DENTAL PROGRAM FOR KAISER PERMANENTE FEHBP ENROLLEES

Transcription

1 DENTAL PROGRAM FOR KAISER PERMANENTE FEHBP ENROLLEES You must be a Kaiser Permanente FEHBP enrollee to participate in the dental plan. KAISER PERMANENTE AND DELTA DENTAL Kaiser Permanente and Delta Dental Insurance Company recognize that good oral care is an important part of your general health. Your enrollment in a Kaiser Permanente FEHB plan option gives you and your family two ways to maintain good oral health a preventive dental benefit administered by Delta Dental (Delta Dental Premier ), which is included as part of your High Option or Standard Option benefits, and a separate optional plan (DeltaCare USA), which you may be eligible to purchase for an additional premium.*

2 PREVENTIVE DENTAL COVERAGE (DELTA DENTAL PREMIER) With your FEHBP medical coverage through Kaiser Permanente, you receive dental coverage for preventive services. Your only costs will be the patient s share of the procedure at the time of treatment. With Delta Dental Premier, you may visit the dentist of your choice, but your out-of-pocket costs are usually less when you choose to visit a Delta Dental dentist. Your FEHBP preventive dental coverage covers the following procedures: > Periodic oral evaluation > Comprehensive oral evaluation > Intraoral films, complete series > Bitewings, 2 films per six months or 4 films per year > Prophylaxis, adult > Prophylaxis, child > Topical application of fluoride, child > Topical application of fluoride, adult This is a brief description of the features of Kaiser Foundation Health Plan of Georgia, Inc. s High Option and Standard Option. Before making a final decision, please read the Plan s Federal brochure (RI ). All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochure. Your medical plan also provides coverage for a select number of other procedures such as accidental injuries and treatment of TMJ. DELTACARE USA COVERAGE (OPTIONAL PLAN*) If you would like more inclusive coverage for you and your family, you may obtain separate coverage through Delta Dental s prepaid program, for an additional monthly premium. The DeltaCare USA program has set copayments and no annual deductibles or maximums for covered benefits. Enrollees select a dentist in the DeltaCare USA network from whom they receive treatment. Coverage includes the following types of services (refer to your copayment schedule for a complete list of covered services): > X-rays > Root canals > Fillings > Orthodontics > Extractions > Dentures > Crowns > Periodontal scaling and root planing THE COST OF COVERAGE FOR DELTACARE USA IS: Monthly or Twice a year Employee $10.96 $ Employee and Spouse $18.81 $ Employee and Child(ren) $18.93 $ Employee and Family $27.29 $ Rates are effective 1/1/15 through 12/31/15. HOW TO ENROLL No enrollment form is necessary for Delta Dental Premier. If you wish to purchase the optional DeltaCare USA coverage, please see the enclosed DeltaCare USA booklet for enrollment and payment authorization forms. Delta Dental Premier and DeltaCare USA are offered and administered by Delta Dental Insurance Company (Delta Dental) in Georgia. * These benefits are neither offered nor guaranteed under contract with the FEHB program, but are made available to all enrollees and family members who become members of the Kaiser Foundation Health Plan of Georgia, Inc. s High Option and Standard Option.

3 HOW COVERAGE WORKS Your preventive dental coverage and the DeltaCare USA optional plan work differently. To help you choose the right coverage for your needs, this chart provides helpful information on how your benefits work. You must be a Kaiser Permanente FEHBP enrollee to participate in the dental plan. Features Premium cost to patient Covered services Copayments Dentist network advantages Out-of-area coverage Deductibles/maximums Additional advantages Delta Dental Premier* (preventive care benefit) Coverage already included with your medical plan. Limited to eight procedures; each procedure limited to two times per year for each covered enrollee. Bitewings are 2 films per six months or 4 films per year. Delta Dental pays 70% of the allowed amount or 70% of the fee actually charged, whichever is less. The patient pays the remaining 30%. Freedom to visit any licensed dentist each time treatment is needed: > No need to select a dental office > Ability to change dentists at any time without contacting Delta Dental Service area not restricted visit any licensed dentist: > Patients may have lower out-of-pocket costs when visiting a Delta Dental Premier dentist No deductible or maximums on covered procedures. Claims convenience Delta Dental dentists file all claim forms for you if you visit a Delta Dental dentist. DeltaCare USA (optional plan) Monthly premium applies Covers broad range of procedures listed on copayment schedule, including orthodontics, crowns and fillings. Most diagnostic and preventive services have minimal, if any, copayments. Minimal copayments on most restorative services. All covered procedures have predetermined copayments. The patient can reference the copayment schedule to know the copayment amount before a dental visit. (Employees receive the copayment schedule as part of their DeltaCare USA enrollment welcome kit, or they may refer to the enclosed DeltaCare USA brochure.) Visit your assigned DeltaCare USA dentist to receive benefits: > Ability to change primary care network dentist monthly via phone or online > Easy referrals to a large pre-screened specialty care network (referred by assigned primary care dentist) Service area applies, but out-of-area emergency care allowance covers up to $100 per incident. No annual deductible and no annual dollar maximum except for accidental injury. No claim forms required. Patient pays fixed copayment amount at time of treatment. Orthodontic takeover provision new enrollees who were previously covered by another dental plan may continue treatment with the same dentist, even if he or she is not a DeltaCare USA dentist. *This is a summary or brief description of the features of the Kaiser Foundation Health Plan of Georgia, Inc. Before making a final decision, please read the Plan s Federal brochure (RI ). All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure. Contact Us Delta Dental Premier Customer Service (includes automated voice Dentist Search, Online Eligibility, Claims Submission attendant and fax-on-demand) Benefits and Claims Status Delta Dental Insurance Company Call toll-free: deltadentalins.com P.O. Box 1809 Alpharetta, GA DeltaCare USA Customer Service (includes automated voice Dentist Search, Online Eligibility Claims and Preauthorization Submission attendant and fax-on-demand) and Benefits DeltaCare USA Call toll-free: deltadentalins.com/deltacareusa P.O. Box 1810 Alpharetta, GA

4 PAYMENT EXAMPLE USING A DELTA DENTAL PREMIER DENTIST (PREVENTIVE CARE COVERAGE) Dentist Bills Allowed Amount Delta Dental Pays Dentist (70% of allowed amount) Patient Pays Dentist (30% of allowed amount) D0120 Periodic oral evaluation $38.00 $35.00 $24.50 $10.50 D0150 Comprehensive oral evaluation $69.00 $60.00 $42.00 $18.00 D0210 Intraoral, complete series $ $ $74.20 $31.80 D0272/ Bitewings, 2 films per six D0274 months or 4 films per year $39.00 $32.00 $22.40 $9.60 D1110 Prophylaxis, adult $70.00 $65.00 $45.50 $19.50 D1120 Prophylaxis, child $60.00 $53.00 $37.10 $15.90 D1208 Topical application of fluoride (child or adult) $33.00 $27.00 $18.90 $8.10 TOTAL PATIENT PAYMENT $ PAYMENT EXAMPLE USING A NON-DELTA DENTAL DENTIST (PREVENTIVE CARE COVERAGE) Dentist Bills Allowed Amount Delta Dental Pays Dentist (70% of allowed amount) Patient Pays Dentist (30% of allowed amount plus the difference between the billed and allowed amounts) D0120 Periodic oral evaluation $38.00 $35.00 $24.50 $13.50 D0150 Comprehensive oral evaluation $69.00 $60.00 $42.00 $27.00 D0210 Intraoral, complete series $ $ $74.20 $35.80 D0272/ Bitewings, 2 films per six D0274 months or 4 films per year $39.00 $32.00 $22.40 $16.60 D1110 Prophylaxis, adult $70.00 $65.00 $45.50 $24.50 D1120 Prophylaxis, child $60.00 $53.00 $37.10 $22.90 D1208 Topical application of fluoride (child or adult) $33.00 $27.00 $18.90 $14.10 TOTAL PATIENT PAYMENT $ The claims examples above are based on average charges for ZIP codes and are intended for illustrative purposes only. Actual charges may vary by provider or geographic area. SAMPLE DELTACARE USA PATIENT COPAYMENT AMOUNTS (OPTIONAL PLAN) D0150 Comprehensive oral evaluation D0210 intraoral, complete series D0272 Bitewings, 2 films or 4 films per year Patient Pays Dentist No Cost No Cost No Cost D1110 Prophylaxis, adult $10.00 D1120 Prophylaxis, child $10.00 D1208 Topical application of fluoride (child) D1208 Topical application of fluoride (adult) DeltaCare USA enrollees will receive a complete schedule of copayments with their enrollment materials. No Cost Not Covered E #78958_FEHP (rev. 07/14)

5 YOUR SMILE IS COVERED The DeltaCare USA program is the prepaid plan available to FEHBP members for an additional premium. DELTACARE USA PROVIDED BY DELTA DENTAL INSURANCE COMPANY KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC. SCGACS04 WE KEEP YOU SMILING HL_DCU_GAA11_5450_V14_

6 Welcome To DeltaCare USA Quality, Convenience, Predictable Costs DeltaCare USA is a dental program that provides you and your family with quality dental benefits at an affordable cost. The DeltaCare USA program is designed to encourage you and your family to visit the dentist regularly to maintain your dental health. When you enroll, you select a contract dentist to provide services. The DeltaCare USA network consists of private practice dental facilities that have been carefully screened for quality. ENROLL IN DELTACARE USA AND YOU LL ENJOY THESE FEATURES: QUALITY > Extensive benefits for you and your family > No restrictions on pre existing conditions, except for work in progress > Large, stable network of dentists, so you can enjoy a long term relationship with your dentist CONVENIENCE > No claim forms to complete > Expanded business hours for toll free customer service, from 8 a.m. to 9 p.m., Eastern time PREDICTABLE COSTS > No deductibles > Out of pocket costs are clearly defined > Out of area dental emergency coverage up to $100 per emergency > No annual or lifetime dollar maximums except for accidental injury DeltaCare USA is administered by Delta Dental Insurance Company (Delta Dental). These benefits are neither offered nor guaranteed under contract with the FEHB Program, but are made available to all enrollees and family members who become members of a Kaiser Foundation Health Plan of Georgia, Inc., FEHBP health plan option. FIND A DELTACARE USA DENTIST Select from among the many conveniently located DeltaCare USA contracted general dentists. To find the most current listing of DeltaCare USA dental offices you can: > Visit our website at deltadentalins.com/enrollees. Under Find a dentist, select DeltaCare USA as your network. > Call Customer Service at for help in finding a DeltaCare USA dentist.

