Delta Dental of Oklahoma. Dental Program Options for Individuals & Families

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1 Delta Dental of Oklahoma Dental Program Options for Individuals & Families

2 Solutions for You & Your Family Option 1 Delta Dental Patient Direct 2 Option 2 Delta Dental PPO Choice Advantage 3 Option 3 Delta Dental PPO Point of Service 4 Frequently Asked Questions 5

3 Delta Dental of Oklahoma Program Options for Individuals & Families 1 Delta Dental of Oklahoma Individual and Family Dental Programs At Delta Dental of Oklahoma, we believe that all Oklahomans deserve access to great dental care. So, whether you are self-employed, a student, or simply want a dental program that is not tied to your place of employment, Delta Dental has the perfect solution for you and your family. Only a well-established leader like Delta Dental of Oklahoma could make individual and family dental coverage so easy and affordable. Review your options in the following pages; if you need help making a decision, please call our Customer Service Department at or at (OKC Metro), or consult with a licensed insurance agent in your area. The Delta Dental Difference Most Experienced Delta Dental is the oldest, largest, and most experienced leading provider of dental benefits in the state and the nation. Since our beginning in 1954, dental benefits have always been our primary focus. Excellent, Local Customer Service Delta Dental of Oklahoma boasts a friendly and knowledgeable Customer Service Department located entirely in Oklahoma. Added Benefits Regardless of the program selected, you re entitled to the following benefits at no additional charge:» Discounts on vision services and materials through EyeMed Vision Care» Access to a members-only website for answers to dental questions and treatment options» Sign up for Spotlight, our online resource designed to help you get the most from your dental program Largest Dental Networks Delta Dental maintains the largest dental networks in the state and the nation. More than 90% of all licensed dentists in Oklahoma, and nearly two-thirds nationwide, participate. Not-for-Profit Nearly 90% of all premium dollars go to our dentists for the delivery of care. Remaining proceeds go towards our Foundation for education programs, scholarships and helping those unable to afford benefits receive treatment. Choice Delta Dental of Oklahoma is committed to offering a wide variety of dental care solutions for individuals and families across the state. Choose from our discount dental referral program Patient Direct, or from one of our fully-insured dental options. With Delta Dental, the choice is yours!

4 2 Delta Dental of Oklahoma Program Options for Individuals & Families Option 1 Delta Dental Patient Direct Discount Referral Program Delta Dental Patient Direct is a discount referral dental program for individuals and families in Oklahoma who do not receive dental benefits through an employer. It s affordable, valuable, and easy to use! Unlike other discount referral programs, Patient Direct features a sizeable and growing network of participating dentists. Once you enroll and pay the annual fee, you will receive a Patient Direct membership card. This card is your ticket to substantial savings on dental care. It s so easy to use sign up today!» No claim forms» No annual maximums or deductibles» No waiting periods for services» Discounts on a majority of dental services» Your program is typically effective within 1 to 4 business days» All Oklahoma residents are accepted regardless of dental history or pre-existing conditions» Pay by bank draft, Visa, or Mastercard» Complimentary vision care discounts through EyeMed Vision Care Real savings you can see when visiting a Patient Direct participating dentist! Procedure Typical Cost Your Cost Savings* Periodic Evaluation $40.00 $26.00 $14.00 Comprehensive Evaluation $63.00 $41.00 $22.00 Full Mouth X-ray $ $80.00 $43.00 Crown $ $ $ Complete Upper Denture $1, $ $ * For example purposes only. A full list of discounts will be made available after you enroll. Patient Direct Annual Rates To enroll: Please see enclosed enrollment form for current rates. Visit or Call Toll Free Important Note: Patient Direct is a discount referral program. This product is not dental insurance.

