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DeltaCare USADelta Dental Individual & FamilyTMDeltaCare USABasic Plan for FamiliesDental benefitsmade easy.What is DeltaCare USA?DeltaCare USA is a copay plan that works similar to a dental HMO.With this type of plan, you must visit your selected DeltaCare USAdentist to receive benefits.1 When you visit the dentist, simply payyour predefined copayment and you’re all set! Since we provide alist of copayments for covered services up front, you can preparefor treatment costs ahead of time.This plan has no waiting periods; you can use your benefits on thefirst day your coverage becomes effective.Customer lta Dental of New York, Inc.575 Madison Ave.New York, NY 10022Claims and CorrespondenceP.O. Box 1803Alpharetta, GA 30023PB DCU NY I FAM BSC 22

Is a DeltaCare USA plan right for me?DeltaCare USA can be a great choice if you are budgetconscious. Many enrollees appreciate the transparentpricing and affordable premiums the plans offer. Plus,with a large network of quality dentists, you can getgreat service close to home.Need more reasons to love DeltaCare USA? Most diagnosticand preventive procedures, like routine cleanings, areoffered at low or no copay. And if you need emergencydental care, even when you’re away from home, we’ve gotyou covered with an emergency services provision.Important tips This plan only covers you when you visit your selectedDeltaCare USA dentist. We pick one for you when you enroll, butyou can easily change your dentist online or on the phone. You can use our Find a Dentist tool to find a DeltaCare USAdentist near you. Too many choices? The included Yelp ratingsmay help you decide. Review the plan highlights on the next page to view copaymentsfor the most common covered services. Want more? View thefull copayment schedule, plus limitations and mThis benefit information is only a summary and is not intended to replace or serve as theplan Policy. Please consult the plan Policy for a description of plan benefits, limitations andexclusions. In the event of any inconsistency between this document and the plan Policy,the terms of the Policy will prevail. View the full copayment schedule, plus limitations andexclusions or call 888-857-0337.Change your selected network dentist at any time online, by phone or in writing. Changesmade by the 21st of the month are effective the first day of the following month.1 Delta Dental and DeltaCare USA are registered marks of Delta Dental Plans Association.Copyright 2021 Delta Dental. All rights reserved.HCR DCU #132634 (08/21)

D e l t a D e n t a l I n d i v i d u a l & F a m i l y TMDeltaCare USABasic Plan for FamiliesP la n Highlights - Pedi atric E nroll ees (up to age 19)PEDIATRIC DENTAL C ARE ESSENTIALHEALTH BENEF ITP art ic ip at in gP rovid er M em berRes p ons i bilit y f orCos t-Sh ari ngNon-P art ic ip at in gP rovid er M em berRes p ons i bilit y f orCos t-Sh ari ngNoneNon-ParticipatingProvider services arenot Covered except asrequired for EmergencyDental Care describedin the Pediatric DentalCare section of thisPolicyD e d u c t i b l e s a n d Ma xi m um sDe duc ti bleO ut -o f -P o c ket Max im u mAfter this amount is reached, the plan pays 100%of the remaining covered services for that calendaryear. 375 for one pediatricenrollee 750 for two or morepediatric enrolleesS a m ple of Covered S ervices 2C a te go r yP r o c ed ur e C o d e a nd D e s c r i p t i o n 3P E DIA TR IC D E N TA L E SSE N T IA L HE A LT H BE N E F IT & C A RED0999 - Office visitParti c i p ati ngProvi d erMemb erResp o nsi b i l i tyf or C ostShari ngNonParti c i p ati ngProvi d erMemb erResp o nsi b i l i tyf or C ostShari ng 25D0120 - Periodic oral exam – established patientNo costD0150 - Comprehensive oral evaluation – new orestablished patientNo costD0210 - Complete series of x-raysDia gnos tic &P reve nt iv eServ ic esC o p a ym e nt A m o u n t 1 25D0220 - Periapical x-ray of tooth's rootNo costD0230 - Periapical x-ray of tooth’s root, eachadditional imageNo costD0272 - Bitewing x-rays (2 images)No costD0274 - Bitewing x-rays (4 images)No costD0330 - Panoramic x-ray 25D1110 - Prophylaxis (cleaning) – adult 15D1120 - Prophylaxis (cleaning) – child 15D1208 - Fluoride treatment 15D1351 - Sealant – per tooth 15NonParticipatingProviderServices AreNot coveredand You Paythe Full CostHL DCU NY I FAM BSC 22