7 e Highlights of your DeltaCare USA Program Eligibility for you and your family What if I have questions about my DeltaCare USA Program? If you are a subscriber in a Kaiser Foundation Health Plan of Georgia, Inc. FEHBP health plan option, you can enroll in the DeltaCare USA program. You may also enroll eligible dependents. Easy enrollment Simply complete the enclosed Dental Enrollment Form. Be sure to indicate a dentist (from the list of contract dental facilities) for both yourself and your eligible dependents. Include the name of your group. Payment choices include the automatic deduction option, for which you will need to enclose a check for the first month's payment and a voided blank check, or the semi-annual payment option, for which you will need to enclose a check for the first semi-annual payment. How your DeltaCare USA program works Your selected contract dentist will take care of your dental care needs. If you require treatment from a specialist, your contract dentist will handle the referral for you. After you have enrolled, you will receive a membership packet that includes an identification card and an Evidence of Coverage that fully describes the benefits of your dental program. Also included in this packet are the name, address and phone number of your contract dentist. Simply call the dental facility to make an appointment. Under the DeltaCare USA program, many services are covered at no cost, while others have copayments (amount you pay your contract dentist) for certain benefits. See the "Description of Benefits and Copayments" for a list of your benefits. Please note: Dental services that are not performed by your selected contract dentist, a contract specialist or are not covered under provisions for emergency care below, are not covered by your DeltaCare USA program. Provisions for emergency care Under your DeltaCare USA program, you and your eligible dependents are covered for out-of-area dental emergencies (35 or more miles from your contract dentist). Your program pays up to $100 for emergency dental expenses per emergency for each enrollee. Accident injury benefit The DeltaCare USA program provides coverage for accidental injury (caused by external forces) at 100% of the contract dentist's "filed fees" for benefits (less any applicable copayments). The enrollee must be eligible under the DeltaCare USA program when the accident occurs. Accident injury benefits are subject to a $1,600 maximum, per 12 months, per person. My dentist is a Delta Dental dentist but is not on the list of DeltaCare USA dentists. Can I still receive treatment from this dentist? You must receive treatment from your selected DeltaCare USA contract dentist. Please note that Delta Dental dentists are not necessarily DeltaCare USA dentists. Do my family members receive treatment from the same DeltaCare USA contract dentist? You and your eligible dependents may receive care from the same contract dentist, or if you prefer, you may collectively select up to a maximum of three contract dental facilities. Can I change my contract dentist? You may change contract dentists by notifying us either by phone or in writing, or by visiting our website (deltadentalins.com). If you contact us by the 21st of the month, the change will become effective the first of the following month. 1

8 e Highlights of your DeltaCare USA Program Can I have my teeth whitened under the DeltaCare USA program? External bleaching is a benefit under your program, subject to certain limitations. Talk to your contract dentist about your options. Does my DeltaCare USA program cover tooth-colored fillings and crowns on molars? The upgrade to porcelain and other tooth-colored materials on molars is included as a benefit under your program. The copayment shows you what your out of pocket cost will be. How long does it take to get an appointment with a DeltaCare USA dentist? Two to four weeks is a reasonable amount of time to wait for a routine, non-urgent appointment. If you require a specific time, you may have to wait longer. Most DeltaCare USA dentists are in private group practices, which means greater appointment availability and extended office hours. Are pre-existing dental conditions and work in progress covered? Treatment for pre-existing conditions, such as extracted teeth, is covered under the DeltaCare USA program. However, benefits are not provided for any dental treatment started before joining the program (that is, work in progress, such as preparations for crowns, root canals and impressions for dentures). Orthodontic treatment in progress may be covered for new DeltaCare USA enrollees. See the "Limitations and Exclusions of Benefits." How does the DeltaCare USA program encourage preventive care? Your DeltaCare USA program is designed to encourage regular visits to the dentist by having no copayments (fees you pay to the contract dentist) on most diagnostic and preventive benefits. See the enclosed "Description of Benefits and Copayments." Does my DeltaCare USA program cover specialists' services? Your contract dentist will coordinate your specialty care needs for oral surgery, endodontics, periodontics or pediatric dentistry with an approved contract specialist. If there is no contract specialist within your service area, there are no benefits for specialist services. What if I have questions about my DeltaCare USA program? Call Customer Service at We have multilingual representatives available from 8 a.m. to 9 p.m. Eastern time, Monday through Friday. Our Customer Service representatives can answer benefits questions, as well as arrange facility transfers and urgent care referrals. Our Customer Service representatives have can answer worked benefits in dental questions facilities and as can well as answer arrange benefits facility transfers questions, and as well urgent care as arrange referrals facility transfers and urgent care referrals. 2

9 Plan GAA11 DeltaCare USA Description of Benefits and Copayments SCHEDULE A Description of Benefits and Copayments The Benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the Program. Please refer to Schedule B for further clarification of Benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered. Text that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA program and is not to be interpreted as CDT-2015 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation. ENROLLEE CODE DESCRIPTION PAYS D0100-D0999 I. DIAGNOSTIC - When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * D0120 Periodic oral evaluation - established patient... No Cost D0140 Limited oral evaluation - problem focused... No Cost D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver... No Cost D0150 Comprehensive oral evaluation - new or established patient... No Cost D0160 Detailed and extensive oral evaluation - problem focused, by report... No Cost D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit)... No Cost D0171 Re-evaluation - post-operative office visit... $5.00 D0180 Comprehensive periodontal evaluation - new or established patient... No Cost D0190 Screening of a patient... No Cost D0191 Assessment of a patient... No Cost D0210 Intraoral - complete series of radiographic images - limited to 1 series every 24 months... No Cost D0220 Intraoral - periapical first radiographic image... No Cost D0230 Intraoral - periapical each additional radiographic image... No Cost D0240 Intraoral - occlusal radiographic image... No Cost D0250 Extraoral - first radiographic image... No Cost D0260 Extraoral - each additional radiographic image... No Cost D0270 Bitewing - single radiographic image... No Cost D0272 Bitewings - two radiographic images... No Cost D0273 Bitewings three radiographic images... No Cost D0274 Bitewings - four radiographic images - limited to 1 series every 6 months... No Cost D0277 Vertical bitewings - 7 to 8 radiographic images... No Cost D0330 Panoramic radiographic image... No Cost D0460 Pulp vitality tests... No Cost D0470 Diagnostic casts... No Cost D0472 Accession of tissue, gross examination, preparation and transmission of written report... No Cost D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report... No Cost D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report... No Cost D0999 Unspecified diagnostic procedure, by report - includes office visit, per visit (in addition to other services)... $10.00 D1000-D1999 II. PREVENTIVE - When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * D1110 Prophylaxis cleaning - adult - 1 per 6 month period... $10.00 D1120 Prophylaxis cleaning - child - 1 per 6 month period... $10.00 D1206 Topical application of fluoride varnish - child to age 19; 1 D1206 or D1208 per 6 month period... No Cost D1208 Topical application of fluoride - excluding varnish - child to age 19; 1 D1206 or D1208 per 6 month period... No Cost D1310 Nutritional counseling for control of dental disease... No Cost D1330 Oral hygiene instructions... No Cost D1351 Sealant - per tooth - limited to permanent molars through age $18.00 D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth - limited to permanent molars through age $18.00 D1353 Sealant repair - per tooth - limited to permanent molars through age $18.00 D1510 Space maintainer - fixed - unilateral... $ D1515 Space maintainer - fixed - bilateral... $