5 Option 2 Delta Dental PPO Choice Advantage for individuals and families Delta Dental of Oklahoma Program Options for Individuals & Families 3 With Delta Dental PPO Choice Advantage, you will save on the majority of dental services and procedures including routine cleanings, fillings, crowns, x-rays, and much more even orthodontics for dependent children up to age 19. This program uses a Description of Covered Services and Enrolle Co-payments table that shows you the exact co-payments and deductibles for which you are responsible when using a Delta Dental PPO participating dentist. Examples of Savings Delta Dental PPO Choice Advantage covers 5 levels of benefits ranging from preventive to major services. The table below illustrates your potential savings on some common dental treatments. Real savings you can see when visiting a Delta Dental PPO participating dentist! Example of Treatment/Cost 1 Your Cost Your Savings Percentage Savings D1110 Adult Cleaning/$70 $0 $70 100% D2330 One Surface Filling (Composite)/$126 $24 $102 81% D2750 * Crown (Porcelain Fused to High Noble Metal)/$862 $391 $471 55% 1 Based upon average submitted fees to DDOK. For example purposes only. * Must meet the waiting period requirements and applicable deductible(s). Examples of Covered Services & Co-payments Level of Service Level 1 Level 1 Level 1 Level 2 Level 2 Level 4 Procedure Code Description Subscriber Co-payment D0120 D1110 D1120 D2150 D7111 D2750 Periodic oral evaluation established patient Prophylaxis (cleaning) adult Prophylaxis (cleaning) child Amalgam (filling) two surface, primary or permanent Extraction coronal remnants deciduous tooth Crown porcelain fused to high noble metal $0 $0 $0 $26 $18 $391 These services are provided as examples of the types of services and co-payments under the Delta Dental PPO Choice Advantage option. For a complete list, see Description of Covered Services and Enrollee Co-payments table online at Deductibles and Annual Maximums Deductibles: A $50 deductible applies per member per year for Levels 2, 3, & 4 combined. Maximum Payment: $1,500 for Levels 1, 2, 3, & 4 combined. Orthodontic Services: $1,500 lifetime maximum per enrolled dependent child for orthodontic services (Level 5). PPO Choice Advantage Rates Please see enclosed enrollment form for current rates. Note: An initial 12-month waiting period applies to Level 3 services, an initial 24-month waiting period applies to Level 4 services, and a 36-month waiting period applies to Level 5 services.

6 4 Delta Dental of Oklahoma Program Options for Individuals & Families Option 3 Delta Dental PPO Point of Service for individuals and families Delta Dental PPO Point of Service features the perfect combination of access and savings. Individuals choosing this option will realize the greatest benefit level and maximum savings when utilizing a dentist in the Delta Dental PPO network, but may also utilize providers from the Delta Dental Premier network. Delta Dental PPO Point of Service Benefit Examples Delta Dental PPO Network Annual Maximum $1,000 per person Lifetime Ortho Maximum $1,000 per dependent child Delta Dental Premier Network Non-Participating (out-of-network) Class I: Diagnostic & Preventive Cleanings, evaluations, X-rays, etc. 100% 80% 70% Class II: Basic Restorative Fillings, simple extractions, oral surgery, root canal therapy, etc. After a $50 deductible per person per year and an initial 6-month waiting period 80% 60% 50% Class III: Major Restorative Crowns, dentures, implants, etc. After a $200 deductible per person per year and an initial 12-month waiting period 50% 30% 20% Class IV : Orthodontic Services The necessary treatment and procedures required for the correction of malposed teeth. Available to eligible Dependent Children under age 19, after an initial waiting period of 18 months 50% 50% 30% Note: Percentages listed are the portion of the dentist s fee that Delta Dental of Oklahoma will pay toward covered services subject to the maximum allowable charge or prevailing fee, as determined by DDOK. Plan limitations and exclusions apply. Examples of Covered Services & Co-payments With Delta Dental PPO Point of Service you may see any licensed dentist; however, your out-of-pocket expenses will be lower typically when treatment is performed by a Delta Dental participating dentist. For example, payment of a covered Class II dental service is illustrated below (the illustration assumes the annual deductible has been satisfied). Delta Dental PPO Dentist Delta Dental Premier Dentist Non-Participating Dentist (Out-Of-Network) PPO Dentist Charge $100 Premier Dentist Charge $100 Dentist Charge $100 PPO Maximum Allowable $70 Premier Maximum Allowable $85 Prevailing Fee $75 Plan Pays (80% of Delta Dental PPO Maximum Allowable) $56 Plan Pays (60% of Delta Dental Premier Maximum Allowable) $51 Plan Pays (50% of the Prevailing Fee) $37.50 You Pay * $14 You Pay * $34 You Pay * $62.50 * 20% of Delta Dental PPO Allowable * 40% of the Delta Dental Premier Allowable * Balance of the dentist charge PPO Point of Service Rates Please see enclosed enrollment form for current rates.

