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Your 2017 Dental Program Options

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 three dental options from which to select: Delta Dental PPO, Delta Dental PPO – Plus Premier and Delta Dental PPO – Choice.

See chart below or view the 2017 Benefits Brochure.

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 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.

Option 1: Delta Dental PPO

This option provides access to both the Delta Dental PPO and the Delta Dental Premier network. Subscribers choosing this option will realize maximum savings when utilizing a dentist in the Delta Dental PPO network, but may also utilize a provider from the Delta Dental Premier 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 maximum allowable amounts, but only up to the Delta Dental Premier maximum allowable amount.

BENEFIT PLAN		Delta Dental PPO	Delta Dental Premier	Out of Network

Diagnostic & Preventive-Class I		100%	100%	100%
Basic Restorative-Class II		85%	85%	85%
Major Restorative-Class III		60%	60%	60%
Orthodontics-Class IV		60%	60%	60%

Deductible:		$25 Per Person Per Benefit Year	$25 Per Person Per Benefit Year	$25 Per Person Per Benefit Year
Applies to:		Classes II & III Only	Classes II & III Only	Classes II & III Only

Maximum Benefit Payment:	$2,500 Per Person Per Benefit Year for Class I, Class II, and Class III Services Combined. $2,000 Lifetime Maximum Per Eligible Person for Class IV Services.

Notes:

Deductibles do not apply to Class I or Class IV services.

Option 2: Delta Dental PPO – Plus Premier

You can choose any properly licensed dentist to provide treatment under the Delta Dental PPO – Plus Premier product option. If you choose a Delta Dental participating provider, all benefit claims under this option are reimbursed based on the lesser of the dentist’s actual charge or the maximum allowable amount for Delta Dental network providers, based on their network participation. If you choose an out of network provider, any benefit payment will be based on the lesser of the dentist’s submitted fee or the prevailing fee (an amount established by the Delta Dental Plan in the state in which the dental services are rendered). You are responsible for all charges that exceed the Delta Dental of Oklahoma payment.

BENEFIT PLAN		Delta Dental PPO	Delta Dental Premier	Out of Network

Diagnostic & Preventive-Class I		100%	100%	100%
Basic Restorative-Class II		70%	70%	70%
Major Restorative-Class III		50%	50%	50%
Orthodontics-Class IV		60%	60%	60%

Deductible:		$50 Per Person Per Benefit Year	$50 Per Person Per Benefit Year	$50 Per Person Per Benefit Year
Applies to:		Classes I, II & III Only	Classes I, II & III Only	Classes I, II & III Only

Maximum Benefit Payment:	$3,000 Per Person Per Benefit Year for Class I, Class II, and Class III Services Combined. $2,000 Lifetime Maximum Per Eligible Person for Class IV Services.

Notes:

Deductibles do not apply to Class IV Services.

Option 3: 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 Delta Dental PPO – 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 amounts.

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 maximum allowable amounts, but only up to the Delta Dental Premier maximum allowable amount.

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.

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.