10 Plan GAA11 DeltaCare USA Description of Benefits and Copayments D1520 Space maintainer - removable - unilateral... $ D1525 Space maintainer - removable - bilateral... $ D1550 Re-cement or re-bond space maintainer... $18.00 D1555 Removal of fixed space maintainer... $18.00 D2000-D2999 III. RESTORATIVE - When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * - Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures. D2140 Amalgam - one surface, primary or permanent... $28.00 D2150 Amalgam - two surfaces, primary or permanent... $32.00 D2160 Amalgam - three surfaces, primary or permanent... $35.00 D2161 Amalgam - four or more surfaces, primary or permanent... $40.00 D2330 Resin-based composite - one surface, anterior (tooth colored)... $36.00 D2331 Resin-based composite - two surfaces, anterior (tooth colored)... $42.00 D2332 Resin-based composite - three surfaces, anterior (tooth colored)... $47.00 D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) (tooth colored)... $53.00 D2390 Resin-based composite crown, anterior... $78.00 D2391 Resin-based composite - one surface, posterior (tooth colored)... $75.00 D2392 Resin-based composite - two surfaces, posterior (tooth colored)... $80.00 D2393 Resin-based composite - three surfaces, posterior (tooth colored)... $85.00 D2394 Resin-based composite - four or more surfaces, posterior (tooth colored)... $ D2510 Inlay - metallic - one surface 1, 2... $ D2520 Inlay - metallic - two surfaces 1, 2... $ D2530 Inlay - metallic - three or more surfaces 1, 2... $ D2542 Onlay - metallic - two surfaces 1, 2... $ D2543 Onlay - metallic - three surfaces 1, 2... $ D2544 Onlay - metallic - four or more surfaces 1, 2... $ D2610 Inlay - porcelain/ceramic - one surface 1... $ D2620 Inlay - porcelain/ceramic - two surfaces 1... $ D2630 Inlay - porcelain/ceramic - three or more surfaces 1... $ D2642 Onlay - porcelain/ceramic - two surfaces 1... $ D2643 Onlay - porcelain/ceramic - three surfaces 1... $ D2644 Onlay - porcelain/ceramic - four or more surfaces 1... $ D2650 Inlay - resin-based composite - one surface (tooth colored) 1... $ D2651 Inlay - resin-based composite - two surfaces (tooth colored) 1... $ D2652 Inlay - resin-based composite - three or more surfaces (tooth colored) 1... $ D2662 Onlay - resin-based composite - two surfaces (tooth colored) 1... $ D2663 Onlay - resin-based composite - three surfaces (tooth colored) 1... $ D2664 Onlay - resin-based composite - four or more surfaces (tooth colored) 1... $ D2710 Crown - resin-based composite (indirect) 1... $ D2710 Crown - resin-based composite (indirect) - (molars) 1... $ D2712 Crown - ¾ resin-based composite (indirect) 1... $ D2712 Crown - ¾ resin-based composite (indirect) - (molars) 1... $ D2720 Crown - resin with high noble metal 1... $ D2720 Crown - resin with high noble metal - (molars) 1... $ D2721 Crown - resin with predominantly base metal 1... $ D2721 Crown - resin with predominantly base metal - (molars) 1... $ D2722 Crown - resin with noble metal 1... $ D2722 Crown - resin with noble metal - (molars) 1... $ D2740 Crown - porcelain/ceramic substrate 1... $ D2740 Crown - porcelain/ceramic substrate - (molars) 1... $ D2750 Crown - porcelain fused to high noble metal 1... $ D2750 Crown - porcelain fused to high noble metal - (molars) 1... $ D2751 Crown - porcelain fused to predominantly base metal 1... $ D2751 Crown - porcelain fused to predominantly base metal - (molars) 1... $ D2752 Crown - porcelain fused to noble metal 1... $

11 Plan GAA11 DeltaCare USA Description of Benefits and Copayments D2752 Crown - porcelain fused to noble metal - (molars) 1... $ D2780 Crown - ¾ cast high noble metal 1... $ D2781 Crown - ¾ cast predominantly base metal 1... $ D2782 Crown - ¾ cast noble metal 1... $ D2783 Crown - ¾ porcelain/ceramic 1... $ D2783 Crown - ¾ porcelain/ceramic - (molars) 1... $ D2790 Crown - full cast high noble metal 1... $ D2791 Crown - full cast predominantly base metal 1... $ D2792 Crown - full cast noble metal 1... $ D2794 Crown - titanium 1... $ D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restorations... $18.00 D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core... $18.00 D2920 Re-cement or re-bond crown... $18.00 D2921 Reattachment of tooth fragment, incisal edge or cusp (anterior) (tooth colored)... $53.00 D2929 Prefabricated porcelain/ceramic crown - primary tooth - anterior primary tooth... $ D2930 Prefabricated stainless steel crown - primary tooth... $ D2931 Prefabricated stainless steel crown - permanent tooth... $ D2932 Prefabricated resin crown - anterior primary tooth... $ D2933 Prefabricated stainless steel crown with resin window - anterior primary tooth... $ D2940 Protective restoration... $30.00 D2941 Interim therapeutic restoration - primary dentition... $30.00 D2949 Restorative foundation for an indirect restoration... $34.00 D2950 Core buildup, including any pins when required... $34.00 D2951 Pin retention - per tooth, in addition to restoration... $34.00 D2952 Post and core in addition to crown, indirectly fabricated 2... $85.00 D2953 Each additional indirectly fabricated post - same tooth 2... $85.00 D2954 Prefabricated post and core in addition to crown... $70.00 D2957 Each additional prefabricated post - same tooth... $70.00 D2970 Temporary crown (fractured tooth) - palliative treatment only... $18.00 D2971 Additional procedures to construct new crown under existing partial denture framework... $66.00 D2980 Crown repair necessitated by restorative material failure... $45.00 D2981 Inlay repair necessitated by restorative material failure... $45.00 D2982 Onlay repair necessitated by restorative material failure... $45.00 D2983 Veneer repair necessitated by restorative material failure... $45.00 D2990 Resin infiltration of incipient smooth surface lesions - limited to permanent molars through age $18.00 D3000-D3999 IV. ENDODONTICS - When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * D3110 Pulp cap - direct (excluding final restoration)... $18.00 D3120 Pulp cap - indirect (excluding final restoration)... $18.00 D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament... $25.00 D3221 Pulpal debridement, primary and permanent teeth... $44.00 D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development... $25.00 D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)... $44.00 D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)... $44.00 D3310 Root canal - endodontic therapy, anterior tooth (excluding final restoration) 3... $ D3320 Root canal - endodontic therapy, bicuspid tooth (excluding final restoration) 3... $ D3330 Root canal - endodontic therapy, molar (excluding final restoration) 3... $ D3346 Retreatment of previous root canal therapy - anterior 3... $ D3347 Retreatment of previous root canal therapy - bicuspid 3... $ D3348 Retreatment of previous root canal therapy - molar 3... $ D3410 Apicoectomy - anterior 3... $ D3421 Apicoectomy - bicuspid (first root) 3... $ D3425 Apicoectomy - molar (first root) 3... $ D3426 Apicoectomy (each additional root) 3... $

12 Plan GAA11 DeltaCare USA Description of Benefits and Copayments D3427 Periradicular surgery without apicoectomy... $ D3430 Retrograde filling - per root 3... $84.00 D3450 Root amputation, per root - not covered in conjunction with a hemisection 3... $96.00 D4000-D4999 V. PERIODONTICS - When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * - Includes preoperative and postoperative evaluations and treatment under a local anesthetic. D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant... $ D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant... $ D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth... $ D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per D4241 quadrant... $ Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant... $ D4249 Clinical crown lengthening - hard tissue... $ D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant... $ D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant... $ D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area)... $ D4341 Periodontal scaling and root planing - four or more teeth per quadrant - limited to 4 quadrants during any 12 consecutive months... $78.00 D4342 Periodontal scaling and root planing - one to three teeth per quadrant - limited to 4 quadrants during any 12 consecutive months... $78.00 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis - limited to 1 treatment in any 12 consecutive months... $78.00 D4910 Periodontal maintenance - limited to 1 treatment each 6 month period... $62.00 D4921 Gingival irrigation - per quadrant... No Cost D5000-D5899 VI. PROSTHODONTICS (removable) D5110 Complete denture - maxillary 4, 5... $ D5120 Complete denture - mandibular 4, 5... $ D5130 Immediate denture - maxillary 4, 5... $ D5140 Immediate denture - mandibular 4, 5... $ D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 4, 5... $ D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) 4, 5... $ D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 4, 5... $ D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 4, 5... $ D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth) 4, 5... $ D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth) 4, 5... $ D5410 Adjust complete denture - maxillary 4... $18.00 D5411 Adjust complete denture - mandibular 4... $18.00 D5421 Adjust partial denture - maxillary 4... $18.00 D5422 Adjust partial denture - mandibular 4... $18.00 D5510 Repair broken complete denture base... $40.00 D5520 Replace missing or broken teeth - complete denture (each tooth)... $18.00 D5610 Repair resin denture base... $40.00 D5620 Repair cast framework... $40.00 D5630 Repair or replace broken clasp... $40.00 D5640 Replace broken teeth - per tooth... $18.00 D5650 Add tooth to existing partial denture... $18.00 D5660 Add clasp to existing partial denture... $18.00 D5670 Replace all teeth and acrylic on cast metal framework (maxillary)... $ D5671 Replace all teeth and acrylic on cast metal framework (mandibular)... $ D5710 Rebase complete maxillary denture 6... $

