Small Business Program

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Delta Dental of California

Small Business Program

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Businesses of all sizes are big on value.

That’s why Delta Dental created a portfolio of its most popular plans — each specially designed to provide maximum value for your small business. You can rely on Delta Dental to provide cost management, superior access to dentists and dental plans to meet your needs.

No matter which Delta Dental plan you choose, you can feel confident knowing that you’ve chosen a plan that protects your employees and offers your business big value.

Delta Dental PPO

SM

Delta Dental PPO is our open network plan that balances moderate savings with maximum access to network dentists. Enrollees may visit any licensed dentist but usually have the lowest out-of-pocket costs when visiting a PPO dentist. Delta Dental offers access to one of the largest networks of its kind in the U.S., with two levels of savings; Delta Dental PPO and Delta Dental Premier®_{. Through this}

two-tier network approach, enrollees are protected from the higher costs that are likely when services are provided by non-Delta Dental dentists. Our small business program offers employers access to a variety of plan options often available only to large employers. These options include PPO plan designs that reimburse the dentist based on the PPO provider’s contracted fee both in- and out-of-network or the PPO plus Premier plan designs that will reimburse Delta Dental Premier dentists based on their contracted Premier fee.

With PPO plus Premier — our unique PPO plan design feature — employers can take advantage of the savings from the PPO plan while providing employees with expanded access to Delta Dental dentists who can limit their out-of-pocket costs. PPO dentists accept fees that are more deeply discounted than the fees accepted by dentists who participate in the larger Premier network. Employees who visit a non-PPO dentist can save more by visiting a Premier dentist than they can by visiting a non-Delta Dental dentist. PPO plus Premier provides maximum network access while offering deeper savings within the PPO network and a level of cost protection with the Premier network.

All Delta Dental dentists make visits easy and convenient because they file claims and accept payment for services directly from Delta Dental. Patients are only responsible for their share at the time of treatment —they pay no more than the fees allowed by Delta Dental, thus are not required to pay the entire claim up front and wait for reimbursement when they visit a Delta Dental dentist.

DeltaCare

®

_USA

DeltaCare USA is our closed network prepaid plan that features set copayments, no annual deductibles and no maximums for covered benefits. Enrollees must select a primary care dentist in the DeltaCare USA network from whom they receive treatment, as in a traditional dental HMO. With DeltaCare USA, businesses enjoy higher cost controls, while still providing employees with a broad range of dental benefits.

DeltaCare USA delivers quality care for less cost than our traditional fee-for-service plans. DeltaCare USA dentists undergo a comprehensive credentialing process to ensure they meet high-quality standards. The majority of diagnostic and preventive procedures are covered at no cost to the enrollee.

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PPO C — PPO plus Premier — Delta Dental PPO dentists are reimbursed at the lesser of the submitted charge or the PPO provider’s contracted fee. Delta Dental Premier dentists are reimbursed at the lesser of the submitted charge or the Premier provider’s contracted fee. Non-contracted dentists are paid the lesser of the submitted fee or the fee charged by dentists of similar training in the same geographical area.

Waiting period for benefits None None None

Diagnostic (deductible waived) Exams (two per calendar year)

Bitewing x-rays

100% 100% 100% 100% 100% 100%

Preventive (deductible waived)

Prophylaxis (cleaning) (two per calendar year) One additional cleaning for pregnant women2

Fluoride treatments (two per calendar year) Space maintainers

100% 100% 100% 100% 100% 100%

The calendar year maximum is waived for diagnostic and preventive services.

Optional Optional Optional

Basic services

Amalgam fillings primary or permanent teeth

Sealants (permanent 1st molars through age 8 and 2nd molars through age 15)

80% 80% 90% 80% 80% 80%

Oral surgery

Extraction and oral surgery procedures including pre- and post-operative care

General anesthesia and IV sedation are covered when used in conjunction with covered oral surgical procedures

80% 80% 90% 80% 80% 80%

Major services

Crowns and cast restorations

Prosthodontic services (dentures and bridges) Implants

50% 50% 60% 50% 60% 50%

Endodontics and Periodontics Pulpal therapy, root canal therapy

Treatment to the gums and supporting structures of the teeth

80% 80% 90% 80% 80% 80%

Calendar year deductible per patient $50 $50 $25 $50

Calendar year maximum per patient (select)

$1,000 $1,500 $2,000 $1,000 $1,500 $2,000 $1,000 $1,500 $2,000

Orthodontics (optional) (requires a minimum of 10 PEs)

— Child only

— Lifetime orthodontic maximum per patient

50% $1,000 50% $1,000 50% $1,000

Rate tier Three Three Three

1 _{Subject to Limitations and Exclusions shown on pages 10-11.}

2 _{If the enrollee is pregnant, Delta Dental will pay for the following additional services per calendar year: one additional oral evaluation and either one additional}

routine cleaning or one additional periodontal scaling and root planing per quadrant.