C a te go r yP r o c ed ur e C o d e a nd D e s c r i p t i o n 3C o p a ym e nt A m o u n t 1Parti c i p ati ngProvi d erMemb erResp o nsi b i l i tyf or C ostShari ngBas ic Servic esD2140 - Amalgam (silver-colored) filling – 1surface 60D2150 - Amalgam (silver-colored) filling – 2surfaces 85D2160 - Amalgam (silver-colored) filling – 3surfaces 110D2330 - Resin (tooth-colored) filling, front tooth,1 surface 90D2331 - Resin (tooth-colored) filling, front tooth, 2surfaces 100D2332 - Resin (tooth-colored) filling, front tooth,3 surfaces 110D2391 - Resin (tooth-colored) filling, back tooth, 1surface 90D2392 - Resin (tooth-colored) filling, back tooth,2 surfaces 110D2393 - Resin (tooth-colored) filling, back tooth,3 surfaces 140D3310 - Root canal, front toothEndo do nt ic sD3320 - Root canal, premolar toothD3330 - Root canal, molar toothP eriodo nt ic s 350 105D4910 - Periodontal maintenance 55D7210 – Extraction of erupted (exposed) toothD7240 - Extraction (removal) of fully impactedtooth, completely bonyMajor S ervic es 350D4341 - Periodontal scaling and root planing –four or more teeth per quadrantD7140 - Extraction (removal) of a fully exposedtoothO ral Sur ger y 350 85 165 280D2750 - Crown, porcelain and precious metal 350D2790 - Crown, precious metal 350D5110 - Full upper denture 350D6240 - Bridge pontic, porcelain and preciousmetal 350NonParti c i p ati ngProvi d erMemb erResp o nsi b i l i tyf or C ostShari ngNonParticipatingProviderServices AreNot coveredand You Paythe Full CostNonParticipatingProviderServices AreNot coveredand You Paythe Full CostNonParticipatingProviderServices AreNot coveredand You Paythe Full CostNonParticipatingProviderServices AreNot coveredand You Paythe Full CostNonParticipatingProviderServices AreNot coveredand You Paythe Full CostHL DCU NY I FAM BSC 22

D6750 - Bridge crown, porcelain and preciousmetalO rt hodo nt ic sD8080 - Pediatric servicesD8090 - Adult services 350 3504 3504NonParticipatingProviderServices AreNot coveredand You Paythe Full Cost1Featured benefits represent the most frequently used services covered under your plan; otherservices are also covered. After enrollment, DeltaCare USA will make available a complete list ofcovered services and copayments, along with any limitations and exclusions that apply. If applicable,service areas are detailed in the limitations and exclusions.2Copayments and procedure descriptions referenced above are intended to clarify the delivery ofbenefits under the DeltaCare USA plan. They are not to be interpreted as CDT-2021 descriptors ornomenclature, which are under copyright by the American Dental Association.3A copayment is the amount the enrollee pays for covered services at the time of treatment.4Orthodontic Services for Pediatric Enrollees must meet medical necessity as determined by adentist.HL DCU NY I FAM BSC 22