13 Plan GAA11 DeltaCare USA Description of Benefits and Copayments D5711 Rebase complete mandibular denture 6... $ D5720 Rebase maxillary partial denture 6... $ D5721 Rebase mandibular partial denture 6... $ D5730 Reline complete maxillary denture (chairside) 6... $84.00 D5731 Reline complete mandibular denture (chairside) 6... $84.00 D5740 Reline maxillary partial denture (chairside) 6... $84.00 D5741 Reline mandibular partial denture (chairside) 6... $84.00 D5750 Reline complete maxillary denture (laboratory) 6... $ D5751 Reline complete mandibular denture (laboratory) 6... $ D5760 Reline maxillary partial denture (laboratory) 6... $ D5761 Reline mandibular partial denture (laboratory) 6... $ D5820 Interim partial denture (maxillary) 4... $40.00 D5821 Interim partial denture (mandibular) 4... $40.00 D5850 Tissue conditioning, maxillary 4, 6... $40.00 D5851 Tissue conditioning, mandibular 4, 6... $40.00 D5900-D5999 D6000-D6199 VII. MAXILLOFACIAL PROSTHETICS - Not Covered VIII. IMPLANT SERVICES - Not Covered D6200-D6999 IX. PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture [bridge]) D6210 Pontic - cast high noble metal 7... $ D6211 Pontic - cast predominantly base metal 7... $ D6212 Pontic - cast noble metal 7... $ D6240 Pontic - porcelain fused to high noble metal 7... $ D6240 Pontic - porcelain fused to high noble metal - (molars) 7... $ D6241 Pontic - porcelain fused to predominantly base metal 7... $ D6241 Pontic - porcelain fused to predominantly base metal - (molars) 7... $ D6242 Pontic - porcelain fused to noble metal 7... $ D6242 Pontic - porcelain fused to noble metal - (molars) 7... $ D6245 Pontic - porcelain/ceramic 7... $ D6245 Pontic - porcelain/ceramic - (molars) 7... $ D6250 Pontic - resin with high noble metal 7... $ D6250 Pontic - resin with high noble metal - (molars) 7... $ D6251 Pontic - resin with predominantly base metal 7... $ D6251 Pontic - resin with predominantly base metal - (molars) 7... $ D6252 Pontic - resin with noble metal 7... $ D6252 Pontic - resin with noble metal - (molars) 7... $ D6600 Inlay - porcelain/ceramic, two surfaces 7... $ D6601 Inlay - porcelain/ceramic, three or more surfaces 7... $ D6602 Inlay - cast high noble metal, two surfaces 7... $ D6603 Inlay - cast high noble metal, three or more surfaces 7... $ D6604 Inlay - cast predominantly base metal, two surfaces 7... $ D6605 Inlay - cast predominantly base metal, three or more surfaces 7... $ D6606 Inlay - cast noble metal, two surfaces 7... $ D6607 Inlay - cast noble metal, three or more surfaces 7... $ D6608 Onlay - porcelain/ceramic, two surfaces 7... $ D6609 Onlay - porcelain/ceramic, three or more surfaces 7... $ D6610 Onlay - cast high noble metal, two surfaces 7... $ D6611 Onlay - cast high noble metal, three or more surfaces 7... $ D6612 Onlay - cast predominantly base metal, two surfaces 7... $ D6613 Onlay - cast predominantly base metal, three or more surfaces 7... $ D6614 Onlay - cast noble metal, two surfaces 7... $ D6615 Onlay - cast noble metal, three or more surfaces 7... $ D6720 Crown - resin with high noble metal 7... $

14 Plan GAA11 DeltaCare USA Description of Benefits and Copayments D6720 Crown - resin with high noble metal - (molars) 7... $ D6721 Crown - resin with predominantly base metal 7... $ D6721 Crown - resin with predominantly base metal - (molars) 7... $ D6722 Crown - resin with noble metal 7... $ D6722 Crown - resin with noble metal - (molars) 7... $ D6740 Crown - porcelain/ceramic 7... $ D6740 Crown - porcelain/ceramic - (molars) 7... $ D6750 Crown - porcelain fused to high noble metal 7... $ D6750 Crown - porcelain fused to high noble metal - (molars) 7... $ D6751 Crown - porcelain fused to predominantly base metal 7... $ D6751 Crown - porcelain fused to predominantly base metal - (molars) 7... $ D6752 Crown - porcelain fused to noble metal 7... $ D6752 Crown - porcelain fused to noble metal - (molars) 7... $ D6780 Crown - ¾ cast high noble metal 7... $ D6781 Crown - ¾ cast predominantly base metal 7... $ D6782 Crown - ¾ cast noble metal 7... $ D6783 Crown - ¾ porcelain/ceramic 7... $ D6783 Crown - ¾ porcelain/ceramic - (molars) 7... $ D6790 Crown - full cast high noble metal 7... $ D6791 Crown - full cast predominantly base metal 7... $ D6792 Crown - full cast noble metal 7... $ D6930 Re-cement or re-bond fixed partial denture... $26.00 D6940 Stress breaker 7... $66.00 D6980 Fixed partial denture repair necessitated by restorative material failure... $50.00 D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY - When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * - Includes preoperative and postoperative evaluations and treatment under a local anesthetic. D7111 Extraction, coronal remnants - deciduous tooth... $22.00 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)... $22.00 D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated... $48.00 D7220 Removal of impacted tooth - soft tissue... $84.00 D7230 Removal of impacted tooth - partially bony... $ D7240 Removal of impacted tooth - completely bony... $ D7241 Removal of impacted tooth - completely bony, with unusual surgical complications... $ D7250 Surgical removal of residual tooth roots (cutting procedure)... $65.00 D7251 Coronectomy - intentional partial tooth removal... $ D7286 Incisional biopsy of oral tissue - soft - does not include pathology laboratory procedures... $35.00 D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant... $80.00 D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant... $80.00 D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant... $ D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant... $ D7471 Removal of lateral exostosis (maxilla or mandible)... $80.00 D7472 Removal of torus palatinus... $80.00 D7473 Removal of torus mandibularis... $80.00 D7510 Incision and drainage of abscess - intraoral soft tissue... $35.00 D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure $90.00 D8000-D8999 XI. ORTHODONTICS ** If a Copayment dollar amount is not listed, Enrollee pays 75 percent of the Contract Orthodontist's "filed fees." D8050 Interceptive orthodontic treatment of the primary dentition 8... ** D8060 Interceptive orthodontic treatment of the transitional dentition 8... ** D8070 Comprehensive orthodontic treatment of the transitional dentition - child or adolescent to age ** D8080 Comprehensive orthodontic treatment of the adolescent dentition - adolescent to age ** 8

15 Plan GAA11 DeltaCare USA Description of Benefits and Copayments D8090 D8660 Comprehensive orthodontic treatment of the adult dentition - adults, including covered dependent adult children 8... ** Pre-orthodontic treatment examination to monitor growth and development - not to be charged with any other consultation procedure(s) 9... No Cost D8680 Orthodontic retention (removal of appliances, construction and placement of removable retainers) ** D8999 Unspecified orthodontic procedure, by report - includes the START-UP FEE, which includes initial examination, diagnosis, consultation and initial banding... $ D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICES - When referable services are provided by a Contract Specialist, the Enrollee pays 75 percent of that Dentist's "filed fees." * D9110 Palliative (emergency) treatment of dental pain - minor procedure... $18.00 D9211 Regional block anesthesia... No Cost D9212 Trigeminal division block anesthesia... No Cost D9215 Local anesthesia in conjunction with operative or surgical procedures... No Cost D9219 Evaluation for deep sedation or general anesthesia... No Cost D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician... $30.00 D9430 Office visit for observation (during regularly scheduled hours) - no other services performed... $5.00 D9440 Office visit - after regularly scheduled hours... $28.00 D9450 Case presentation, detailed and extensive treatment planning... No Cost D9931 Cleaning and inspection of a removable appliance... No Cost D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays... $ D9986 Missed appointment - without 24 hour notice - per 15 minutes of appointment time... $18.00 D9987 Canceled appointment - without 24 hour notice - per 15 minutes of appointment time... $18.00 * If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed procedures that are not available in the contract facility or that require a Dentist to provide specialized services, may be provided by a contracted oral surgeon, endodontist, periodontist or pediatric dentist at 75 percent of the Contract Specialist's "filed fees." Specialist services are only available in areas where there is a DeltaCare USA Contract Specialist, and upon referral by the assigned Contract Dentist. Procedures not listed above are not covered, however, may be available at the Contract Dentist's "filed fees." "Filed fees" means the Contract Dentist's fees on file with Delta Dental. Questions regarding these fees should be directed to the Customer Service department at Emergency Services - The Contract Dentist is responsible for providing covered emergency dental care while an Enrollee is within 35 miles of the contract facility. If an Enrollee is more than 35 miles from the Contract Dentist's facility, Delta Dental will reimburse the Enrollee for the cost of covered emergency dental care, less any applicable Enrollee copayments, to a maximum of $ per enrollee, per emergency. All services are subject to the limitations and exclusions of the program. Accident Injury Benefit - this program provides coverage for dental accident injuries up to 100 percent of the Dentist's usual fee, less any applicable Enrollee copayments, to a maximum of $1, per Enrollee, in any 12-month period. The benefit is subject to the limitations and exclusions of the program. FOOTNOTES 1 Replacement is subject to a limitation requiring the existing restoration to be 5+ years old. 2 Base or noble metal is the benefit. If an inlay, onlay or indirectly fabricated post and core is made of high noble metal, an additional fee up to $ per tooth will be charged for the upgrade. 3 A benefit for permanent teeth only. 4 Includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement, if the Enrollee continues to be eligible and the service is provided at the Contract Dentist's facility where the denture was originally delivered. 5 Replacement is subject to a limitation requiring the existing denture to be 5+ years old. 6 Limited to 1 per denture during any 12 consecutive months. 7 Replacement is subject to a limitation requiring the existing bridge to be 5+ years old. 8 Listed Copayment covers up to 24 months of active orthodontic treatment excluding the services listed for D8999 (Startup fee), and D8680 (Orthodontic retention). Beyond 24 months, an additional monthly fee not to exceed 75 percent of the Contract Orthodontist's "filed fee" applies. 9

16 Plan GAA11 DeltaCare USA Description of Benefits and Copayments 9 In the event orthodontic treatment is not required or is declined by the Enrollee, a fee of $50.00 will apply. The Enrollee is also responsible for any incurred orthodontic diagnostic record fees. 10 Includes adjustments and/or office visits up to 24 months. After 24 months, a monthly fee not to exceed 75 percent of the Contract Orthodontist's "filed fee" applies. 10