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Summary of Benefits1

OPTIONS

PPO 1 PPO 2 PPO 3

PPO plus

Premier PPO plus Premier PPO plus Premier

PPO

Dentists Non-PPO Dentists DentistsPPO Non-PPO Dentists DentistsPPO Non-PPO Dentists

Reimbursement basis

PPO 1, 2 & 3 — PPO plus Premier — Delta Dental PPO dentists are reimbursed at the lesser of the submitted charge or the PPO provider’s contracted fee. Delta Dental Premier dentists are reimbursed at the lesser of the submitted charge or the Premier provider’s contracted fee. Non-contracted dentists are paid the lesser of the submitted fee or the fee charged by dentists of similar training in the same geographical area.

Waiting period for benefits None None None

Diagnostic (deductible waived) Exams (two per calendar year)

Bitewing x-rays

100% 100% 100% 80% 100% 100%

Preventive (deductible waived)

Fluoride treatments (two per calendar year) Space maintainers

100% 100% 100% 80% 100% 100%

The calender year maximum is waived for diagnostic and preventive services.

Optional Optional Optional

Basic services

Sealants (permanent 1st molars through age eight and 2nd molars through age 15)

90% 80% 80% 80% 80% 80%

Oral surgery

Extraction and oral surgery procedures including pre- and post-operative care

General anesthesia and IV sedation are covered when used in conjunction with covered oral surgical procedures

90% 80% 80% 80% 80% 80%

Major services

Crown and cast restorations

Prosthodontic services (dentures and bridges) Implants

60% 50% 50% 50% 50% 50%

Endodontics and Periodontics (select) Pulpal therapy, root canal therapy

Treatment to the gums and supporting structures of the teeth

90% 60% 80% 50% 80% 50% 80% 50% 80% 50% 80% 50%

Calendar year deductible per patient/per family (select) $50/$150 _$25/$75 $50/$150 _$25/$75 $40/$120 _None $50/$150 _$25/$75 Calendar year maximum per patient (select)

$1,000 $1,500 $2,000 $1,000 $1,500 $2,000 $1,000 $1,500 $2,000 Orthodontics (optional)

— Child only or adult and child(ren)

— Lifetime orthodontic maximum per patient (select)

50% $1,000 $1,500 50% $1,000 $1,500 50% $1,000 $1,500

Rate tier (options) Three or Four Three or Four Three or Four

Delta Dental PPO Plans

For businesses with 50 – 99 eligible employees

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Delta Dental PPO Plans — Voluntary

For businesses with 5 – 99 eligible employees

1 _{Subject to Limitations and Exclusions shown on pages 10-11.}

2 _{If the enrollee is pregnant, Delta Dental will pay for the following additional services per calendar year: one additional oral evaluation and either one}

additional routine cleaning or one additional periodontal scaling and root planing per quadrant.

3 _{Covers conditions caused directly and independent of all other causes, by external, violent and accidental means occurring after the enrollee’s eligibility}

date. Services must be provided to an enrollee within 180 days following the date of accident. Accidental Benefits are subject to all plan limitations exclusions, deductibles and annual maximums.

Summary of Benefits1 _{PPO VOL}

VOLUNTARY

PPO Dentists Non-PPO Dentists Reimbursement basis All dentists are reimbursed at the lesser of the submitted _{charge or the PPO provider’s contracted fee.} Diagnostic and Preventive (deductible waived)

Periodic oral evaluation Bitewing x-rays

100% 100%

Sealants, simple restorations & simple extractions

Sealants (permanent 1st molars through age 8 and 2nd molars through age 15)

80% 80%

Dental Accident3 _100% _100%

Covered only following 12-months of continuous enrollment

Endodontics

Root canal — endodontic therapy, anterior teeth (excluding final restoration)

50% 50%

Periodontics

Gingivectomy or gingivoplasty — four or more contiguous teeth or bounded teeth per quadrant

50% 50%

Oral surgery

Removal of impacted tooth

50% 50%

Crowns, inlays, onlays and cast restorations

Crown — full cast noble metal

50% 50%

Prosthodontics

Implants Complete denture Pontic cast noble metal

50% 50%

Orthodontics (optional)(requires min 25 PEs)

Coverage

Lifetime orthodontic maximum per patient

50% Child only

$1,000

Calendar year deductible per patient $50

Calendar year maximum per patient (select) $1,000

$1,500

Rate tier Four

FIRS T 12 MONTHS SE COND 12 MONTHS

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1 _{Subject to the Limitations and Exclusions shown on pages 12 – 13. A complete listing of the Description of Benefits and Copayments is available upon}

request.

2 _{2014 Current Dental Terminology codes under copyright by the American Dental Association (ADA).}

DeltaCare USA Plans

For businesses with 2 – 99 eligible employees

Sample Procedures1 Procedure

Code2 DeltaCare USA 10A DeltaCare USA 11A DeltaCare USA 12A DeltaCare USA 15B Plan 48N Diagnostic services

Intraoral — complete series of radiographic images D0210 $0 $0 $0 $0 $0

Preventive services

Prophylaxis — adult Prophylaxis — child Sealant — per tooth

D1110 D1120 D1351 $0 $0 $5 $0 $0 $10 $0 $0 $10 $5 $5 $15 $0 $0 $0 Restorative services

Amalgam — one surface, primary or permanent Resin-based composite — one surface, anterior Resin-based composite — one surface, posterior Crown — porcelain fused to high noble metal Crown — full cast high noble metal

