2014 Rates. About Delta Dental networks BENEFITS OVERVIEW. Employee Only: $ Employee & Spouse: $ Employee & Child(ren): $83.

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1 BENEFITS OVERVIEW Benefit Summary for: Denny s, Inc. Effective Date: January 1, 2014 Plan Option: HIGH PLAN Delta Dental PPO Dentacare M Delta Dental PPO & Premier Non- Participating Providers Part-Time Employees Contract Year Deductible Applied to Basic and Major services $25 individual $25 individual $25 individual Annual Maximum Preventive Services Basic Services Major Services Applied to Preventive, Basic and Major services Oral examinations, twice per benefit period Bitewing x-rays; 1 set per benefit period Full mouth x-rays, once in any 36 months Prophylaxis (cleanings), twice in any benefit period Topical fluoride treatments for dependent children under age 16, once per benefit period Space maintainers under age 19, initial appliance only Sealants for dependent children under age 16, once in 36 months Fillings Non-Surgical Periodontics Surgical Periodontics Endodontics Simple extractions Surgical extractions General anesthesia Emergency palliative treatment Oral Surgery Bridges & dentures, once in five years Crowns, Inlays, Onlays once in five years $1,500 $1,500 $1, % 100% 100% available immediately 80% 80% 80% available after 6 months on the plan 50% 50% 50% available after 12 months on the plan Orthodontia Orthodontia for all eligible participants **Part-time employees must be enrolled for 12 months before becoming eligible for the Orthodontia Benefit 50% up to $2,000 lifetime maximum No deductible 50% up to $2,000 lifetime maximum No deductible 50% up to $2,000 lifetime maximum No deductible** About Delta Dental networks Delta Dental PPO Providers: offer deep discounts from standard charges with no balance billing in excess of coinsurance, deductibles, and plan maximums. Delta Dental Premier Providers: offer lesser discounts than PPO but the assurance of no balance billing in excess of coinsurance, deductibles, and plan maximums. Non-Network Providers: are not contracted with Delta Dental benefit payments are made up to the 90 th percentile; balance billing is possible over that level Rates Employee Only: $37.66 Employee & Spouse: $77.00 Employee & Child(ren): $83.82 Employee & Family: $ Customer Service Toll Free: am-6pm EST Please refer to your complete Summary Plan Description for a detailed listing of your benefits and any limitations

2 BENEFITS OVERVIEW Benefit Summary for: Denny s, Inc. Effective Date: January 1, 2014 Plan Option: LOW PLAN Delta Dental PPO Dentacare M Delta Dental PPO & Premier Non - Participating Providers Part-Time Employees Contract Year Deductible Applied to Basic services $50 individual $50 individual $50 individual Annual Maximum Preventive Services Basic Services Major Services Applied to Preventive, and Basic services Oral examinations, twice per benefit period Bitewing x-rays; 1 set per benefit period Full mouth x-rays, once in any 36 months Prophylaxis (cleanings), twice in any benefit period Topical fluoride treatments for dependent children under age 16, once per benefit period Space maintainers under age 19, initial appliance only Sealants for dependent children under age 16, once in 36 months Fillings Non-Surgical Periodontics Surgical Periodontics Endodontics Simple extractions Surgical extractions General anesthesia Emergency palliative treatment Oral Surgery Not Covered $750 $750 $ % 100% 100% available immediately 80% 80% 80% available after 6 months on the plan NA NA NA Orthodontia Not Covered NA NA NA About Delta Dental networks Delta Dental PPO Providers: offer deep discounts from standard charges with no balance billing in excess of coinsurance, deductibles, and plan maximums. Delta Dental Premier Providers: offer lesser discounts than PPO but the assurance of no balance billing in excess of coinsurance, deductibles, and plan maximums. Non-Network Providers: are not contracted with Delta Dental benefit payments are made up to the 90 th percentile; balance billing is possible over that level Rates Employee Only: $20.87 Employee & Spouse: $42.69 Employee & Child(ren): $42.36 Employee & Family: $68.07 Customer Service Toll Free: am-6pm EST Please refer to your complete Summary Plan Description for a detailed listing of your benefits and any limitations

