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County of Stanislaus(Buy-Up Plan, Actives)Group No: 03351 - 00003Plan Benefit Highlights for:In this incentive plan, Delta Dental pays 70% of the PPO contract allowance for covered diagnostic, preventiveand 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 thatperson visits the dentist at least once during the year. If an enrollee does not use the plan during the calendaryear, the percentage will be reduced by 10% (the percentage will never drop below 70%. If an enrollee becomesineligible for benefits and later regains eligibility, the percentage will drop back to 70%.EligibilityPrimary enrollee, spouse (includes domestic partner) and eligibledependent children to the end of the month dependent turns age 26DeductiblesPPO dentists:NoneNon-PPO dentists: 10 per person each calendar yearPPO dentists;Not applicableNon-PPO dentists: YesDeductibles waived forDiagnostic & Preventive (D & P)?MaximumsWaiting Period(s)Benefits andCovered Services* 2,000 per person each calendar yearBasic ServicesNoneMajor a Dental PPO dentists**Non-PPO dentists**In-PPO NetworkOut-of-PPO Network70-100 %70-100 %70-100 %70-100 %Endodontics (root canals)70-100 %70-100 %Periodontics (gum treatment)70-100 %70-100 %Oral Surgery70-100 %70-100 %70-100 %70-100 %50 %50 %50 %50 % 2,000 Lifetime 2,000 LifetimeDiagnostic & PreventiveServices (D & P)Exams, cleanings and x-raysBasic ServicesFillings, simple tooth extractionsand sealantsMajor ServicesCrowns, inlays, onlays and castrestorationsProsthodonticsBridges, dentures and implantsOrthodontic BenefitsDependent childrenOrthodontic Maximums100 %(Included in the calendar year maximum)* 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 Premierdentists and program allowance for non-Delta Dental dentists.Dental Accident BenefitsDelta Dental of California100 First St.San Francisco, CA 94105Customer Service800-765-6003Claims AddressP.O. Box 997330Sacramento, CA 95899-7330deltadentalins.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 INCEN DDC (Rev. 10/2/2017)

Keep SmilingDelta Dental PPOSMSave with PPOVisit a dentist in the PPO network to maximizeyour savings.2 These dentists have agreed toreduced fees, and you won’t get charged morethan your expected share of the bill.3 Find a PPOdentist at deltadentalins.com.1Set up an online accountGet information about your plan anytime,anywhere by signing up for an Online Servicesaccount at deltadentalins.com. This free service,available once your coverage kicks in, lets youcheck benefits and eligibility information, find anetwork dentist and more.Check in without an ID cardYou don’t need a Delta Dental ID card when youvisit the dentist. Just provide your name, birthdate and enrollee ID or social security number.If your family members are covered under yourSave with aPPO dentistPPOplan, they will need your information. Prefer totake a paper or electronic ID card with you?Simply sign in to Online Services, where you canview or print your card with the click of a button.Coordinate dual coverageIf you’re covered under two plans, ask your dentaloffice to include information about both planswith your claim, and we’ll handle the rest.Understand transition of careDid you start on a dental treatment plan beforeyour PPO coverage kicked in? Generally, multistage procedures are only covered under yourcurrent plan if treatment began after your plan’seffective date of coverage.4 You can find this dateby logging in to Online Services.Newly covered?Visit deltadentalins.com/welcome.NON–PPO1 In Texas, Delta Dental Insurance Company offers 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 plan maximums and charges for non-covered services.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 forany costs. Group- and state-specific exceptions may apply. If you are currently undergoing active orthodontic treatment, you may be eligible to continue treatmentunder 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 .Copyright 2017 Delta Dental. All rights reserved.HL PPO #104383D (rev. 3/17)

Go PPO!6 great reasons tostay in-networkYour Delta Dental PPOSM plan lets you visit any licensed dentist, but you’ll maximizeplan value by taking advantage of our robust, nationwide PPO network.1 Here are sixgreat reasons to “go PPO”:1Reduced costs. Stretch yourdental budget further! Wecontract directly with PPOdentists to bring you reduced fees forservices.2Quality assurance. Make sureyour smile gets the care itdeserves. We monitor PPOdentists to ensure that proper licensing,cleanliness and safety procedures arefollowed and send regular updates onpolicies and contracting requirements.3No balance billing. PPO dentistsagree not to charge more thanthe amount determined by yourplan. Out-of-network dentists may bill thedifference between their usual fee andDelta Dental’s contracted rate — a processknown as “balance billing.”4Avoid unbundling. PPO dentistsagree not to “unbundle” servicesthat are part of a treatment, liketooth preparation or local anesthesia. Outof-network dentists may charge for theseservices separately, making their overallcharges higher.5Less paperwork. PPO dentistshandle all claim forms and otherpaperwork for you. If you choosean out-of-network dentist, you may needto submit a claim yourself.6No prepayment required.When you choose a PPOdentist, you’ll pay only yourportion of the bill.2 We’ll pay our sharedirectly to your dentist. Out-of-networkdentists may require you to pay the fullcost of treatment up front and requestreimbursement from Delta Dental.1 In Texas, Delta Dental Insurance Company provides a Dental Provider Organization (DPO) plan.2 You are responsible for any applicable deductibles, coinsurance, amounts over plan maximumsand charges for non-covered services.We keep you smiling deltadentalins.com/enrollees

