Benefit information for Delta Dental DPO

DPO, our Dental Provider Organization plan in Texas provides access

to the largest network of its kind in the U.S. DPO dentists agree

to accept reduced fees for covered procedures when treating DPO

patients. This means you will usually have lower out-of-pocket costs

when you visit a DPO dentist than when you visit a non-Delta Dental

dentist; however, you have the freedom to visit any licensed dentist,

anywhere in the world.

Your Delta Dental plan provides you with a dual-network advantage.

Not only do you have access to DPO dentists you also have access

to the Delta Dental Premier® network. While DPO dentists generally

offer deeper discounts, the Premier network provides you with

access to more dentists than any other carrier in the nation. Delta

Dental dentist also provide other advantages such as filing claim

forms for you and accepting payment directly from Delta Dental.

DPO from Delta Dental offers:

• Reduced fees when you visit a DPO dentist• Freedom to choose any licensed dentist, anywhere in the world • The nation’s largest reduced fee-for-service dental network• Contractual protections which shield employees from balance billing and billing for

non-allowable procedures• Dual network access with the Delta Dental Premier safety net• Claims convenience: Delta Dental dentists handle all claims paperwork and most inquiries

for Delta Dental patients

The following pages contain the benefits for your plan.

[2]

We’re pleased to be your partner in maintaining great oral health. The Delta Dental PPO* plan makes it easy for you to find a dentist, and easy to control your costs when you visit a network dentist. Here are some of the great things you’ll need to know about enrolling with Delta Dental:

E HL_PPO_ENG_2col_BW #60586 (9/10)

Save money with a Delta Dental PPO dentist. Our PPO network dentists accept reduced fees for covered services they provide you, so you’ll usually pay the least when you visit a PPO network dentist. This also ensures Delta Dental dentists won’t balance bill you the difference between the contracted amount and their usual fee.

Visit the dentist of your choice. Want to visit a non-Delta Dental dentist? No problem. You can visit any licensed dentist, but your costs are usually lowest when you see a PPO dentist.

Many network dentists to choose from. Since Delta Dental offers access to some of the largest dentist networks in the U.S., chances are there’s a wide choice of network dentists near your home or office. Four out of five dentists nationwide

are contracted Delta Dental dentists, giving more enrollees convenient access to more dentists. Visit us at www.deltadentalins.com to search our dentist directory by location or specialty.

Easy to use your benefits. When you visit a Delta Dental dentist, pay only your portion for services. Delta Dental dentists will file claim forms for you and receive payment directly from us. Many non-Delta Dental dentists ask that you pay the entire cost up front and wait for reimbursement.

Delta Dental’s Online Services make getting information quick and easy. Access your benefits and eligibility, print ID cards and get information about your claims. And check out Delta Dental’s oral health resources too for tips and information that can help keep your smile healthy.

* In Texas, Delta Dental Insurance Company offers a Dental Provider Organization (DPO) plan.

WE KEEP YOU SMILING®

Greatest potential savings when you visit a Delta Dental PPO dentist

PPODENTIST

NON-NETWORKDENTIST

AMOUNT YOU SAVE

AMOUNT YOU PAY

OUT-OF-POCKET COSTS

SAVE LESS SAVE MORE

Illustration showing sample enrollee share of cost for information purposes only. Actual dentist fees and contract allowances will vary by region, procedure and by group contract.

Delta Dental PPOSM– Easy, Friendly, Accessible

We’ll do whatever it takes and then some.

Eligibility Primary enrollee, spouse and eligible dependent children to age 26

Deductibles* $50 per person / $150 per family each calendar year—CORE PLAN $50 per person / $100 per family each calendar year—PLUS PLAN

Deductibles waived for D & P? Yes

Maximums* $1500 per each calendar year D & P counts toward maximum? No

Waiting Period(s) Basic Benefits 0 Months

Major Benefits 0 Months

Orthodontics 0 Months

Core Plan Plus Plan

Benefits and Covered Services**

Delta Dental PPO dentists†

Non-DeltaDental dentists†

Delta Dental PPO dentists†

Non-DeltaDental dentists†

Diagnostic & Preventive Services (D & P)