3 Dental Plan Overview During the 2013 open enrollment period, the employees of Denny s will again have the opportunity to enroll in the dental benefits plan. Denny s is pleased to announce that beginning on January 1, 2014, our dental plan will be administered by Delta Dental of South Carolina. Our employees will receive world-class customer service and will now have access to two networks of dentists: 1. Delta Dental s PPO sm Network for the deepest discounts with no balance billing in excess of coinsurance, deductibles, and plan maximums; and 2. Delta Dental s Premier Network for discounted services and no balance billing in excess of coinsurance, deductibles, and plan maximums. The Denny s dental plan includes the following features: Freedom to Choose Any Dentist: You may receive dental services from any licensed dentist you choose you do not have to pre-select a dentist. However, you receive the deepest discounts if you use a Delta Dental PPO dentist. Extensive PPO and Premier Networks with Delta Dental: Delta Dental PPO and Delta Dental Premier are the largest dental provider networks in the nation. Simple to Receive : Dentists in both of Delta Dental s networks agree to file claims for you and your family. You will have to provide the network dentist s office with your new identification card and the dentist s office will handle the rest no paperwork for you. No Up-front Charges: All Delta Dental network dentists agree that they will not charge you up-front for expenses that are covered by your plan. They may only charge you for deductibles, your co-insurance, amounts over the benefit maximum and/or for expenses that are not covered under your dental benefits plan. Cost Saving Features: Delta Dental network dentists agree to accept contracted reimbursement and will not bill the patient for amounts over that fee. Also, Delta Dental network dentists agree to not bill Delta Dental patients for : Services that are considered part of general overhead (i.e. infection control); A normal component of a standard procedure (i.e. tooth preparation, temporary crowns, impressions); or The repair/adjustment of fillings/prosthetics within certain time periods following the initial placement (i.e. repair of fillings within 24 months of original placement.) To determine if your dentist participates in the PPO or Premier Network: 1. Visit Delta Dental s website Call the Delta Dental customer service department at: Ask your dentist if they are in the Delta Dental PPO or Premier network. Scan to find a dentist.

4 V Questions and Answers 1. Is the Denny s dental benefits plan changing effective January 1, 2014? Effective January 1, 2014, Delta Dental of South Carolina will be processing your dental claims and you will have access to Delta Dental s network of dentists. 2. When will Delta Dental begin processing Denny s dental claims? Delta Dental will begin processing claims for services you (and covered family members) receive on or after January 1, Our former claims administrator will continue to process claims for services received prior to January 1, Be sure to submit your claims in a timely manner! 3. May I go to any dentist? Yes, you may go to the dentist of your choice. However, we encourage you to choose a Delta Dental PPO Network dentist so that you will receive the deepest discounts and maximize your benefits from the Denny s dental plan. Delta Dental PPO and Premier Network dentists will handle the paperwork for you. 4. If the dentist I choose is not in either Delta Dental network, how will benefits be paid? If your dentist is not in either Delta Dental network, benefits will be paid up to the submitted amount or the maximum non-network fee allowed per procedure. The benefit payment will be made directly to the dentist's office and the dentist s office will bill you for all charges not covered by the plan. 5. I am currently in the Denny s dental plan. If I am in the middle of treatment (i.e. a root canal, crown etc) and the treatment continues after January 1, 2014, how will claims be handled? If you are currently covered by Denny s dental plan and treatment for a root canal, crown, bridge etc. begins prior to January 1, 2014, the current administrator will process benefits for that service. Dentist s offices are very familiar with handling claims when there is a change in administrators. The dentist s office usually accommodates claims for these types of situations by coordinating with the former and new claims administrators. 6. If I was not previously enrolled in the Denny s dental plan, but decide to enroll during open enrollment, when will coverage be effective? If you enroll in the dental plan during this open enrollment period, coverage will be effective for dental care that begins on or after January 1, However, benefits are not available for treatment in progress. Treatment in progress refers to treatment that begins prior to January 1, 2014, but is not completed until January 1, 2014, or later. Examples of such services are: Impression for a crown is taken prior to January 1, 2014, the crown is placed after January 1, 2014; Root canal opened for endodontic treatment prior to January 1, 2014, service is completed after January 1, How do I know if my dentist participates in one of Delta Dental s networks? There are several ways to determine if your dentist is in a Delta Dental network, or, if you don t have a regular dentist, to find a Delta Dental participating dentist in your area: Visit Delta Dental s website at and select Looking for a Dentist. Choose Delta Dental PPO or Premier, and locate a list of dentists by zip code or a specific dentist by name. Call Delta Dental at to request a dentist directory. Simply ask your dentist if he or she is in the Delta Dental PPO or Premier networks.