Crown — full cast noble metal

Post and core in addition to crown, indirectly fabricated

D2140 D2330 D2391 D2750 D2790 D2792 D2952 $0 $0 $45 $195 $170 $110 $0 $0 $0 $55 $240 $210 $150 $35 $5 $22 $65 $295 $260 $200 $60 $8 $22 $65 $395 $395 $335 $110 $0 $28 $65 $485 $485 $465 $85 Endodontics

Root canal — endodontic therapy, anterior tooth (excluding final

restoration)

Root canal — endodontic therapy, molar (excluding final restoration)

D3310 D3330 $45 $205 $55 $250 $85 $280 $125 $365 $110 $245 Periodontics

Osseous surgery (including flap entry and closure) — four or more contiguous teeth or tooth bounded spaces per quadrant

Periodontal scaling and root planing — four or more teeth per quadrant

D4260 D4341 $175 $0 $280 $25 $300 $40 $385 $60 $360 $50 Prosthodontics(removable)

Complete denture — maxillary

Maxillary partial denture — resin base (including any conventional clasps, rests and teeth)

Maxillary partial denture — cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

Reline complete maxillary denture (laboratory)

D5110 D5211 D5213 D5750 $100 $80 $120 $35 $145 $120 $160 $60 $215 $180 $240 $75 $365 $325 $395 $95 $510 $535 $610 $125

Oral and maxillofacial surgery

Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated

Removal of impacted tooth — completely bony

D7140 D7210 D7240 $0 $15 $70 $5 $25 $90 $8 $45 $95 $14 $55 $120 $18 $30 $80 Orthodontics

Comprehensive orthodontic treatment of the transitional dentition — child

or adolescent to age 19

D8070 $1,700 $1,700 $1,700 $1,900 $2,100 Comprehensive orthodontic treatment of the adult dentition — adults,

including covered dependent adult children

D8090 $1,900 $1,900 $1,900 $2,100 $2,250

Deductible None None None None None

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Program Guidelines — PPO and DeltaCare USA

Group size Businesses headquartered in California with 2 – 99 eligible employees. Out-of-state enrollees PPO

Primary enrollees that reside outside of California:

• Groups with greater than 4 eligible employees: no more than 50%. • Groups with 4 eligible employees: no more than 1.

• Groups less than 4 eligible employees: none.

DeltaCare USA

Services must be rendered in the state where the contract is issued.

Eligible industries See page 14 for a complete list of eligible/ineligible industries.

Eligible employees • Full-time, permanent employees, as defined by the employer. • Contract employees (category 1099 employees) are not eligible.

• A group of two cannot be comprised of a dependent relationship; e.g., husband and wife.

Eligible dependents • Legal spouse or domestic partner. • Children to age 26.

Employer contribution

requirements PPO Employer Paid:• 75% to 100% of the employee premium.

PPO Voluntary:

• Less than 75% of the employee premium.

DeltaCare USA:

• 0% to 100% of the employee premium (refer to the DeltaCare USA rate sheet for more details on contribu-tion opcontribu-tions).

Employer enrollment participation requirements

All Plans:

• 100% employer paid - all eligible employees must enroll.

PPO Plans

• Employer must submit a DE-9C to verify a true employer/employee relationship. • 75% - 99.9% employer paid:

- 80% of all eligible employees must enroll (excluding those with dental coverage elsewhere). - Minimum enrollment:

° PPO Classic plans (groups with 2-4 employees) – 2 eligible employees. ° PPO Classic plans (groups with 5-99 employees) – 5 eligible employees. ° PPO Options plans (groups with 50-99 employees) - 35 eligible employees. • Less than 75% employer paid (PPO Voluntary).

- Minimum enrollment:

° Groups with 2-4 employees - 2 eligible employees. ° Groups with 5-99 employees – 5 eligible employees.

DeltaCare USA:

• 0 – 99.9% employer paid DeltaCare USA Plans: - Minimum enrollment – 2 eligible employees.

Eligible employee/

dependent enrollment 100% Employer Paid:• All eligible employees must enroll following completion of employer’s eligibility period. • If dependents are 100% employer paid, all must enroll.

Less than 100% Employer Paid:

• Employees and their dependents may enroll following completion of employer’s eligibility period. • All eligible dependents not covered under another group plan must be enrolled if dependent coverage is

selected.

• Children under the age of 4 may be enrolled during the group’s open enrollment up to or immediately fol-lowing their 4th birthday.

• Coverage cannot be dropped or changed other than during the group’s annual open enrollment or within 30 days of a qualifying event.

Waive coverage Coverage can be waived for:

• Employees who contribute towards the cost of coverage for themselves.

• Dependents, when the employee contributes toward the cost of dependent coverage.

• Employees and/or dependents with coverage elsewhere (not available if the employer pays 100% of the cost of dependent coverage).

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Carve-out Employee class carve-out is allowed and can consist of management/non-management, union/non-union and hourly/salaried employees. The following will apply:

• Delta Dental PPO can be offered to one population and DeltaCare USA can be offered to another (multiple PPO plans are not allowed).

• Carve-out is not allowed with another carrier.