17 DENTAL ENROLLMENT FORM 1 Primary Enrollee Information DIRECTIONS: Please complete items 1 through 6 on both sides of the page. Indicate your choice of Contract Facilities as well as those of your dependents (if applicable). Once you have completed items 1 through 2, please indicate one payment option choice on the reverse side. Name: (Last) (First) (M.I.) Mailing Address: (Street Address) (City) (State) (Zip Code) Home Phone #: ( ) Address Soc. Security #: Employee Identification #: Date of Birth: (Month) (Day) (Year) Dental Facility Name: Dental Facility #: 2 Dependent Information Note: You may choose up to three separate offices for yourself and all dependent enrollees. (To add additional dependents, please attach a separate sheet.) PLEASE LIST ELIGIBLE DEPENDENTS TO BE COVERED IN ADDITION TO YOURSELF Relationship Code * Dependent Name Male/ Female (Check One) M F Date of Birth Contract Facility Name Contract Facility #: (Month) (Day) (Year) *Relationship Codes: Place the following two character code in the first column to designate each dependent as follows: Spouse - SP Child - CH Kaiser Foundation Health Plan for Georgia Continue on reverse side

18 AUTOMATIC PAYMENT AUTHORIZATION FORM For your convenience, Delta Dental has made it possible to choose from two payment options. Your monthly premium may be paid directly to Delta Dental or you may choose to elect automatic deduction. Please choose ONE payment method only. 3 Automatic Deduction Payment Option 4 Semi-Annual Payment Option 1.) Complete and sign the Automatic Payment Authorization section on the enrollment form. Be sure to enclose a voided blank check from this account. 2.) Enclose a check for the first month s premium. 3.) Your monthly dues will be deducted from the account specified on the 15th of each month prior to the coverage month (e.g., April dues will be deducted on March 15th). Your coverage will automatically be terminated if your automatic deduction is declined by your bank for insufficient funds, a closed account, etc. 4.) Return the enrollment materials, along with the first month s payment, by the 15th for coverage to begin the 1st of the following month. Delta Dental Insurance Company Dept 0170 Los Angeles, CA I choose the Automatic Deduction Payment Option. Checking Savings Credit Union account MONTHLY (AUTOMATIC DEDUCTION) Employee $ Employee + Spouse $ Employee + Child $ Employee + 2 or more $ OR 1.) Submit the first payment with your enrollment form. Once enrolled, you will be billed thereafter. Dues must be paid in full by the 15th of the month prior to the coverage month or your coverage will be automatically terminated. You cannot break coverage. 2.) Return the enrollment form and the first payment by the 15th of the month for coverage to begin the 1st of the following month. Delta Dental Insurance Company Dept 0170 Los Angeles, CA I choose the Semi-Annual Payment Option SEMI-ANUALLY (PAYMENT BY CHECK) Employee $ Employee + Spouse $ Employee + Child $ Employee + 2 or more $ Rates effective 01/01/ /31/2014 Rates effective 01/01/ /31/ Automatic Deduction Payment Authorization (If Automatic Deduction was completed) I (we) hereby authorize Delta Dental to charge the applicable monthly dues for dental coverage to my account designated below. I understand that coverage will only become and remain effective if there are sufficient funds at the time of the deduction. I understand eligibility begins the first of the month following my initital deduction. This authority to deduct funds from my account is to remain in full force and effective until I notify Delta Dental in writing 30 days prior to termination. I also understand there cannot be any lapse of coverage in a 12-month period from the time of my enrollment. I agree to comply with the terms as outlined in the Combined Evidence of Coverage and Disclosure Form. (My bank is authorized to make corrections if any should be necessary.) Bank or savings and loan name Branch Branch telephone number City, State ZIP code Account number ABA (bank routing #) 6 Signature I hereby enroll in the DeltaCare USA program. I understand that enrollment in the dental plan is for a period of one year, and that I will no longer be eligible for coverage if I fail to maintain my membership. Signature of Enrollee Date

19 Limitations and Exclusions of Benefits SCHEDULE B Limitations of Benefits 1. A full mouth x-ray series (including any combination of periapicals or bitewings with a panoramic film) or a series of seven or more vertical bitewings is limited to one series every 24 months. 2. Bitewing x-rays are limited to not more than one series of four films in any six month period. 3. Diagnostic casts are limited to aid in diagnosis by the Contract Dentist for covered benefits. 4. Prophylaxis or periodontal maintenance is limited to one procedure each six month period. 5. Benefits for sealants include the application of sealants only to permanent first and second molars with no decay, with no restorations and with the occlusal surface intact through age 15. Benefits for sealants do not include the repair or replacement of a sealant on any tooth within three years of its application. 6. Amalgams and composites are benefits for the removal of decay, for minor repairs of tooth structure or to replace a lost or failing restoration. 7. The placement of a crown, inlay or onlay is a benefit when there is insufficient tooth structure to support a filling. Replacement of an existing crown, inlay or onlay that is non-functional or non-restorable is a benefit when the existing restoration is five+ years old. 8. If a porcelain margin is also chosen by the Enrollee for a covered porcelain-fused-to-metal crown, the maximum additional cost for this laboratory upgrade is $ A covered metallic inlay, onlay, or indirectly fabricated post and core using base or noble metal is available for listed Copayment(s). If the Enrollee elects to have high noble metal used instead, the maximum additional cost of this material upgrade is $ per tooth. 10. A direct or indirect pulp cap is a benefit only on a vital permanent tooth with an open apex or a vital primary tooth. 11. With the exception of pulp caps and pulpotomies, endodontic procedures (e.g. root canal therapy, apicoectomy, retrofill, etc.) are only a benefit on a permanent tooth with pathology. 12. A therapeutic pulpotomy on a permanent tooth is limited to palliative treatment when the Contract Dentist is not performing root canal therapy. 13. Clinical crown lengthening - hard tissue is limited to one per tooth per lifetime. 14. Periodontal scaling and root planing are limited to four quadrants during any 12 month period. 15. Full mouth debridement (gross scale) is limited to one treatment in any 12 month period. 16. Coverage for the placement of a fixed partial denture ("bridge") is limited to: a. The initial placement of a bridge when all the following conditions are present: - a single permanent tooth requires prosthetic replacement. - the abutment teeth can adequately support and retain a new bridge. - the missing tooth cannot be replaced by adding a prosthetic tooth to a serviceable existing removable partial denture. - no other missing teeth in the same arch require prosthetic replacement with a new removable partial denture; and (for a bridge replacing a posterior tooth) one or more of the abutment teeth meet Limitation #7. b. The replacement of an existing bridge that is not serviceable due to decay, fracture or other non-cosmetic defect, if: - the existing bridge is at least five years old; and - the same abutment teeth can adequately support and retain a new bridge; and - no other missing teeth in the same arch require prosthetic replacement. 17. Coverage for a new removable partial or complete denture is limited to: a. The initial placement of removable partial or complete denture in an arch when: - one or more permanent teeth require prosthetic replacement; and - the missing tooth/teeth cannot be replaced by adding a prosthetic tooth to a serviceable existing removable partial denture; and - (for partial dentures only) there are suitable abutment teeth to retain and support a removable partial denture. b. The replacement of an existing removable partial or complete denture with non-cosmetic defect(s) that cause the denture to be non-serviceable if: - the existing removable denture is at least five years old; and - the existing removable denture cannot be made serviceable by adjustment, repair, relining or rebasing. 11

20 Limitations and Exclusions of Benefits 18. Relines, tissue conditioning and rebases are limited to one per denture during any 12 consecutive months. 19. Interim partial dentures (stayplates), in conjunction with fixed or removable appliances, are limited to: - The replacement of extracted anterior teeth for adults during a healing period when the teeth cannot be added to an existing partial denture or - The replacement of permanent tooth/teeth for children under 16 years of age. 20. A new removable partial, complete or immediate denture includes after delivery adjustments and tissue conditioning at no additional cost for the first six months after placement if the Enrollee continues to be eligible and the service is provided at the Contract Dentist's facility where the denture was originally delivered. 21. Retained primary teeth shall be covered as primary teeth. 22. Excision of the frenum is a benefit only when it results in limited mobility of the tongue, it causes a large diastema between teeth or it interferes with a prosthetic appliance. 23. External bleaching is limited to fabrication of one bleaching tray per arch; bleaching gel for two weeks of patient self treatment; and no more than one treatment per arch, per 36 months. 24. Benefits provided by a contract pediatric Dentist are available at 75 percent of the specialist's "filed fees." Referral by the assigned Contract Dentist is required before services are received. 25. Benefits for a soft tissue management program are limited to those parts, which are listed covered services listed on Schedule A. If an Enrollee declines non-covered services within a soft tissue management program, it does not eliminate or alter other covered benefits. 26. Emergency Services - The Contract Dentist is responsible for providing covered emergency dental care while an Enrollee is within 35 miles of the Contract Dentist's facility. If an Enrollee requires emergency dental care and is more than 35 miles from the Contract Dentist's facility, then Delta Dental will reimburse the Enrollee for the cost of covered emergency dental care, less any applicable Enrollee copayments, to a maximum of $ per Enrollee, per emergency. Emergency dental care is limited to listed procedures required to alleviate severe pain, swelling and/or bleeding or to avoid placing the Enrollee's health in serious jeopardy. Any further treatment of the cause of such emergency dental care must be preauthorized by Delta Dental or provided by the assigned Contract Dentist. All services are subject to the limitations and exclusions of the program. 27. Accident Injury Benefit - An accident injury is damage to the hard and soft tissue of the mouth caused directly and independently of all other causes by external forces. Damage to the hard and soft tissue of the mouth from normal chewing function is covered under Schedule A, Description of Benefits and Copayments. Delta Dental will pay up to 100 percent of the Dentist's usual fee, for expenses an Enrollee incurs for an accident injury, less any applicable Copayment(s), up to a maximum of $1, in any 12-month period. Accident injury benefits include the following procedure in addition to those listed in Schedule A, Description of Benefits and Copayments: D7270 tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth and/or alveolus - includes splinting and/or stabilization. Payment of accident injury benefits are subject to Schedule B, Limitations and Exclusions of Benefits, excluding Limitations #7, 16, and 17. Benefits are limited to services provided as a result of an accident that occurred: a. while the Enrollee was covered under the DeltaCare USA program, or b. while the Enrollee was covered under another DeltaCare USA program, provided benefits for the expenses incurred would have been paid had the Enrollee continued to be eligible under that program. 28. An Optional procedure is defined as any alternative procedure presented by the Contract Dentist that satisfies the same dental need as a covered procedure, is chosen by the Enrollee, and is subject to the limitations and exclusions of the Program. The applicable charge to the Enrollee is the difference between the Contract Dentist's "filed fee" for the Optional procedure and the "filed fee" for the covered procedure, plus any applicable Copayment for the covered procedure. "Filed fees" mean the Contract Dentist's fees on file with Delta Dental. Questions regarding these fees should be directed to the Customer Service department at Exclusions of Benefits 1. Any procedure that is not specifically listed under Schedule A, Description of Benefits and Copayments. 2. Restorations placed solely due to cosmetics, abrasions, attrition, erosion, restoring or altering vertical dimension, congenital or developmental malformation of teeth. 12