5 8. If my dentist does not participate with Delta Dental, and I do not want to change dentists, will my dental services still be covered? Certainly! You are eligible for benefits even if your dentist does not participate in a Delta Dental network. However, you may have to file a claim for dental benefits yourself and the benefit payment will be sent directly to you by Delta Dental the payment will not be made to your dentist. The benefit payment for each service is based on the amount charged by the majority of dentists also referred to as the prevailing fee. If the dentist s fee is higher than the prevailing fee, the patient is responsible for the balance, in addition to the deductible, coinsurance and any non-covered charges. Your out-of-pocket costs will be more if you do not use a Delta Dental network dentist. 9. Will I receive a Delta Dental identification card? Yes! You will receive a Delta Dental identification card. When you (or a covered family member) receive dental care, simply present your card to the dentist s office. Delta Dental dentists will file the claim for you. Please remind your dentist that your dental program is with Delta Dental of South Carolina the address is on the reverse side of the identification card. 10. Will Delta Dental provide a benefit predetermination before I receive extensive dental treatment? Predetermination is the process of reviewing a dental treatment plan and identifying the eligible benefits prior to the services being rendered. Delta Dental recommends (it is not required) that you receive a predetermination of benefits for any proposed dental treatment in excess of $200. Delta Dental s participating dentists are very familiar with this process and will gladly submit the predetermination documents for you. If you use a non-participating dentist, simply ask the dentist to forward a copy of the treatment plan to Delta Dental of South Carolina. Our customer service department is available to answer any questions about benefit predetermination. 11. I am receiving orthodontia treatment. Will that still be covered? Yes, Delta Dental will continue to process eligible claims for orthodontic treatment for services received on or after January 1, 2014, until your orthodontic lifetime maximum benefit is reached or treatment ends, whichever occurs first. Please ask your orthodontist to submit a copy of the original treatment plan to Delta Dental, and Delta Dental will start making quarterly payments for orthodontia services received on or after January 1, Where can I get a claim form and how do I file a claim to receive benefits? You will not need a claim form if you visit a Delta Dental dentist. If you visit a non-network dentist, Delta Dental will accept any standard American Dental Association (ADA) claim form that details the services and treatment provided a special claim form is NOT NECESSARY. However, a claim form is available on Delta Dental s website by selecting Subscribers, then My, then selecting Claim Form. The completed claim form may be mailed to: Delta Dental P O Box 8690 St. Louis, MO 63126

6 13. How do I contact Delta Dental if I have questions? Delta Dental s nationwide toll-free number is listed on the ID card. Customer service is available Monday through Friday from 8 a.m. until 6 p.m. Eastern time. Experienced representatives are able to answer over 99 percent of all questions during the initial phone conversation. If your question requires further research, the customer service representative will call you back within one business day with either a response or an update on the progress made. Delta Dental s toll free number will also take you to the automated response system that provides eligibility, benefits, claims status and a means to request a dentist directory 24 hours a day, 7 days a week. You will have access to this voice response system as of January 1, You may also questions to Delta Dental s customer service team at service@ddpmo.org or visit the Delta Dental website, and select Contact Us. 14. If I have a question, who do I contact before January 1, 2014? If you have questions prior to January 1, 2014, please call the Delta Dental customer service department at the nationwide toll-free number and: At the first prompt press 2; Follow the prompts; and Tell the representative that you are an employee of Denny s.

7 Subscribers: Visit DeltaDentalSC.com Here, you can access the participating dentist directory, oral health information, personal benefits information and frequently asked questions. To get started, click on Subscribers To access your personal benefits information, click on My Login View previously covered procedures, coverage levels, deductibles/maximums, claim history, and the subscriber s benefit booklet Print or request an ID card To obtain benefit information online, users can register for a username and password. To find a Delta Dental dentist, click on Find a Participating Dentist Find a Delta Dental PPOSM Network dentist or a Delta Dental Premier Network dentist in your area. BEN

8 FREQUENTLY ASKED QUESTIONS For convenient access to benefits and service 24/7! Visit to: Verify your eligibility Review and print your dental plan s coverage levels, deductibles, maximums, age limits and limitations Request a list of participating dentists in your area Order or print an ID card Request or download a claim form Obtain Delta Dental s contact information Contact customer service at: If you are new to Delta Dental and wish to speak with a customer service representative, press 5. If you are enrolled with Delta Dental, press 2 to receive automated assistance. If you still have questions, press 9 after entering your personal information and a customer service representative will assist you. Customer service representatives are available during business hours, Monday through Friday, 8 a.m. to 6 p.m. Eastern Time. Send written inquiries and claims to: Delta Dental of Missouri BEN FAQ Is it possible for me to access benefits information online? Yes. Visit Delta Dental of South Carolina s web site at deltadentalsc.com. Click Subscribers on the home page, then My Login to view and print your benefits information. You will need to register an online account with us to access your personal dental plan information. What information do I need to access my personal dental benefits plan information? To protect your privacy, the automated phone assistant will ask for your name, date of birth, and, depending upon your plan, either your Social Security number or member ID before reviewing the benefit information you request. If you choose to access your dental benefits online, this information will be required to register an online account. What if I have trouble using the online member portal or wish to speak with a customer service representative? You may call to contact customer service. If you are new to Delta Dental and wish to speak with a customer service representative, press 5. If you are enrolled with Delta Dental, press 2 to receive automated assistance. If you still have questions, press 9 after entering your personal information and a customer service representative will assist you. Our customer service representatives are available during business hours, Monday through Friday, 8 a.m. to 6 p.m. Eastern Time. P.O. Box 8690 St. Louis, MO 63126

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