• Level 2 rating applies to carve-out groups regardless of industry. • Employer must provide DE-9C identifying the carve-out employees. • Underwriting guidelines apply to each of the carve-out plans.

Retiree coverage Dental coverage for retirees is available in conjunction with an active employee plan provided there is no break in coverage and the employer contribution is identical for both active employees and retirees. Coverage must be available to all retirees, not just a select few.

Open enrollment Employees who contribute towards the cost of coverage for themselves and/or their dependents using pretax dollars may add or delete coverage for themselves and/or their dependents during the group’s open enroll-ment.

Dual choice Dual Choice — PPO plan and a DeltaCare USA plan:

• Delta only – no other carrier.

• Employer contribution percentage for employee and dependent coverage must be identical for both plans. • Plan requirements:

- Classic

° 10 or more eligible and enrolled employees – minimum of at least 2 in one plan with remainder in other plan.

° Less than 10 eligible and/or enrolled employees – please see insert for plans available for 2-4 em-ployees. Minimum of 2 enrolled in each plan.

° Minimum requirement of 10 eligible and enrolled in PPO plan for orthodontic coverage. - Options:

° Minimum enrollment of 50 eligible employees.

° At least 10 enrolled in one plan and remainder in other plan. - PPO Voluntary:

° Minimum of 5 enrolled in PPO plan and 5 in DeltaCare USA plan. ° Minimum of 25 enrolled in PPO for orthodontic coverage.

• Groups with open enrollment – coverage cannot be dropped or changed other than during the group’s an-nual open enrollment or within 30 days of a qualifying event.

Benefits waiting period PPO Voluntary only:

• 12-month waiting period applies to all covered services except D&P, sealants, simple restorations, simple extractions and dental accident.

• The waiting period for initial employees and eligible dependents may be waived with proof of coverage in this employer’s prior comprehensive dental plan with no break in coverage (copy of group’s prior carrier’s EOC and last bill).

• New hires and their dependents are subject to the 12-month waiting period regardless of previous coverage.

Terminations • Dental coverage will end on the last day of the month when primary enrollee is no longer eligible for cover-age.

• Dependent coverage will end at the same time as the primary enrollee or when the dependent is no longer eligible.

Transferring into the

Small Business Program Existing Delta Dental and DeltaCare USA groups, outside of the Small Business Program, will not be allowed to transfer into the Small Business Program.

Changing benefits Groups must wait until anniversary to change benefits.

Deductible rollover credit Not available for new and existing groups.

Program Guidelines — PPO and DeltaCare USA

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How the PPO Plan Works

Delta Dental PPO plans provide access to one of the largest networks of its kind nationwide. Delta Dental PPO dentists agree to accept reduced fees as payment in full for covered procedures when treating PPO patients. This means enrollee’s out-of-pocket costs are usu-ally lower when they visit a PPO dentist than when they visit a non-Delta Dental dentist.

When covered under the PPO plan, enrollees:

•

Can visit any licensed dentist, including a dental specialist of choice

•

May change dentists at any time without notifying us

•

Can receive dental care anywhere in the world (Non-PPO benefits apply)

•

Will not have to pay more than the patient’s share1_{for covered services or file claim forms when visiting a Delta Dental dentist.}

Delta Dental dentists file claim forms for enrollees and accept payment directly from Delta Dental.

•

Can visit a Delta Dental Premier dentist. Delta Dental Premier dentists will not bill above their contracted fees, but they may charge the difference between the PPO contracted fee and the Premier contracted fee.

Delta Dental PPO plus Premier plans combine the PPO and Premier networks to maximize opportunities to save money. If an enrollee cannot visit a PPO dentist, the best alternative is to choose a dentist from the Delta Dental Premier network because these dentists also agree to accept limited fees for services and will not bill above the Premier contracted fees.

Locating a Delta Dental PPO dentist

Enrollees may visit our online directory at deltadentalins.com to find a Delta Dental PPO dentist anywhere in the U.S.

For a comparative example of out-of-pocket costs that PPO enrollees might incur when visiting either a Delta Dental PPO, Delta Dental Premier or non-Delta Dental dentist, please see the hypothetical chart below:

PPO

Delta Dental PPO Dentist Delta Dental Premier Dentist Non-Delta Dental Dentist

Dentist bills (submitted charge) $180 $180 $180

Dentist accepts as payment in full $90 (PPO provider’s contracted fee) $130 (Premier provider’s contracted fee) $180 (No fee agreement with

Delta Dental)

Delta Dental’s payment (50%)2 _$45 _$45 _$45

Patient’s share $45 $85 $135

1 _{The patient’s share for covered services is their coinsurance, remaining deductible, any amount over the annual maximum, and any unpaid difference between}

the Premier provider’s contracted fee and the PPO contracted fee.

2_{Hypothetical example for illustrative purposes assumes that the plan’s deductible has been previously satisfied, that the annual maximum has not been reached,}

and that benefit levels for in- and out-of-network treatment are both at 50%.