21 Limitations and Exclusions of Benefits 3. Porcelain crowns, porcelain fused to metal or resin with metal type crowns and fixed partial dentures (bridges) for children under 16 years of age. 4. Loss or theft of full or partial dentures, space maintainers, crowns and fixed partial dentures (bridges). 5. Appliances or restorations necessary to increase vertical dimension, replace or stabilize tooth structure loss by attrition, realignment of teeth, periodontal splinting, gnathologic recordings, equilibration or treatment of disturbances of the temporomandibular joint (TMJ). 6. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization of complete and partial dentures. 7. An initial treatment plan which involves the removal and reestablishment of the occlusal contacts of 10 or more teeth with crowns, onlays, fixed partial dentures (bridges), or any combination of these is considered to be full mouth reconstruction under the DeltaCare USA program. Crowns, onlays and fixed partial dentures associated with such a treatment plan are not covered Benefits. This exclusion does not eliminate the benefit for other covered services. 8. Implant placement or removal, appliances placed on or services associated with implants, including but not limited to prophylaxis and periodontal treatment. 9. Extraction/removal of an erupted, partially erupted or impacted tooth: a. Solely for orthodontic purposes. b. When the tooth exhibits no signs or symptoms of infection, cystic degeneration, fracture, caries and/or having caused damage to an adjacent tooth; or c. When the extraction or removal would be inconsistent with generally accepted professional standards. 10. Treatment or extraction of primary teeth when exfoliation (normal shedding and loss) is imminent. 11. Consultations for non-covered benefits. 12. Replacement of restorations, crowns, bridges, dentures or prosthetic teeth to enhance cosmetics and/or better match bleached teeth. 13. Dental services received from any dental facility other than the assigned Contract Dentist including the services of an out-of-network dental specialist, unless expressly authorized by Delta Dental or as cited under Emergency Services. 14. Any procedure that in the professional opinion of the Contract Dentist: a. has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures, or b. is inconsistent with generally accepted standards for dentistry. 15. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility. 16. Congenital malformations (e.g. congenitally missing teeth, supernumerary teeth, enamel and dentinal dysplasias, etc.), except for the treatment of newborn children with congenital defects or birth abnormalities. 17. Dispensing of drugs not normally utilized in the delivery of dental services. 18. Dental expenses incurred in connection with any dental procedure started before the Enrollee's eligibility with the DeltaCare USA program. Examples include: teeth prepared for crowns, root canals in progress, orthodontics (unless qualified for the orthodontic treatment in progress provision). 19. Dental expenses incurred in connection with any dental procedures started after termination of eligibility for coverage. 20. Dental conditions arising out of and due to Enrollee's employment for which Worker's Compensation is paid. Services that are provided to the Enrollee by state government or agency thereof, or are provided without cost to the Enrollee by any municipality, county or other subdivision. 21. Treatment required by reason of war declared or undeclared. Orthodontic Limitations The DeltaCare USA program provides coverage for orthodontic treatment plans provided through Contract. Startup fees, retention fees, and the cost to the Enrollee for the treatment plan are listed in Schedule A, Description of Benefits and Copayments and subject to the following: 1. Orthodontic treatment must be provided by the selected Contract Orthodontist. 13

22 Limitations and Exclusions of Benefits 2. Orthodontic Copayments are listed on Schedule A, Description of Benefits and Copayments for both interceptive and comprehensive orthodontic treatment. Additional fees will be charged for start-up and retention. 3. Benefits cover 24 months of active interceptive orthodontic treatment. 4. Benefits cover 24 months of active comprehensive orthodontic treatment, including initial banding, de-banding and any commonly used appliances such as headgear. 5. Following benefited interceptive or comprehensive orthodontic treatment, retention is covered up to a maximum of 24 months. Retention includes the initial construction, placement and adjustment to removable retainers and office visits. 6. Treatment plans extending beyond 24 months of active interceptive or comprehensive orthodontic treatment, or 24 months of retention, will be subject to a monthly office visit fee to the Enrollee not to exceed 75 percent of the Contract Orthodontist's "filed fee" per month. 7. Should an Enrollee's coverage be cancelled or terminated for any reason, and at the time of cancellation or termination the Enrollee is receiving orthodontic treatment, the Enrollee will be solely responsible for payment for treatment provided after cancellation or termination. In this event the Enrollee's obligation shall be based on 100 percent of the Contract Orthodontist's "filed fee." The Contract Orthodontist will prorate the amount over the number of months remaining in the initial 24 months of treatment. The Enrollee will make payments based on an arrangement with the Contract Orthodontist. 8. If treatment is not required or the Enrollee chooses not to start treatment after the diagnosis and consultation has been completed by the Contract Orthodontist, the Enrollee will be charged a consultation fee of $50.00 in addition to diagnostic record fees. 9. Three recementations or replacements of a bracket/band on the same tooth or a total of five rebracketings/rebandings on different teeth during the covered course of treatment are Benefits. If any additional recementations or replacements of brackets/bands are performed, the Enrollee is responsible for the cost at the Contract Orthodontist's usual fee. 10. The Copayment is payable to the Contract Orthodontist who initiates banding in a course of orthodontic treatment. If, after banding has been initiated, the Enrollee changes to another Contract Orthodontist to continue orthodontic treatment, the Enrollee: a. will not be entitled to a refund of any amounts previously paid; and b. will be responsible for all payments, up to and including the full Copayment, that are required by the new Contract Orthodontist for completion of the orthodontic treatment. 11. Orthodontic treatment in progress is limited to new DeltaCare USA Enrollees who, at the time of their original effective date, are in active treatment started under their previous employer sponsored dental plan, as long as they continue to be eligible under the DeltaCare USA program. Active treatment means tooth movement has begun. Enrollees are responsible for all Copayments and fees subject to the provisions of their prior dental plan. Delta Dental is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases. Orthodontic Exclusions 1. Pre-, mid- and post-treatment records that include cephalometric x-rays, tracings, photographs and study models. 2. Lost, stolen or broken orthodontic appliances. 3. Changes in treatment necessitated by accident of any kind, and/or lack of Enrollee cooperation. 4. Surgical procedures incidental to orthodontic treatment. 5. Myofunctional therapy. 6. Surgical procedures related to cleft palate, micrognathia or macrognathia. 7. Treatment related to temporomandibular joint disturbances. 8. Supplemental appliances not routinely used in comprehensive orthodontics, including, but not limited to: palatal expander, habit control appliance, pendulum, quad helix or herbst. 9. Restorative work caused by orthodontic treatment. 10. Extractions solely for the purpose of orthodontics. 11. Treatment in progress at inception of eligibility, unless qualified for the orthodontic treatment in progress provision. 12. Patient initiated transfer after bands have been placed. 13. Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances. 14

