Dental Chart – High Option - University System of New Hampshire

Delta Dental PPO & Premier NetworksThis chart represents the level of coverage for services performed by dentists who participate in the Delta Dental PPO and Delta DentalPremier National Networks. Employees and their eligible dependents are free to visit any dentist, participating or nonparticipating. Visit ourWeb site at www.nedelta.com for an updated list of participating dentists. This chart is provided for summary purposes only; certain benefitlimitations may apply. Please refer to your Summary Plan Description (SPD) booklet for complete benefit information. In the event of aconflict or discrepancy between this benefit chart and either the Group Contract or the DPD, the Group Contract or SPD will prevail.Diagnostic/PreventiveCoverage ADeductible: NoneUniversity System of New HampshireHigh OptionGroup Number: 1775Basic RestorativeCoverage BMajor RestorativeCoverage CDeductible: $25 Per Person Per Calendar Year, appliedto Basic & Major servicesOrthodonticsCoverage DDeductible: NoneCovered at 100% ** Covered at 80% ** Covered at 50% ** Covered at 50% **Diagnostic:Evaluations – four visits percalendar yearX-rays (Complete series orpanoramic film) - once in 3consecutive years; bitewingx-rays twice in a calendar yearOral cancer screening – once per12 month periodPreventive:Cleanings – (routine) four percalendar yearFluoride twice per calendar yearunder age 19Sealant application to permanentmolars, once per 3 consecutiveyear period per tooth forchildren to age 19Basic Restorative:Amalgam (silver) fillingsComposite (white) fillings(anterior and posterior teeth)X-rays (of individual teeth asneeded)Oral Surgery:Surgical and routine extractionsEndodontics:Root canal therapyPeriodontics:Periodontal cleaning(maintenance procedures)Treatment of gum diseaseClinical crown lengthening –once per lifetime per siteDenture Repair:Repair of a removable dentureto its original conditionEmergency PalliativeTreatmentMajor Restorative:Removable and fixed partialdentures (bridge)Complete denturesRebase & reline (dentures)CrownsOnlaysImplantsOrthodontics:Correction of crooked(malposed) teeth for adultsand dependent childrenNote: If Northeast Delta Dentalhas made an ortho payment for aparticipant under the Basicoption, no additional paymentwill be made under this option.Occlusal guards/adjustmentsSpace maintainers for childrento age 16Calendar Year Maximum: $1,500 per person (Diagnostic, Basic & Major combined)Your plan also includes a Carryover Benefit feature; please refer to the CarryoverBenefit flyer, posted on the USNH web site at http://usnhhr.unh.edu/Orthodontic LifetimeMaximum: $1,500 Per Person** Benefit percentages shown are based upon the actual charge submitted to a maximum of the participating dentist's approved fees, or Delta Dental'sallowance for non-participating and dentists.Rev 01/12

Delta Dental PPO and Delta Dental PremierNational Network DentistsYou'll get the best dollar value from your program when youreceive your dental care from a Delta Dental PPO participatingdentist. Delta Dental PPO dentists generally accept lower fees forservices. You may also choose to visit a dentist who participatesin the larger, Delta Dental Premier network and still enjoy savings.Nearly 3 out of 4 dentists in the country participate in the DeltaDental Premier network.The benefits of seeing a participating provider include:▲ No Balance Billing: Because participating dentists acceptDelta Dental’s maximum allowable amount for service, youwill normally pay less when you visit a participating dentist.▲ Less Paperwork: Participating dentists will prepare andsubmit claims for you.▲ Direct payment: Northeast Delta Dental pays the dentistdirectly, so you don’t have to pay the covered amount up-frontand wait for a reimbursement check.To find out if your dentist is part of the Delta Dental PPO and DeltaDental Premier national network, call your dentist or visit our Website at www.nedelta.com and click on National Dentist Directory.You can also call our Customer Service department at 800-832-5700or 603-223-1234.Claim Process for Delta Dental Premier andDelta Dental PPO Dentists▲ Present your ID card to the dentist at the time of your visit.▲ The dentist will submit your claim to Northeast Delta Dental.▲ Northeast Delta Dental will send you an Explanation ofBenefits detailing what has been processed under yourprogram coverage. You are responsible to pay any remainingbalance directly to the dentist as defined by the plan.Non-Participating/Out of Network DentistsYour dental plan also provides coverage for care receivedfrom providers who do not participate in a Delta Dentalnetwork; however, your out-of-pocket costs may be more.Delta Dental makes payment to non-participating dentists attheir actual fee to Delta Dental’s maximum allowablepayment. If you utilize the services of a non-participatingdentist whose fees are higher than the allowable fees, you willbe responsible for the difference between what Delta Dentalallows and what your non-participating dentist charges. TheExplanation of Benefits and claim payment will go directly toyou, unless the state in which the treatment was performedrecognizes assignment of benefit. In this case the paymentcan be directed to the dentist.Predetermination of BenefitsNortheast Delta Dental strongly encourages predetermination of casesinvolving costly or extensive treatment plans. Although it’s notrequired, predetermination helps avoid any potential confusionregarding Delta Dental’s payment and your financial obligation tothe dentist.Coordination of BenefitsWhen a covered individual under this program has additional groupdental coverage, the COB (Coordination of Benefits) provisiondescribed in your Summary Plan Description booklet will determinethe sequence and extent of payment. If you have any questions,please contact our Customer Service department at 1-800-832-5700or, 603-223-1234.Identification CardTwo identification cards from Delta Dental will be produced anddistributed shortly after your enrollment. Both cards are issued in thesubscriber’s name, but can be used by everyone covered under theprogram.Summary Plan Description BookletA copy of the Summary Plan Description is posted on yourcompany’s intranet. If you do not have access to the intranet, pleasesee your Human Resources representative. This booklet describes thebenefits of your program and tells you how to use your plan. Pleaseread it carefully to understand the benefits and provisions of yourDelta Dental program. If you have any questions, please contact ourCustomer Service department at 800-832-5700 or 603-223-1234.Who is EligibleConsult your Human Resources representative for specificinformation on eligibility guidelines.Claims InquiryIf you have further questions, please contact Northeast Delta Dental’sCustomer Service department at 1-800-832-5700 or, 603-223-1234.This information should be used only as a guideline for your dentalbenefits program. For detailed information on your group’s terms,conditions, limitations, exclusions and guarantees, please refer toyour Dental Plan Description booklet or consult your employer.One Delta DriveP.O. Box 2002Concord, NH 03302-2002www.nedelta.com