3_{Non-contracted dentists are paid the lesser of the submitted fee or the fee charged by dentists of similar training in the same geographical area.}

PPO plus Premier

Delta Dental PPO Dentist Delta Dental Premier Dentist Non-Delta Dental Dentist

Dentist bills (submitted charge) $180 $180 $180

Dentist accepts as payment in full $90 (PPO provider’s contracted fee) $130 (Premier provider’s contracted fee) $180

(No fee agreement with Delta Dental)

Delta Dental’s payment (50%)2 _$45 _$65 _$503

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DeltaCare USA promotes great dental health for enrollees and their families with quality dental benefits at an affordable cost. By cover-ing many services at no cost to the enrollee, Delta Dental encourages regular preventive dental visits. Enrollees must select a contracted DeltaCare USA dentist to provide covered services.

DeltaCare USA enrollees also enjoy great features including out-of-area emergency coverage, an orthodontic treatment in progress pro-vision and expanded business hours for toll-free customer service (subject to Limitations and Exclusions).

When covered by a DeltaCare USA plan, enrollees:

•

Won’t be subject to annual deductibles or maximums;

•

Will know in advance what out-of-pocket costs will be;

•

Won’t be subject to restrictions on pre-existing conditions, except for work in progress;

•

Won’t have to complete claim forms and submit them for reimbursement;

•

Will be covered for accidental injury based on procedures listed in the Description of Benefits and Copayments; and

•

Will receive a plan in which all listed procedures are covered with set fixed copayments.

Know the name and location of a DeltaCare USA dentist

Enrollees must visit their selected DeltaCare USA dentist to receive benefits under the DeltaCare USA plan. If enrollees change their DeltaCare USA dentist by the 21st of the month, the change will be effective on the first day of the following month. If the dentist’s network status changes, Delta Dental will notify the enrollee, but they should verify their dentist’s status with us by calling Customer Service or by visiting our web site — deltadentalins.com.

How the plan works

Following enrollment in DeltaCare USA, enrollees will receive an ID card and a plan booklet. The booklet contains a complete list of the procedures and copayments that are covered for the DeltaCare USA plan, as well as plan limitations and exclusions. Delta Dental will also include in the packet the name, address and phone number of the enrollees’ DeltaCare USA dentist. Enrollees simply call the dental office to make an appointment. We will notify the DeltaCare USA dentist about the enrollees’ enrollment in the plan, as well as other important details about enrollee coverage such as dependent information, group number and enrollee ID number. One of the great features of the plan is that enrollees have a list of the copayments and covered services so they can always refer to it before visiting the dentist.

Orthodontic treatment in progress

DeltaCare USA has an orthodontic treatment in progress provision that allows new enrollees to continue treatment with their current orthodontist, so long as the enrollee is in active treatment started under his or her previous employer-sponsored dental plan. Enrollees are responsible for all copayments and fees subject to the provisions of their prior dental plan.

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PPO Limitations and Exclusions

Limitations

1. Only the first two oral examinations, including office visits for observation and specialist consultations, or combina-tion thereof, provided to an Enrollee in a calendar year while he or she is an Enrollee under any Delta Dental plan are Benefits under this plan. See Note on additional Benefits during pregnancy. *

2. Delta Dental pays for full-mouth x-rays only after five years have elapsed since any prior set of full-mouth x-rays was provided under any Delta Dental plan.

Delta Dental pays for a panoramic x-ray provided as an individual service only after five years have elapsed since any prior panoramic x-ray was provided under any Delta Dental plan.

3. Bitewing x-rays are provided on request by the dentist, but no more than twice in a calendar year for children to age 18 or once in a calendar year for adults age 18 and over, while enrolled under any Delta Dental plan.

4. Diagnostic casts are a benefit only when made in connec-tion with subsequent orthodontic treatment covered under this plan.

5. We pay for two cleanings or a dental procedure that includes a cleaning each calendar year under any Delta Dental plan.*

Routine cleanings are covered as a Diagnostic and Preven-tive benefit and periodontal cleanings are covered as a periodontal benefit.

6. Periodontal scaling and root planing are limited to one for each quadrant each 24-month period.

7. Fluoride treatments is a benefit twice each calendar year under any Delta Dental plan.

8. Sealant benefits include the application of sealants only to permanent first molars through age eight and second molars through age 15 if they are without caries (decay) or restorations on the occlusal surface. Sealant Benefits do not include the repair or replacement of a sealant on any tooth within two years of its application.

9. Direct composite (resin) restorations are Benefits on an-terior teeth and the facial surface of bicuspids. Any other posterior direct composite (resin) restorations are optional services and Delta Dental’s payment is limited to the cost of the equivalent amalgam restorations.

10. Crowns, Inlays, Onlays and Cast Restorations are Benefits on the same tooth only once every five years, while you are eligible under any Delta Dental plan, unless Delta Dental determines that replacement is required because the res-toration is unsatisfactory as a result of poor quality of care, or because the tooth involved has experienced extensive loss or changes to tooth structure or supporting tissues since the replacement of the restoration.