Exams, cleanings, x-rays 100 % 100 % 100 % 100 %

Basic Services Fillings, simple tooth extractions, sealants

80 % 80 % 90 % 90 %

Endodontics (root canals) Covered Under Basic Services

80 % 80 % 90 % 90 %

Periodontics (gum treatment) Covered Under Basic Services

80 % 80 % 90 % 90 %

Oral Surgery Covered Under Basic Services

80 % 80 % 90 % 90 %

Major Services Crowns, inlays, onlays and cast restorations, bridges and dentures

50 % 50 % 60 % 60 %

Orthodontic Benefits adults and dependent children

NOT A BENEFIT

NOT A BENEFIT 50 % 50 %

Orthodontic Maximums Lifetime

NOT A BENEFIT

NOT A BENEFIT

$ 1,500

$ 1,500

Other * If you switch plans during the calendar year your Deductible and Annual Maximum may be adjusted

accordingly. ** Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.

Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist’s actual fees. † Fees are based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and

program allowance for non-Delta Dental dentists. Delta Dental Insurance Company 1130 Sanctuary Parkway, Suite 600 Alpharetta, GA 30009

Customer Service 800-521-2651

Claims Address P.O. Box 1809 Alpharetta, GA 30023-1809

deltadentalins.com

This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative. HLT_PPO_2COL_HILO_DDIC (Rev. 2 5/11)

Plan Benefit Highlights for: Austin ISD Group No: 03595 Effective Date: 9/1/2012

D&P Maximum Waiver®

We’ll do whatever it takes and then some.

WE KEEP YOU SMILING®

Easy to useThe annual maximum is waived for defined diagnostic and preventive services when you visit any licensed dentist. There’s nothing for you to keep track of except for your regular checkups. When you need more extensive dental services, there will be more of your annual benefit amount remaining for you to use.

What services are included?Diagnostic and preventive dental services may include examinations, x-rays, cleanings and related treatments as defined by your dental plan. Review your Evidence of Coverage booklet for specific coverage details.

The D&P Maximum Waiver makes it easy for you to save on your out-of-pocket dental costs.

Delta Dental plans have always emphasized diagnostic and preventive benefits, such as coverage for checkups, so that you keep your mouth healthy and need fewer restorative services.

Preventive care is the key to good oral health

Your plan includes the D&P Maximum Waiver benefit, allowing you to obtain diagnostic and preventive dental services without those costs applying to the plan year maximum. This benefit promotes good oral health and may reduce the need for more expensive, restorative dental services that can result from undetected oral or related health problems.

The following sample shows the impact on your annual maximum with and without the D&P Maximum Waiver. Plan benefits and dentist charges vary. Sample assumes two routine checkups and $1,000 annual maximum.

Without D&P Maximum Waiver With D&P Maximum Waiver

Dental treatmentDelta Dental

PaysEnrollee

PaysMaximum Remaining

Delta DentalPays

EnrolleePays

MaximumRemaining

Diagnostic & Preventive (Exams, x-rays, cleanings): covered at 100% for two visits

$350 $0 $650 $350 $0 $1,000

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Please review your Evidence of Coverage, Summary Plan Description or Group Dental Service Contract for specific details about your plan.

E EF27 #63012 (rev. 3/11)

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Questions about oral health?

Mouth-Body Connection• Diabetes and oral health • Heart disease and oral health• Men’s oral health • Oral cancer • Osteoporosis• Pregnancy and oral health• Stress and oral health• Tobacco use and oral health

Preventive Care• Brushing and flossing• Dental cleanings• Fighting bad breath• Fluoride• Nutrition and oral health• Choosing and caring for

your toothbrush

Emergency Care• Dental care when traveling• Handling dental emergencies

Kids & Teens• Baby bottle tooth decay• Children’s oral health• Eating disorders• Teens’ oral health

Seniors• Dental care of Alzheimer’s

patients• Dentures• Seniors’ oral health

Dental Treatments• Amalgam and resin fillings• Braces• Dental implants• Dental x-rays• Sealants

Conditions• Dry mouth• Mouth sores• Sensitive teeth• TMJ

If you’ve got questions about oral health, be sure to check out our website at deltadentalins.com for answers.

To help you and your family keep your smiles healthy, we’ve compiled an extensive library of articles on oral health topics from amalgam fillings to x-rays and just about every oral health topic in between.

?Visit the Oral Health & Wellness section on deltadentalins.com to take the following quizzes:

• Dental Cavity Quiz • Gum Disease Quiz

How healthy is your smile? Take our online quizzes to find out!

