontic Maximum 1500Services for the treatment of irregularities of theteeth and their correction, including appliancetherapy, so as to bring about proper occlusion.Dependent children are eligible until the end ofthe month in which the child reaches age 19 or23 if a student.50%up to 1,500**50% up to 1,500**50%* up to 1,500**The Annual Maximum Payment per person, per benefit year is 1,500 for all services except Orthodontics.The Annual 25 Deductible is for class 2 and class 3 services combined.**The separate lifetime maximum payment for orthodontic services is 1,500 per person.Orthodontic payment is based on the treatment plan submitted by the dentist including but not limited to the date of thebanding or placement of the appliance, and the number of months of treatment. Payment begins once the bands or theappliance is placed and will continue on a monthly basis as long as you are eligible under the dental plan until the end oftreatment or your 1,500 maximum has been met.*The percentages in the “Nonparticipating Dentist’ column will be paid based on Delta Dental’s Allowed Amount fornon-participating dentists for that service, not necessarily the amount the dentist bills. This could leave a balance due,which you are responsible for. See the example on page 12.11

dental benefit informationConditions forproviding benefitsCertain plan benefits, as explainedin the next section, are payableaccording to important conditionsdescribed below.Alternate benefitDental benefits will be based onthe materials and method oftreatment which cost the least andwhich, in the opinion of the claimsadministrator, generally meetaccepted dental standards.Dental has the right to a refundfrom you. The refund amount willequal the difference between whatwas actually paid and what shouldhave been paid. Instances whererefunds may occur: when you failto pay all or some of the expensesyou’re required to, or another partypays all or some of the expenses onyour behalf. Annual deductible appliesto Class 2 and 3 servicescombined Full mouth x-rays have a 3 yearfrequency Class 3 appliances have a fiveyear frequency limit Orthodontia has a separateonce in a lifetime benefit; thelifetime maximum payment is 1,500Plan limitsGenerally, plan benefits arelimited by the frequency orbenefit amount per plan year.A full description is available online,or you can get a copy from the UBT.Overpayments Plan year July 1 to June 30If the plan pays more than it shouldfor expenses incurred by you oryour covered dependents, Delta Plan year benefit 1,500 perpersonExample of UBT Dental Plan paymentPPO DentistPremier DentistNon-participating DentistFile claim andreceive paymentThe PPO DentistWhat is thepayment basedon?The billed fee or the amountin your dentist’s local PPO FeeSchedule1, whichever is less.The billed fee or theMaximum Approved Fee2,whichever is less.The billed fee or the Nonparticipating Dentist Fee3,whichever is less.Payment exampleof a Class 2dental benefit(assuming anyapplicabledeductiblehas been met)Billed Charges: 100.00Billed Charges: 100.00Billed Charges 100.00PPO Fee Scheduleamount: 76.00MaximumApproved Fee: 92.00Non-Par DentistFee amount: 88.00Delta Dental pays100% of the PPOfee schedule: 76.00Delta Dental pays65% of the MaximumApproved Fee: 59.80Delta Dental pays 65% of theNon-Participating DentistFee amount: 57.20Member pays: 0.00Member pays:Member pays:The PPO dentist cannot chargeyou the 24 difference betweenthe PPO Fee Schedule amountand his/her fee.The Premier Dentist 32.20The Premier dentist cannotcharge you the 8 differencebetween the MaximumApproved Fee and his/her fee.You 42.80Because the dentist does notparticipate, you are responsiblefor the difference between Delta’spayment and his/her fee.A PPO Dentist is one that has agreed to the PPO Fee Schedule, which is lower than Maximum Approved Fee used for adentist who participates in Delta Dental Premier.1Maximum Approved Fee is the maximum amount approved for a specific procedure determined by Delta Dental in thePremier program.23Non-participating Dentist Fee is the maximum fee allowed when the dentist does not participate.12

CLAIMSSeeking a pretreatment estimate(Pre-determination)You can find out what your planpays before your d

District 1199/SEIU, OSTA, FOP/OLC, SCOPE/OEA and CWA. ABOUT THIS BOOkLET This booklet describes three UBT benefits: Dental Plan This booklet describes the UBT Benefits Trust and EyeMed Vision Dental Plan effective July 1, 2010. This plan booklet replaces the prior booklet and is incorporated with the Administrative Services