7 Frequently Asked Questions About Our Individual Programs Frequently Asked Questions 5 Q. Can I obtain more information about Delta Dental of Oklahoma Individual and Family programs online? A. More information can be found on our website at or call our Customer Service Department at or (OKC Metro). Q. How do I know if my dentist participates in the Delta Dental PPOnetwork? A. You can ask your dentist if he or she is a Delta Dental participating dentist and which networks he or she participates in, or you can check the Dentist Directory on our website at Q. Are there any differences between the Delta Dental PPO and Delta Dental Premier networks? A. The PPO network, consisting of nearly 60% of all dentists in Oklahoma, provides deeper network discounts and savings for our subscribers. Providing greater access, the Delta Dental Premier is the largest network locally (and nationwide), consisting of nearly 94% of Oklahoma s dentists. Q. My dentist is not a Delta Dental participating dentist. Can I go to any dentist? A. Delta Dental fully-insured dental programs allow you to use any licensed dentist. However, these programs are designed to offer greater benefits and savings when a Delta Dental network dentist is utilized. Your savings will be significantly reduced if treatment is performed by an out-of-network dentist. If enrolling in Patient Direct, you must utilize a Patient Direct network dentist. Search our Patient Direct network online at Q. Are there waiting periods? A. Specific waiting periods apply to individual and family programs Options 2 & 3, and are illustrated in this brochure. If you provide proof of previous, comparable, and verifiable dental coverage and apply within 60 days from your previous policy cancellation date, we will, in most cases, credit certain waiting periods. (No waiting periods apply to the Patient Direct Program.) Q. What happens after I enroll? A. Once your application and initial payment are processed, an enrollment kit with ID cards will be mailed to you in 7 to 10 days of your approved application. Q. What are my payment options for your fully-insured programs? A. We accept electronic funds transfers (drafts) from checking or savings accounts on a monthly basis. Debit and credit card payments are not accepted at this time. Q. What are my payment options for Patient Direct? A. You may pay your annual fee for Patient Direct via a one-time bank draft, or with a Visa or Mastercard. Q. Is everyone accepted? A. All Oklahomans, 18 years of age or older, may purchase a dental program and acceptance is guaranteed regardless of dental history or pre-existing conditions. Current Delta Dental members are not eligible. These programs may not be used in conjunction with another dental plan. Q. Can I switch between plans at any time? A. No, once enrolled, you must remain in your selected program until January 1 of the next calendar year. If you enroll and drop your dental program, you will not be eligible for coverage until 24 months later. Note: The information contained in this brochure is not intended as a policy nor is it designed to serve as evidence of coverage. Some benefits are subject to limitations, such as age of patient, frequency of procedures, etc., or excluded in some instances. For specific questions, consult your policy or call our Customer Service Department at (toll-free) or (OKC Metro).

8 Application for Individual and Family Dental Plans Name: Date of Birth: Sex: M F Street Address: City: State: Zip: Social Security #: Phone #: Mobile # Home # Program Selection (Choose one) Mail to: Delta Dental of Oklahoma Attn: Client Relations PO Box Oklahoma City, OK Fax to: Broker/Agent Code (5-6 digit) Delta Dental Patient Direct Individual - $60.00 per year Family - $84.00 per year To enroll: Visit or call (Toll Free) Note: Do not use this application form Delta Dental PPO Choice Advantage Group #4906 Program Type (Choose one) Your Cost Individual $30.00 per month Individual + 1 $55.64 per month (spouse or one child) Individual + Family $ per month Delta Dental PPO Point of Service Group #4905 Program Type (Choose one) Your Cost Individual Individual + 1 (spouse or one child) Individual + Family $35.00 per month $64.40 per month $ per month List all dependents to be enrolled (Please complete for spouse and/or all dependent children under 19 years of age.) Spouse Name: Sex: Date of Birth (DOB): Child Name: Relationship: Sex: DOB: Child Name: Relationship: Sex: DOB: Child Name: Relationship: Sex: DOB: Will this program replace existing dental coverage? Yes No (If Yes, submit copy of current coverage & effective dates.) Bank Draft (EFT): Monthly* Bank Account Type: Checking Savings Bank Name: Bank Routing Number: Bank Account Number: (Please attach a voided check to application. Only applies for electronic payments.) *Initial premium will be drafted from your account immediately upon approval of this application. Subsequent drafts will be made on the 21st of each month and applied to the next month s premium. Termination Requirement: Please note that you must provide a minimum of 30 days written notice to Delta Dental of Oklahoma prior to requested termination date. Warning: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, provides false information herein and makes any claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is guilty of a felony. Acknowledgement and Authorization: By signing this form, I agree to continue coverage as provided in the Individual Dental Policy issued by Delta Dental of Oklahoma and acknowledge I have read the privacy policy detailed on the back of this form. To cover the cost of my dental benefits for which I have made request, and for which I am or may become insured, I hereby authorize Delta Dental to draft my designated personal bank account until further notice. In lieu of a DDOK automatic draft of my designated personal bank account, I shall have the option of payment in full, in advance, for each annual coverage period commencing on the effective date of my individual coverage, such payment to be made by check or DDOK automatic draft of my designated account. Regardless of the payment method I elect, I understand and agree that failure to make funds available in sufficient amounts to cover the cost of my dental benefits for which I have made request shall result in the termination of my coverage effective on the paid-through date reflected in DDOK records at the time of such failure. Applicant Signature: Date: TURN OVER / NEXT PAGE»