P la n Highlights - Adult E nroll ees (age 19 and older)A D U L T D E N T A L C A REP art ic ip at in gP rovid er M em berRes p ons i bilit y f orCos t-Sh ari ngNon-P art ic ip at in gP rovid er M em berRes p ons i bilit y f orCos t-Sh ari ngD e d u c t i b l e s a n d Ma xi m um sDe duc ti bleNoneO ut -o f -P o c ket Max im u mAfter this amount is reached, the plan pays 100%of the remaining covered services for that calendaryear.Non-ParticipatingProvider Services AreNot covered and YouPay the Full CostNoneS a m ple of Covered S ervices 2C a te go r yP r o c ed ur e C o d e a nd D e s c r i p t i o n 3C o p a ym e nt A m o u n t 1Parti c i p ati ngProvi d erMemb erResp o nsi b i l i tyf or C ostShari ngD0999 - Office visitDia gnos t ic &P reve nt iv eServ ic es 20D0120 - Periodic oral exam – established patient 5D0150 - Comprehensive oral evaluation – new orestablished patient 5D0210 - Complete series of x-raysNonParti c i p ati ngProvi d erMemb erResp o nsi b i l i tyf or C ost- Sha ri ng 20D0220 - Periapical x-ray of tooth's root 5D0230 - Periapical x-ray of tooth’s root, eachadditional image 5D0272 - Bitewing x-rays (2 images) 5D0274 - Bitewing x-rays (4 images) 5D0330 - Panoramic x-ray 20D1110 - Prophylaxis (cleaning) – adult 15D1208 - Fluoride treatment 15NonParticipatingProviderServices AreNot coveredand You Paythe Full CostHL DCU NY I FAM BSC 22

C a te go r yP r o c ed ur e C o d e a nd D e s c r i p t i o n 3C o p a ym e nt A m o u n t 1Parti c i p ati ngProvi d erMemb erResp o nsi b i l i tyf or C ostShari ngBas ic Servic esEndo do nt ic sP eriodo nt ic sO ral Sur ger yMajor S ervic esD2140 - Amalgam (silver-colored) filling – 1surface 55D2150 - Amalgam (silver-colored) filling – 2surfaces 75D2160 - Amalgam (silver-colored) filling – 3surfaces 100D2330 - Resin (tooth-colored) filling, front tooth,1 surface 80D2331 - Resin (tooth-colored) filling, front tooth, 2surfaces 90D2332 - Resin (tooth-colored) filling, front tooth,3 surfaces 100D2391 - Resin (tooth-colored) filling, back tooth, 1surface 80D2392 - Resin (tooth-colored) filling, back tooth,2 surfaces 100D2393 - Resin (tooth-colored) filling, back tooth,3 surfaces 130D3310 - Root canal, front tooth 280D3320 - Root canal, premolar tooth 340D3330 - Root canal, molar tooth 350D4341 - Periodontal scaling and root planing –four or more teeth per quadrant 105D4910 - Periodontal maintenance 55D7140 - Extraction (removal) of a fully exposedtooth 75D7210 – Extraction of erupted (exposed) tooth 165D7240 - Extraction (removal) of fully impactedtooth, completely bony 235D2750 - Crown, porcelain and precious metal 350D2790 - Crown, precious metal 350D5110 - Full upper denture 350D6240 - Bridge pontic, porcelain and preciousmetal 350NonParti c i p ati ngProvi d erMemb erResp o nsi b i l i tyf or C ostShari ngNonParticipatingProviderServices AreNot coveredand You Paythe Full CostNonParticipatingProviderServices AreNot coveredand You Paythe Full CostNonParticipatingProviderServices AreNot coveredand You Paythe Full CostNonParticipatingProviderServices AreNot coveredand You Paythe Full CostNonParticipatingProviderServices AreNot coveredHL DCU NY I FAM BSC 22

D6750 - Bridge crown, porcelain and preciousmetalO rt hodo nt ic sD8090 - Adult services 350 3,250and You Paythe Full CostNonParticipatingProviderServices AreNot coveredand You Paythe Full Cost1Featured benefits represent the most frequently used services covered under your plan; otherservices are also covered. After enrollment, DeltaCare USA will make available a complete list ofcovered services and copayments, along with any limitations and exclusions that apply. If applicable,service areas are detailed in the limitations and exclusions.2Copayments and procedure descriptions referenced above are intended to clarify the deliveryof benefits under the DeltaCare USA plan. They are not to be interpreted as CDT-2021 descriptorsor nomenclature, which are under copyright by the American Dental Association.3A copayment is the amount the enrollee pays for covered services at the time of treatment.HL DCU NY I FAM BSC 22

Service AreasCoverage is available in the following counties in New York:CayugaCortlandGeneseeKingsNassauNew estchesterSA DCU NY 22