23 Participating DeltaCare USA Dental Offices Consultorios dentales de la red DeltaCare USA Kaiser Foundation Health Plan of Georgia Open Offices/ Consultorios abiertos October through December 2014 / Octubre a Diciembre de 2014 ACWORTH # COAST DENTAL OF ACWORTH 3509 BAKER RD NW STE 401, (770) F/T 3 P/T 2 # DNTL ESSENTIALS FAMILY DNTSTY 4450 CALIBRE XING NW # 1206, (770) F/T 1 # LAKE POINT DENTAL 3950 COBB PKWY NW STE 402, (770) F/T 3 ALPHARETTA # ALPHARETTA DENTAL ASSOC PC 2795 OLD MILTON PKWY STE 900, (770) P/T 1 # BYRD DENTAL GROUP NORTH POINT 4000 N POINT PKWY STE 500, (770) F/T 2 P/T 1 (SP, KO) # MCGINNIS FERRY RD, (678) F/T 1 P/T 5 # SOUTH MAIN ST, STE B5, (770) F/T 3 # KIMBALL BRIDGE DENTAL 4380 KIMBALL BRIDGE RD, (678) P/T 1 # UTAH MED HOLDING FACILITY 1130 SANCTUARY PARKWAY, ATLANTA # ALLIANCE ORTHO & FAM DNTSTRY TH ST NW STE 100, (404) P/T 1 # ART OF THE SMILE 3280 HOWELL MILL RD NW #112, (404) F/T 1 # COAST DENTAL OF BUCKHEAD 3330 PIEDMONT RD NE STE 16, (404) F/T 3 P/T 2 # COAST DENTAL OF NORTHLAKE 4805 BRIARC RD NE STE 104, (770) F/T 2 P/T 3 # COAST DENTAL OF PERIMETER 1100 HAMMOND DR STE 210, (770) F/T 1 P/T 4 # COAST DENTAL OF SANDY SPRINGS 7539 ROSWELL RD, (678) F/T 2 P/T 4 # COAST DTL NORTH DRUID HILLS 2484 BRIARCLIFF RD NE STE 29, (404) F/T 5 P/T 5 # COLLINS FAMILY DENTISTRY 759 MLK DR NW STE 200, (404) F/T 1 # DENTAL ONE ASSOCIATES 1901 PHOENIX BLVD#100, (770) F/T 3 # DENTAL ONE ASSOCIATES 600 W PEACHTREE ST NW # 750, (404) F/T 3 # GA DENTISTRY LLC 2460 CUMB PKWY SE STE 210, (770) F/T 1 P/T 1 # HENDERSON MILL RD NE, (770) P/T 11 # W PEACHTREE ST NW # 120, (404) F/T 4 P/T 11 # TH ST NW STE 100, (404) F/T 6 P/T 13 # CORPORATE BLVD BLD13 #12, (678) F/T 4 P/T 13 # CASCADE RD SW STE 190, (678) P/T 10 # PIEDMONT RD NE STE 1110, (404) P/T 5 # ROSWELL ROAD, STE 13A, (404) F/T 2 P/T 4 # VIRGINIA AVE STE A, (404) P/T 5 # PHOENIX BLVD, STE 8, (770) F/T 4 # OLD SPRING HOUSE LN 315, (770) F/T 3 # LEONARD J ROUTENBERG 4511 CHAMBL DUNWDY RD STE A2, (770) F/T 1 # LYNDON NAIPAUL INC 1776 OLD SPR HOUSE LN # 302, (770) F/T 1 (SP) # PERFECT TOUCH DENTAL 80 PEYTON RD SW, (404) F/T 1 # SOUTHSIDE MEDICAL CENTER INC 1046 RIDGE AVE SW, (404) F/T 1 AUGUSTA # WILLIAM MARESKA, DDS 3802 WASHINGTON RD, (706) AUSTELL # ANISA HAILEY, DDS 4760 AUSTELL RD, (770) # MEDICAL PARK DRIVE, (770) F/T 4 CANTON # ASPEN DENTAL 2030 CUMMING HWY STE 110, (404) F/T 2 CARROLLTON # ASPEN DENTAL 1382 SOUTH PARK STREET, (678) F/T 3 CARTERSVILLE # ASPEN DENTAL 215 CHEROKEE PLACE, (770) F/T 3 # CARTERSVILLE DENTAL GROUP 22 FELTON PL, (770) # CARTERSVILLE SMILES 22 FELTON PLACE STE A, (770) F/T 1 (SP) COLUMBUS # ASPEN DENTAL 6783 VETERANS PARKWAY BLDG 4, (706) F/T 1 # PATTERSON DENTAL GROUP 7413 WHITESVILLE RD, (706) F/T 1 CONYERS # ASPEN DENTAL 1450 HIGHWAY 138 SE, (770) F/T 1 # COAST DENTAL OF CONYERS 1910 HIGHWAY 20 SE # 100 # E, (770) F/T 2 P/T 4 # OLD SALEM RD SE, (678) F/T 4 P/T 11 # WALL ST SE STE 120, (770) P/T 4 # SIGNATURE DENTAL LLC 2750 OWENS RD SW STE B, (770) F/T 1 CUMMING # ASPEN DENTAL 1530 MARKET PLACE BLVD, (678) F/T 3 # CASTLEBERRY DENTAL LLC 5905 IRON GATE TRCE, (770) (PE, FR) # NORTH CUMMING DENISTRY LLC 1715 FRIENDSHIP CIR STE 100, (470) F/T 1 DALTON # ASPEN DENTAL 849 SHUGART RD, (706) F/T 4 # DREAM SMILE DENTAL LLC 1100 E WALNUT AVE STE 9 10, (706) F/T 1 (SP, GE, HI) DECATUR # PONCE DE LEON STE#300, (678) F/T 7 P/T 13 # CANDLER RD STE 101, (404) F/T 2 P/T 4 09/09/14 1 DR_DCU_5450 2_OCT2014_ PLGAKFG

24 # LAWRENCENCEVILLE HWY103, (770) F/T 8 # METRO DECATUR DENTAL GROUP 4570 MEMORIAL DR, (404) P/T 1 DOUGLASVILLE # ASPEN DENTAL 6351 DOUGLAS BLVD, (404) F/T 3 # COAST DENTAL OF DOUGLASVILLE 3308 GEORGIA HWY 5 STE E, (770) F/T 1 P/T 3 # HIGHWAY 5 STE E, (770) F/T 1 P/T 12 # HIGHWAY 5, (678) F/T 4 P/T 11 # HOSPITAL DRIVE, 7 & 8, (770) F/T 6 # JERRY NUTT/ASSOC 8505 HOSPITAL DR STE 7, (770) # TIMOTHY BYRD, DMD 6740 DOUGLASVILLE BL STE A, (770) F/T 1 DULUTH # ALLIANCE ORTHO & FAM DNTSTRY 3796 SATELLITE BLVD STE 101, (770) P/T 1 (SP) # COAST DENTAL OF DULUTH 3870 PCHTREE IND BLVD, (770) F/T 3 P/T 5 # COAST DENTAL OF PLEASANT HILL 1630 PLEASANT HL RD STE 200, (770) F/T 2 P/T 3 DUNWOODY # MICHELLE JACQUES, DDS 1853 PEELER RD STE A, (770) F/T 1 (RU) FAIRMOUNT # METROPOLITAN DTL ASSOC 2285 HIGHWAY 411 N, (706) P/T 1 (PE, SP) FAYETTEVILLE # ALLIANCE ORTHO & FAM DNTSTRY 1307 HIGHWAY 85 N STE B, (770) P/T 1 (SP) # COAST DENTAL OF FAYETTVILLE 805 GLYNN ST S STE 131, (770) F/T 1 P/T 8 # LANIER AVE W HWY54 # 2, (678) F/T 2 P/T 6 # N JEFF DAVIS DR STE A, (770) F/T 1 P/T 4 # BANKS STATION, # , (770) F/T 3 FOREST PARK # GOVERNORS DRIVE #405, (404) F/T 7 GAINESVILLE # ASPEN DENTAL 890 DAWSONVILLE HWY STE F, (678) F/T 3 # PEARL NIX PARKWAY STE D, (770) F/T 5 GRAYSON # COMFORT DENTAL STUDIO, PC 2219 LOGANVILLE HWY, (678) # ROYAL DENTAL CARE 2594 LOGANVILLE HWY# 102, (678) F/T 1 JOHNS CREEK # DENTISTRY OF JOHN CREEK MEDLOCK BRG RD STE B3, (770) P/T 1 (SP) JONESBORO # POINTE SOUTH PKWY, (770) F/T 2 P/T 10 (SP) # MOUNT ZION RD, (770) P/T 4 # TARA BLVD FAMILY DENTISTRY 772 NORTH AVE, (770) P/T 1 KENNESAW # DENTISTRY AT KENNESAW POINT 1350 WOOTEN LAKE RD NW # 203, (678) F/T 1 # E W BARR PKWY NW STE 607, (770) F/T 1 P/T 12 (PE, SP) # BUSBEE DR NW STE 200, (678) F/T 6 P/T 15 # SHILOH RD BLVD 600 #660, (770) F/T 2 2 LAKE CITY # COAST DENTAL MORROW 5656 JONESBORO RD STE 103, (678) F/T 3 P/T 3 LAWRENCEVILLE # COAST DENTAL OF LAWRENCEVILLE 650 GWINNETT DR STE 210, (770) F/T 1 P/T 5 # OLD NORCROSS RD STE 120, (770) P/T 12 # RIVERSIDE PKWY STE 105, (678) P/T 9 # RIVERSIDE PKWY STE 200, (678) F/T 4 P/T 16 # SUGARLOAF PKWY STE 204, (770) F/T 1 P/T 4 # DULUTH HIGHWAY STE 5, (770) F/T 4 LILBURN # COAST DENTAL OF LILBURN FORKS RD SW STE H, (770) F/T 3 P/T 3 # LAWRENCEVILLE HWY #15, (770) F/T 6 P/T 18 (VI, SP) # LAWRENCEVILLE HWY STE 5, (770) F/T 3 # ZOOM DENTAL LLC 4574 LVILLE HWY NW STE 120, (770) F/T 1 P/T 3 (KO, SP) LOGANVILLE # COAST DENTAL OF LOGANVILLE 4325 ATLANTA HWY STE 9, (770) F/T 4 P/T 2 # EASTSIDE DENTISTRY 2715 LOGANVILLE HWY # 340 3D, (678) P/T 1 (HI) MABLETON # COAST DENTAL OF MABLETON 4875 FLOYD RD SW STE 113, (770) F/T 4 P/T 1 MACON # ASPEN DENTAL 5019 RIVERSIDE DRIVE UNIT A, (478) F/T 2 # NORTH MACON DENTAL ASSOC 4020 ELNORA DR, (478) F/T 1 MARIETTA # COAST DENTAL OF SPRAYBERRY 2550 SANDY PLAINS RD STE 145, (770) F/T 2 P/T 3 # COAST DTL OF MARIETTA TRADE 270 COBB PKWY S STE 180, (770) F/T 3 P/T 5 # DR JOHN FAMILY DENTISTRY 550 FRANKLIN RD SE STE B, (770) P/T 1 # ROSWELL RD STE 300, (678) F/T 5 P/T 11 # ROSEWELL RD, STE 205, (770) F/T 6 P/T 4 # POWERS FERRY RD SE #220, (770) F/T 1 # JOHN GRAHAM, DDS 50 PLAZA WAY NW STE G, (770) F/T 1 # SPRAYBERRY DENTAL ASSOC 2663 SANDY PLAINS RD, (770) F/T 2 P/T 1 MCDONOUGH # ASPEN DENTAL 1430HIGHWAY 20 WEST, (678) F/T 2 MONROE # PATRICIA PASS DUDLEY, DDS 146 MLK BLVD PMB 387, (770) F/T 1 MORROW # SOUTHLAKE DENTAL ASSOC PC 6630 EXCHANGE PL, (770) P/T 1 MOULTRIE # FARREY FAMILY DENTISTRY 513 S MAIN ST, (229) F/T 1 (SP) (SP) NEWNAN # ASPEN DENTAL 201 NEWNAN CROSSING BYPASS, (678) F/T 3 # JEFFERSON PKWY, (678) F/T 2 P/T 11 # BULLSBORO DRIVE, (770) F/T 3