11. Prosthodontic appliances and implants that were provided

partial denture or complete denture cannot be made satisfactory. Replacement of a prosthodontic appliance or implant supported prosthesis not provided under a Delta Dental plan will be covered if it is unsatisfactory and cannot be made satisfactory. Implant removal is limited to one for each tooth during the Enrollee’s lifetime whether provided under a Delta Dental or any other dental care plan. 12. Delta Dental will pay the applicable percentage of the

Dentist’s Fee for a standard cast chrome or acrylic partial denture or a standard complete denture. A “standard” complete or partial denture is defined as a removable prosthetic appliance provided to replace missing natural, permanent teeth and which is constructed using ac-cepted and conventional procedures and materials. 13. If the enrollee selects a more expensive plan of treatment

than is customarily provided, or specialized techniques, an allowance will be made for the least expensive, profession-ally acceptable, alternative treatment plan. Delta Dental will pay the applicable percentage of the lesser fee for the customary or standard treatment and the enrollee is responsible for the remainder of the dentist’s fee. For example: a crown where an amalgam filling would restore the tooth; or a precision denture where a standard denture would suffice.

14. Orthodontic services, if covered

a) The obligation of Delta Dental to make payments for an Orthodontic treatment plan begun prior to the Eligibil-ity Date of the Enrollee shall commence with the first payment due following the Enrollee’s Eligibility Date. The maximum amount payable will apply fully to this and subsequent payments.

b) The obligation of Delta Dental to make payments for Orthodontics shall terminate on the payment due next following the date the Dependent loses eligibility or the employee loses eligibility, or upon the termination of treatment for any reason prior to completion of the case, or upon termination of the Contract, whichever shall occur first.

c) Delta Dental will pay the applicable percentage of the dentist’s fee for a standard orthodontic treatment plan involving surgical and/or non-surgical procedures. If the enrollee selects specialized orthodontic appliances or procedures, an allowance will be made for the cost of a standard orthodontic treatment plan and the enrollee is responsible for the remainder of the dentist’s fee. d) X-rays and extraction procedures incident to

Orthodon-tics are not covered by Orthodontic Benefits, but may be covered under the provisions of the Contract, subject to all of the terms and provisions thereof.

* If the enrollee is pregnant, Delta Dental will pay for the following additional services per calendar year: one

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PPO Limitations and Exclusions

Exclusions

The following services are not benefits:

1. Services for injuries covered by Workers’ Compensation or Employer’s Liability Laws.

2. Services which are provided to the enrollee by any Federal or State Governmental Agency or are provided without cost to the enrollee by any municipality, county or other political subdivision, except as provided in California Health and Safety Code Section 1373(a). 3. Services with respect to congenital (hereditary) or

developmental (following birth) malformations or cosmetic surgery or dentistry for purely cosmetic reasons, including but not limited to: cleft palate, upper or lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth). 4. Services for restoring tooth structure lost from

wear (abrasion, erosion, attrition, or abfraction), for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth. Such services include but are not limited to equilibration and periodontal splinting.

5. Prosthodontic services or any Single Procedure started prior to the date the person became eligible for such services under this Contract.

6. Prescribed or applied therapeutic drugs, premedication or analgesia.

7. Experimental procedures.

8. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the dentist for treatment in any such facility.

9. Charges for anesthesia, other than general anesthesia or I.V. sedation administered by a licensed Dentist in connection with covered Oral Surgery services and select Endodontic and Periodontic procedures.

10. Grafting tissues from outside the mouth to tissues inside the mouth (“extraoral grafts”).

11. Diagnosis or treatment by any method of any condition related to the temporomandibular (jaw) joints or associated muscles, nerves or tissues.

12. Replacement of existing restoration for any purpose other than active tooth decay.

13. Occlusal guards and complete occlusal adjustment. 14. Charges for replacement or repair of an orthodontic

appliance paid in part or in full by this plan.

15. Orthodontic services unless Delta Dental’s copayment and maximum amount payable are shown on the highlights page of the Evidence of Coverage.

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DeltaCare USA Limitations

Limitations

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 booklet will be sent upon enrollment.

1. The frequency of certain benefits is limited. All frequency limitations are listed in the Description of Benefits and Copayments, which is available upon request.

2. If the enrollee accepts a treatment plan from the general dentist that includes any combination of more than six crowns, bridge pontics and/or bridge retainers, the Enrollee may be charged an additional $100.00 ($125 for plan 48N) above the listed copayment for each of these services after the sixth unit has been provided. 3. General anesthesia and/or intravenous sedation/analgesia

are limited to treatment by a contracted oral surgeon and in conjunction with an approved referral for the removal of one or more partial or full bony impactions, (Procedures D7230, D7240, and D7241).

4. Benefits under plan 48N provided by contract dentists may offer services that utilize brand or trade names at an additional fee. The Enrollee must be offered the plan benefits of a high quality laboratory processed crown/ pontic that may include: porcelain/ceramic; porcelain with base, noble or high-noble metal. If the Enrollee chooses the alternative of a material upgrade (name brand laboratory processed or in-office processed crowns/pontics produced through specialized technique or materials, including but not limited to: Captek, Procera, Lava, Empress and Cerec) the Contract Dentist may charge an additional fee not to exceed $325.00 in addition to the listed Copayment. Contact the Customer Service department at 800-422-4234 if you have questions regarding the additional fee or name brand services.

5. Benefits under all plans, except 48N, provided provided by a pediatric dentist are limited to children through age seven following an attempt by the assigned contract dentist to treat the child and upon prior authorization by Delta Dental, less applicable copayments. Exceptions for medical conditions, regardless of age limitation, will be considered on an individual basis.