9 Coverage Effective Date When valid enrollment documentation and payment are received by DDOK on the 1st through the 20th day of the month, coverage will be effective the first day of the month immediately following receipt of such. When valid enrollment documentation and payment are received by DDOK on the 21st through the last day of the month, coverage will be effective the first day of the second month. Example: Enrollment documentation/payment received January 5, 2012 coverage effective date is February 1, 2012; enrollment documentation/ payment received January 23, 2012 coverage effective date is March 1, Payment Election Bank Draft (EFT) Monthly Check this payment election if you wish DDOK to automatically draft the monthly cost of your individual policy from your designated personal bank account. The designated account number and a voided check are required if electing this payment method. Delta Dental of Oklahoma Individual Privacy Policy All companies that are part of the Delta Dental Plan of Oklahoma family of companies (referred to in this Privacy Policy as Delta Dental ) believe that personal information collected about our customers, subscribers, potential customers, and proposed subscribers (referred to collectively in this Privacy Policy as Customers ) must be treated with the highest degree of confidentiality. For this reason, and in compliance with the Gramm-Leach-Bliley Act of 1999, and HIPPA, Delta Dental has developed a privacy policy that applies to all employees, officers, directors, agents, brokers, and to any other transaction Delta Dental conducts which may contain your confidential information. INFORMATION WE COLLECT We collect and maintain personal, nonpublic information we receive from Customers directly through applications, claims, enrollment forms, our website, and over the telephone or in person, from providers, agents, clearinghouses, and government agencies. This information includes, for example, your name, address, Social Security Number, date of birth, and claim information. We use this information to process our Customers requests and transactions, provide Customers with additional information about new products, and to comply with federal and state laws. UTILIZATION OF INFORMATION Delta Dental has, and will continue to utilize nonaffiliated third parties to conduct certain functions of our business to provide our Customers with services and products. We do this by allowing access to certain nonpublic personal information about our Customers and their transactions. Access to this information is restricted to individuals who require it in order to service Customer accounts or provide information to our Customers, and as permitted by law. Delta Dental reserves the right to disclose this information in these and other circumstances as allowed or required by law. HOWEVER, under no circumstances will we sell information about our Customers or their account to any unaffiliated company, group, or individual without our Customer s permission. OUR SECURITY We maintain physical, electronic, and procedural safeguards to protect the information we collect about our Customers. We consider this nonpublic personal information to be confidential and treat it as such. The personnel who have access to this information are trained in the proper handling of such information. Employees who violate this strict level of confidentiality are subject to our disciplinary process. While we do make available certain nonpublic personal information to non-affiliated third parties in order to service Customer accounts, all information is strictly governed by confidentiality and security agreements to protect our Customers; therefore, our Customers confidential information is protected. If you terminate your coverage, Delta Dental will adhere to the information practices as described in this notice. If you have questions about our Privacy Policy, please do not hesitate to contact your Delta Dental representative at (800) or (in the Oklahoma City metropolitan area). Issued 8/23/ Revised 10/5/11

10 Delta Dental of Oklahoma PO Box Oklahoma City, OK