25 NORCROSS # GIBBONS DENTAL STUDIOS 5635 PEACHTREE PKWY STE 100, (770) P/T 1 # GREAT EXPRESSIONS DENTAL CTR 7760 SPALDING DR, (770) F/T 2 P/T 13 # SPALDING DENTAL CENTER 6460 SPALDING DR STE C, (770) F/T 1 (RU, SP) PEACHTREE CITY # STEVENS ENTRY, (770) F/T 2 P/T 10 POOLER # ASPEN DENTAL 276 POOLER PKWY STE A, (912) F/T 2 POWDER SPRINGS # COAST DTL OF POWDER SPRINGS 3721 NEW MACLAND RD STE 210, (770) F/T 2 P/T 2 RIVERDALE # ALLIANCE ORTHO & FAM DNTSTRY 7218 HIGHWAY 85, (678) P/T 1 (SP) # ZOOM DENTAL 207 UPPER RIVERDALE RD SW, (770) F/T 1 (SP, RU) ROSWELL # HOLCOMB BRIDGE RD, (678) F/T 4 P/T 15 # WEI YEN CHANG, DDS 415 E CROSSVILLE RD STE A, (678) F/T 1 (JA, CH) SAVANNAH # SOUTHERN BOULEVARD, (912) F/T 3 # JAMES MELVIN, DMD 7001 HODGSON DR STE 4, (912) F/T 1 # JAMES WILLIAMS, DDS 310 EISENHOWER DR # 2 # BLD, (912) F/T 1 # SAVANNAH DENTAL ASSOCIATES 413 W DUFFY ST, (912) F/T 1 SNELLVILLE # CAPTIVATING SMILES 2118 SCENIC HWY, (770) F/T 1 # WISTERIA DR STE 300, (678) F/T 5 P/T 14 # HENRY CLOWER BLVD STE A, (770) F/T 1 P/T 5 # S ALABA FAWOLE, DDS MD PC 2488 SCENIC HWY, (678) P/T 1 STOCKBRIDGE # ALLIANCE ORTHO & FAM DNTSTRY 31 HIGHWAY 138 W STE 160, (770) P/T 1 # EAGLES LDG PKWY, #200, (678) F/T 2 P/T 12 # CORPORATE CENTER COURT A, (678) F/T 3 # SACRED DENTAL & ASSOC 4362 N HENRY BLVD, (770) F/T 1 (SP) STONE MOUNTAIN # BURLIN DENTAL ASSOCIATES 4687 ROCKBRIDGE RD STE 7, (404) F/T 1 # DENTURES AND FAMILY DENTISTRY 1825 ROCKBRIDGE RD STE 14C, (770) # METRO DEKALB DENTAL GROUP 4849 MEMORIAL DR, (404) P/T 1 # SMILES FOR LESS 1525 E PARK PL BLVD STE 1500, (770) (VI, SP) SUGAR HILL # THE TEETH DOCTOR LLC 6025 CUMMING HWY STE 610, (678) F/T 1 (VI) SUWANEE # COAST DENTAL 2855 LAWRENCEVILLE SUWANEE, (678) F/T 1 P/T 4 TUCKER # HUGH HOWELL RD STE 140, (770) F/T 2 P/T 11 # TUCKER TOWN DENTAL 4865 LAVISTA RD STE C, (404) F/T 1 (VI) VALDOSTA # ASPEN DENTAL 1609 NORMAN DR STE B, (229) F/T 3 WARNER ROBINS # ASPEN DENTAL 2745 WATSON BLVD, (478) F/T 3 WOODSTOCK # COAST DENTAL OF WOODSTOCK HIGHWAY 92 STE 148, (770) F/T 3 P/T 4 # METROPOLITAN DTL ASSOC 8294 HIGHWAY 92 STE 200, (770) F/T 1 (PE) # TIMOTHY BYRD, DMD 2035 TOWNE LAKE PKWY STE 130, (770) F/T 1 P/T 1 (SP) 3

26 Closed Offices / Consultorios cerrados These offices are presently serving members, but are closed to further enrollment at this time. These offices may open to new enrollment in the future if office capacity permits. / Estos consultorios brindan atención a los miembros actuales, pero se encuentran cerrados a nuevas inscripciones. En el futuro estarán disponibles para nuevas inscripiones, si su capacidad se lo permite. AUGUSTA # FREDERICK THIELKE, DMD 3643 WALTON WAY EXT, (706) F/T 1 BUFORD # LANIER DENTAL ASSOCIATES 4965 LANIER ISLANDS PKWY#105, (770) (SP) LAGRANGE # TARA DENNIS, DDS 1555 DOCTORS DR STE 105, (706) F/T 1 CLOSED TUCKER # MEENA MEHTA, DDS 3981 LAWRENCEVILLE HWY STE A, (770) F/T 1 Visit us at our website/ Visite nuestro sitio de Internet: F/T Full Time Dentist P/T Part Time Dentist F/T Dentista de tiempo completo P/T Dentista de medio tiempo Foreign languages spoken in the dental office are listed by code in ( ). Below is a key to the foreign language codes. Los idiomas que se hablan en la oficina dental estan detallados por códigos en ( ). Abajo detallamos los códigos a los diferentes idiomas. AF Afrikaans EI East Indian IN Indonesian PT Portuguese AM Armenian FR French IT Italian RO Romanian AR Arabic GE German JA Japanese RU Russian KM Cambodian GR Greek KO Korean SM Samoan CA Cantonese HE Hebrew LO Lao SP Spanish / Español CH Chinese HI Hindi 12 Mandarin TA Tagalog CL Creole 4 Hmong 14 Mien TH Thai HR Croatian HU Hungarian PE Persian TR Turkish CS Czech 13 Ilacano PL Polish VI Vietnamese LANGUAGE ASSISTANCE: Language capabilities are self reported by the individual dental facilities and not independently verified by Delta Dental. If an enrollee requires language assistance to enable communication in a dental setting, Delta Dental will arrange for professional services through a certified interpretation vendor at no cost to the enrollee. Additional Dental Offices will be added as required. You may call our Customer Service department at for updates to the provider list. If any office is closed to further enrollment, Delta Dental reserves the right to assign you another dental office as close to your home as possible. In Georgia, DeltaCare USA is underwritten and administered by Delta Dental Insurance Company. NOTE: Contact the provider before making your choice if you have scheduling problems or small children. Se agregaran mas Oficinas Dentales adicionales conforme se vayan necesitando. Puede llamar al departamento de Servicio al Cliente al para obtener una lista de los proveedores. Delta Dental se reserva el derecho de asignarle otra oficina dental lo mas cercana a su casa como sea posible. En Georgia, DeltaCare USA es asegurado y administrado por Delta Dental Insurance Company. NOTA: Contacte al proveedor antes de escogerlo si tiene problemas o niños pequeños. 4

27 Find all of our dental health resources, including a risk assessment tool, articles, videos and a free e-newsletter subscription, at: mysmileway.com. CUSTOMER SERVICE Monday through Friday, 8 a.m. to 9 p.m., Eastern time PROVIDED BY: DELTA DENTAL INSURANCE COMPANY 1130 Sanctuary Parkway, Suite 600 Alpharetta, GA deltadentalins.com/enrollees NOTE: THIS IS ONLY A BRIEF SUMMARY OF THE PLAN. The Group Dental Service Contract must be consulted to determine the exact terms and conditions of coverage. An Evidence of coverage will be sent to you upon enrollment. In Georgia, DeltaCare USA is underwritten and administered by Delta Dental Insurance Company. E #78968_GA_Kaiser (rev. 07/14)

28 YOUR SMILE IS COVERED You must be a Kaiser Permanente FEHBP enrollee to participate in the dental plan DIRECTORY OF DELTA DENTAL PREMIER DENTISTS FOR YOUR FEHBP PREVENTIVE DENTAL BENEFITS DELTA DENTAL INSURANCE COMPANY KAISER PERMANENTE GEORGIA EDITION WE KEEP YOU SMILING