Find a Delta Dental PPO dentist atdeltadentalins.com. Verify that yourdentist is a contracted Delta DentalPPO network dentist before eachappointment.Premier dentists’ contracted fees areusually higher than PPO dentists’, butthey offer many advantages, includinghigh quality assurance standards and nounbundling or prepayment for services.Need another option? The Delta DentalPremier network — the largest dentistnetwork nationwide3 — also providescost protections for PPO enrollees.Save with aPPO dentistPPOPREMIERNON–DELTA DENTAL3 NetMinder Dental Network Trend Report, September 2017. Delta Dental Premier is the largest dentist network nationwide, based on total unique dentists.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-profitdental 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 Dentalof Delaware, Inc.; WV – Delta Dental of West Virginia, Inc.Copyright 2017 Delta Dental. All rights reserved.EF12 #109119A (rev. 10/17)

Delta Dental PPOSMDelta Dental Premier Best of BothCoordinate two plans withdual coverageAre you or your family members coveredunder two dental plans? Dual coveragedoesn’t mean your benefits are doubled,but it can mean added savings on dentalcosts.As soon as you’re covered under two dentalcarriers, let your dental office know. DeltaDental will coordinate with your other carrierto share the cost of your treatment.Basic concepts When you’re covered under two plans, oneplan is considered your primary carrier.This carrier will pay a larger portion of yourbenefits, leaving a smaller amount to yoursecondary carrier. You can find out how toidentify your primary carrier on the back ofthis flyer. Check the plan booklet for your secondarycarrier to see if you have a non-duplicationof benefits clause. If you do, your benefitwill be slightly less than standard dualcoverage.How does dual coverage help me save?How much you save depends on whether your secondary carrier has a non-duplication ofbenefits clause.1Type of coverage1Primary carrier coversSecondary carrier coversYour coverage paysNo dual coverage80%N/A80%Standard dual coverage80%80%100%Dual coverage with nonduplication of benefits80%80%80% You are responsible for any applicable deductibles, coinsurance, amounts over plan maximums and charges for non-covered services. Review your Evidenceof Coverage, Summary Plan Description or Group Dental Service Contract for specific details about your plan. If your primary or secondary carrier is anHMO-type plan, please contact Customer Service for details.We keep you smiling deltadentalins.com/enrollees

Which is my primary carrier?You are.a dependent childan adultAre you covered throughyour spouse or domesticpartner?NoYesYour primary carrier is.the one provided byyour employer.Coverage is through both yourcurrent employer and.Are your parents marriedand living together?YesNoDo they have jointcustody?Your primary carrier is.through the parentwhose birthday (monthand day) falls earlier inthe year. If both parentshave the same birthday,your primary carrier isthe one you’ve beencovered under longer.your former employer(laid off or retired)another currentemployer (you havetwo jobs)YesNoYour primary carrier is.through the parent withlegal custody. Coverage is usuallydetermined in the followingorder2: Custodial parentCustodial stepparentNon-custodial parentNon-custodial stepparentYour primary carrier is.the one provided by yourcurrent employer.Your primary carrier is.the one that hascovered you longer.If you have any questions about how your employer-sponsored or Marketplaceplan coordinates benefits with another plan, please call Customer Service.2 If a court decree establishes a different order of benefits for a dependent child’s coverage, that decision applies instead.Contact usDelta Dental of California: 800-765-6003California School District Employees: 866-499-3001Delta Dental of Delaware; Delta Dental of the District of Columbia; Delta Dental of New York;Delta Dental of Pennsylvania (and Maryland); Delta Dental of West Virginia: 800-932-0783Delta Dental Insurance Company (Alabama, Florida, Georgia, Louisiana, Mississippi,Montana, Nevada, Texas, Utah): 800-521-2651Delta 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-forprofit 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.Copyright 2017 Delta Dental. All rights reserved.EF9 #107549 (rev. 9/17)