Delta Dental is pleased to provide dental benefits for employees of the State of Oklahoma. This Web site provides a brief description of the most important features of your Delta Dental of Oklahoma dental benefits program. For more specific questions regarding your benefits, please contact our friendly Customer Service Department at 800-522-0188 (Toll Free) or 405-607-2100 (OKC Metro).

You have two dental options from which to select: Delta Dental PPO – Point of Service and Delta Dental PPO - Choice.

Delta Dental has two nationwide networks of dentists - the Delta Dental PPO network and the Delta Dental Premier network. These networks are among the largest in the dental benefits industry, both locally and nationwide, providing you easy access to participating dentists in most geographical areas.

Dentists participating in the networks described above have signed unique "participating agreements" with Delta Dental. In most cases, these agreements mean you simply present your identification card to the dentist at the time of treatment and he or she will file your claim for you. Delta Dental Plan of Oklahoma will then pay the participating dentist direct for any covered services. These agreements also provide protection from dental charges exceeding the maximum allowable amounts for each network.

When you select Delta Dental PPO – Point of Service: This option provides access to the Delta Dental PPO network and Delta Dental Premier network (our largest network). Subscribers utilizing a Delta Dental PPO dentist will receive enhanced benefits with lower deductibles. Subscribers utilizing a Delta Dental Premier network dentist will have a higher deductible and a lower percentage of benefit coverage.

When you select Delta Dental PPO – Choice: Eligible members enrolling in this product option will have access to the Delta Dental PPO network and will be responsible for the amounts reflected in the Choice table of benefits, along with any deductibles, over maximum amounts and excluded benefits established for the Delta Dental PPO network.

Delta Dental PPO – Choice subscribers may also access the Delta Dental Premier provider network. Subscribers accessing Delta Dental Premier dentists will be responsible for any amounts in excess of the Delta Dental PPO allowable amount up to the Delta Dental Premier maximum allowable amount - as well as deductibles, over maximum amounts and excluded services.

Option 1: Delta Dental PPO – Point of Service Delta Dental PPO – Point of Service program includes both the Delta Dental PPO and Premier networks under one program, maximizing network savings while increasing network access. One program with access to both the PPO and Premier network Provider reimbursements based on network utilized Additional out-of-pocket savings when utilizing a PPO network provider No balance-billing for either network Pre-existing conditions covered Claim filing by participating dentist

BENEFIT PLAN		Delta Dental PPO	Delta Dental Premier	Out of Network
Diagnostic & Preventive-Class I		100%	100%	100%
Basic Restorative-Class II		85%	70%	70%
Major Restorative-Class III		60%	50%	50%
Orthodontics-Class IV		60%	60%	60%
Deductible:		$25 Per Person Per Benefit Year	$100 Per Person Per Benefit Year	$100 Per Person Per Benefit Year
Applies to:		Classes II & III Only	Classes I, II & III Only	Classes I, II & III Only
Maximum Benefit Payment:	$2,000 Per Person Per Benefit Year for Class I, Class II, and Class III Services Combined. $1,800 Lifetime Maximum Per Eligible Person for Class IV Services.

Notes:

Deductibles do not apply to Class I services if treatment is provided by a Delta Dental PPO provider. Deductibles do not apply to Class IV Services. Participating provider reimbursement based on provider network utilized, non-network provider reimbursement based on the prevailing fee.

Option 2: Delta Dental PPO – Choice The Delta Dental PPO – Choice benefit program with the Delta Dental PPO network provides for a low cost dental benefit program with access to one of the largest PPO provider networks in Oklahoma and nationwide. Subscribers enrolling in the Choice program will have access to the Delta Dental PPO provider network, and will be responsible for only the amounts reflected in the Choice table of benefits, deductibles, non-covered services and all over-maximum services. Subscribers may also access the Delta Dental Premier provider network. Delta Dental's provider reimbursement will be based on the Delta Dental PPO maximum allowable amount. Hence, subscribers will be responsible for any amounts in excess of the Delta Dental PPO allowable amounts, but only up to the Delta Dental Premier maximum allowable.

BENEFIT PLAN

Benefits & Co-payments:		See the Description of Covered Services and Enrollee Co-payments table for a list of the covered services and enrollee co-payments.
Deductible:		$100 Per Person Per Benefit Year. Deductible applies to Level 4 Services only.
Maximum Benefit Payment:	$2,000 Per Person Per Benefit Year for Levels 1, 2, 3 and Level 4 Services Combined. $1,800 Lifetime Maximum Per Eligible Person for Level 5 (Orthodontic) Services.

Note:

Participating provider reimbursement is based on the Delta Dental PPO maximum allowable amount, in or out of network. If treatment is provided by a dentist in the Delta Dental Premier network, the patient is financially responsible for the difference between the Delta Dental PPO maximum allowable amount and the Delta Dental Premier maximum allowable amount.

The information contained herein is not intended as a Summary Plan Description, nor is it designed to serve as Evidence of Coverage for this program. Benefits for some covered services may be subject to waiting periods or limitations such as age of patient, frequency of procedure, etc., or excluded in some instances. If you have specific questions about your dental benefits, consult your Summary Plan Description, or call 405-607-2100 (OKC Metro) or 800-522-0188 (Toll Free). You may write Delta Dental of Oklahoma at P.O. Box 54709, Oklahoma City, Oklahoma 73154-1709.