Benefits under plan 48N provided by a pediatric dentist

are limited to children through age seven following an attempt by the assigned Contract Dentist to treat the child and upon Authorization by the Administrator, less applicable Copayments. The Plan will consider exceptions on an individual basis if a child has a physical or mental impairment, limitation or condition which substantially interferes with that child’s ability to have Benefits provided by a Contract Dentist.

6. The cost to an enrollee receiving orthodontic treatment whose coverage is cancelled or terminated for any reason will be based on the contract orthodontist’s usual fee for the treatment plan. The contract orthodontist will prorate the amount for the number of months remaining to complete treatment. The enrollee makes payment directly to the contract orthodontist as arranged.

7. 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.

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DeltaCare USA Exclusions

Exclusions

1. Any procedure that is not specifically listed in the

Description of Benefits and Copayments, which is available upon request.

2. 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;

b. is inconsistent with generally accepted standards for dentistry.

3. Services solely for cosmetic purposes, with the exception of procedure D9975, External bleaching, per arch, or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw

malformations, congenitally missing teeth and teeth that are discolored or lacking enamel, except for the treatment of newborn children with congenital defects or birth abnormalities.

4. Porcelain crowns, porcelain fused to metal, cast metal or resin with metal type crowns and fixed partial dentures (bridges) for children under 16 years of age.

5. Lost or stolen appliances including, but not limited to, full or partial dentures, space maintainers and crowns and fixed partial dentures (bridges) and orthodontic appliances. 6. Under all plans, except 48N, procedures appliances or

restoration if the purpose is to change vertical dimension, or to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ).

Under plan 48N procedures, appliances or restoration if

the purpose is to change vertical dimension, replace or stabilize tooth structure loss by attrition, realignment of teeth, periodontal splinting, gnathologic recordings or to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ), with the exception of procedures D9951 and D9952 as shown on Schedule A; 7. 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. 8. Implant-supported dental appliances and attachments,

implant placement, maintenance, removal and all other services associated with a dental implant.

9. Consultations or other diagnostic services for for non-covered benefits.

10. Dental services received from any dental facility other than the assigned contract dentist, a preauthorized dental specialist, or a contract orthodontist except for emergency Services as described in the contract and/or Evidence of Coverage (EOC). 11. All related fees for admission, use, or stays in a hospital,

out-patient surgery center, extended care facility or other similar care facility.

12. Prescription drugs and over-the-counter drugs.

13. Dental expenses incurred in connection with any dental or orthodontic procedure started before the enrollee’s eligibility with the DeltaCare USA Program. Examples include: teeth prepared for crowns, root canals in progress, full or partial dentures for which an impression has been taken and orthodontics unless qualified for the orthodontic treatment in progress provision.

14. Lost, stolen or broken orthodontic appliances.

15. Changes in orthodontic treatment necessitated by accident of any kind.

16. Myofunctional and parafunctional appliances and/or therapies.

17. Composite or ceramic brackets, lingual adaption of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances.

18. Treatment or appliances that are provided by a dentist whose practice specializes in prosthodontic services.

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Eligible/Ineligible Industries

Level One SIC code

Advertising (except Misc. not classified #7319) 7311-7313 Agriculture, Forestry, Fishing (except

seasonal employees) 0100-0999 Auto Rental Agencies 7513-7519 Automobile Parking Services 7521 Building Maintenance/Equipment Rental 7349-7359 Collection Agencies & Credit

Reporting Services 7322-7323 Communication (Radio, Telephone,

TV/Radio Broadcasting) 4800-4899 Community Service Organizations/

Social Services 8300-8499 Computer Programming & Related Services 7371-7379 Construction Contractors 1500-1799 Direct Mailing, Reproductions,

Secretarial Services 7331-7338 Disinfecting & Pest Control Services 7342 Electrical Repair (Radio, TV, A/C,

Refrigerator) 7622-7629 Engineering & Management Services 8711-8748 Finance (Banks, Securities, Credit Agencies) 6000-6299 Funeral Services & Crematories 7261 Furniture Repair/Reupholstery 7641 Government-Funded Groups 8300-8499 Hospitals 8062-8069 Independent Auto Repair & Services 7532-7599 Laundry/Garment Services/Shoe

Repair Shops 7211-7219/7251 Manufacturing (except Jewelry

Manufacturing) 2000-2699 Manufacturing (Chemicals, Allied

and Other Products) 2810-3999 Mining, Oil and Gas Extraction 1000-1499 Misc. Computer Services 7379 Misc. Repair (Welding, etc.) 7692-7699 Museum Art Galleries & Gardens 8412, 8422 News Syndicates 7384, 7383

Photofinishing Labs 7384

Printing & Publishing 2700-2799 Public and Private Schools 8200-8299 (Elementary & High School)

Public Administration (Cities, Counties,

Police, etc.) 9000-9720, 9722-9998 Retail 5200-5510, 5610-5699,

5712-5736, 5912-5999 Transportation 4000-4799 Security Systems, Detectives, Armored Cars 7381-7382 Utilities 4900-4999 Wholesale Trade 5000-5199

Eligible Industries1

Delta Dental PPO

Level Two SIC code

Advertising, Misc. not classified 7319 Amusement, Recreation & Entertainment 7800-7999 Auto Dealerships 5511-5599 Churches (Management and

Administrative staff only) 8661 Hotels 7000-7099 Insurance Carriers/Brokers 6300-6499 Jewelry Manufacturing 3911-3915 Legal 8100-8199 Management Carve-out (regardless of industry) 9999 Medical Groups 8000-8059 & 8082-8099 Photographic Studios 7221

Real Estate 6500-6799

Restaurants 5800-5899 Tax Return Preparation Services/Misc.

Personal Services 7291-7299 Watch, Clock & Jewelry Repair 7631

Ineligible Industries SIC code

Associations and Trusts2 (except #8661) 8600-8699 Beauty & Barber Shops 7231-7241 Dentist offices, Dental Labs and

Medical Labs 8021, 8071, 8072 Employment Agencies 7361-7363

High Turnover3_Varies

International Affairs 9721 Misc. Business Services 7389 Misc. Services not elsewhere classified 8999

Private Households 8811

Religious Organizations (except Churches #8661) No SIC Seasonal Employees (Christmas/Part-time help) No SIC Seasonal Employees (Agriculture) 0761-0783

Voluntary PPO

Eligible Industries

All

DeltaCare USA

Eligible Industries

All except for those identified as ineligible below.

Ineligible Industries:

Law firms and associations Seasonal employment High turnover3

1 _{SIC rate level can not change for renewing business.}

2_{Management and the Administrative staff of Associations and Trusts}

are eligible under Level two. Use SIC Code 9999.

3 _{A business has “high turnover” if 20% or more of the average number}

of its employees during the past 12 months were newly hired for rea-sons other than the growth of the business.

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Value Proposition

We keep you smiling

®

Why do 63 million enrollees trust their smiles to Delta Dental?1

Most of our enrollees stay with us year after year2_{, and it’s no wonder. Delta Dental sets the}

industry standard by doing whatever it takes and then some. We deliver:

• Less out-of-pocket. The Delta Dental Difference®_{saves clients and enrollees}

billions of dollars a year.3_{Because Delta Dental dentists agree to our}

determination of fees, clients enjoy extensive cost controls, and enrollees pay less out-of-pocket.

• More dentists. Four out of five dentists4_{nationwide are contracted Delta}

Dental dentists, giving enrollees convenient access and quality assurance through one of the nation's largest dentist networks.

• Simpler process. Our dental plans are easy to use. No ID card is required to

receive services and there are no claim forms to file — Delta Dental dentists do that for you. And because we pay Delta Dental dentists directly, you are responsible only for your share of payment.

1_{Delta Dental of California, Delta Dental of New York, Inc., Delta Dental of Pennsylvania, Delta Dental Insurance}

Company and our affiliated companies form one of the nation’s largest dental benefits delivery systems, covering 27 million enrollees. All of our companies are members, or affiliates of members, of the Delta Dental Plans Association, a network of 39 Delta Dental companies that together provide dental coverage to almost 63 million people in the U.S.

2 _{Delta Dental retained 98 percent of our 27 million enrollees in 2013.}

3_{Savings due to reduction of premiums or claims liability and patient out-of-pocket costs, based on Delta Dental’s}

cost management report, 2013.

4 _{Proportion of total practicing dentists contracted with Delta Dental based on the Delta Dental Plans Association}

(18)

Delta Dental’s Mission Statement

To advance dental health and access through exceptional dental benefits service, technology and professional support.

(19)

Call your broker, participating general agent or one of these Delta Dental of California sales offices

100 First Street San Francisco, CA 94105 415-972-8300

fax 415-972-8466 17871 Park Plaza Drive, Suite 200

Cerritos, CA 90703 562-403-4040 fax 562-924-3172

11155 International Drive, Building B Rancho Cordova, CA 95670 916-861-2409 fax 916-858-0327 1450 Frazee Road Suite 200 San Diego, CA 92108 858-458-1340 fax 619-542-0269 30 East River Park Place Fresno, CA 93720 559-433-3010 fax 559-243-9493

SBP_CA_2015MB #81902 (rev. 12/14)

Call your broker, participating general agent or one of these Delta Dental of California sales offices

100 First Street San Francisco, CA 94105 415-972-8300

fax 415-972-8466 17871 Park Plaza Drive, Suite 200

Cerritos, CA 90703 562-403-4040 fax 562-924-3172

11155 International Drive, Building B Rancho Cordova, CA 95670

916-861-2409 fax 916-858-0327

Delta Dental PPO

SM

Delta Dental PPO is underwritten by Delta Dental of California.

DeltaCare

®

_USA

DeltaCare USA is underwritten in California by Delta Dental of California and administered by Delta Dental Insurance Company.

For Use By:

General Agent Third Party Administrator

Visit Delta Dental’s website at:

deltadentalins.com

1450 Frazee Road Suite 200 San Diego, CA 92108 858-458-1340 fax 619-542-0269 30 East River Park Place Fresno, CA 93720 559-433-3010 fax 559-243-9493

Small Business Program

Delta Dental of California