Why do 54 million enrollees trust their smiles to Delta Dental?

• More dentists • Simpler process • Less out-of-pocket

WE KEEP YOU SMILING®

Get the latest in oral health with Dental Wire, our bi-monthly e-mail newsletter. Sign up at: deltadentalins.com/oral_health

Free Newsletter

facebook.com/deltadentalins

twitter.com/deltadentalins

Delta Dental includes these companies in these states: Delta Dental of California – CA • Delta Dental of Pennsylvania – PA & MD • Delta Dental of West Virginia – WV • Delta Dental of Delaware – DE • Delta Dental of the District of Columbia – DC • Delta Dental of New York – NY • Delta Dental Insurance Company – AL, FL, GA, LA, MS, MT, NV, TX, UT

Connect with us!

deltadentalins.com

FORM # HLT DPO2 DDIC Rev 12/06

DELTA DENTAL INSURANCE COMPANY Client Name: AUSTIN ISD Group No.: 03595

PARTIAL LIST OF PLAN LIMITATIONS FOR DENTAL PROVIDER ORGANIZATION PLAN (DPO) Limitations on Diagnostic and Preventive Benefits:

a. Routine oral examinations and cleanings, including periodontal cleanings, are not provided more than twice in any twelve (12)month period while the patient is an Enrollee under any Delta Dental or any prepaid dental care program provided by the group contract holder.

b. Full-mouth x-rays or panographic x-rays will be provided when required by the Dentist, but no more than once each 5 years willbe paid by Delta.

c. Bitewing x-rays are limited to two (2) bitewing procedures each twelve (12) months when provided to Enrollees under age 18 and one (1) each twelve (12) months for Enrollees age 18 and over,

d. Delta will not pay for topical application of fluoride for anyone 19 years or older.

e. Space maintainers are limited to the initial appliance only and to Enrollees under age 14.

Limitations on Sealant Benefits:

a. Sealant Benefits are available only to Enrollees under the age of 16.

b. Sealants are limited to application to permanent molars with no caries (decay), without restorations and with the occlusal surface intact.

c. Sealant Benefits do not include the repair or replacement of a sealant on any tooth within two (2) years of its application.

Limitations on Basic Benefits: - Delta will not pay to replace an amalgam, synthetic porcelain or plastic restorations (fillings) or prefabricated stainless steel within 24 months of treatment if the service is provided by the same Dentist.

Limitations on Crowns, Jackets and Cast Restorations:

a. Delta will not pay to replace any crown, jacket or cast restoration which the patient received in the previous five (5) years.

Limitations on Prosthodontic Benefits:

a. Delta will not pay to replace any bridge or denture that the patient received in the previous 5 years. An exception is made if the bridge or denture cannot be made satisfactory due to a change in supporting tissues or because too many teeth have been lost.

b. Delta limits Benefits for dentures to a standard partial or complete denture. A “standard” denture means a removable applianceto replace missing natural, permanent teeth that is made from acceptable materials by conventional means.

c. Delta will not pay for implants (artificial teeth implanted into or on bone or gums) or their removal, but Delta will credit the cost of a standard complete or partial denture that would have been allowed under this plan toward the cost of an implant and related services (coinsurance apply).

Limitations on All Benefits - Optional services that are more expensive than the form of treatment customarily provided under accepted dental practice standards are called “Optional Services”. Optional Services also include the use of specialized techniques instead of standard procedures. For example:

a. crown where a filling would restore the tooth;

b. precision denture/partial where a standard denture/partial could be used;

c. an inlay/onlay instead of an amalgam restoration; or

d. composite restoration instead of an amalgam restoration on posterior teeth.

If you receive Optional Services, your Benefits will be based on the lower cost of the customary service or standard practice instead of the higher cost of the Optional Service. You will be responsible for the difference between the higher cost of the Optional Service and the lower cost of the customary service or standard procedure.

NOTE: THIS IS ONLY A PARTIAL LISTING OF SOME OF THE BENEFIT LIMITATIONS UNDER THE PLAN. The dental health plan contract must be consulted to determine the exact terms and conditions of coverage. After you enroll, you will receive an Evidence of Coverage which contains a full explanation of benefits, limitations and exclusions.

Visit the Delta Dental website: deltadentalins.com

We’ll do whatever it takes and then some.

Page 1 of 2

WE KEEP YOU SMILING®

Convenient services and information on our website

Our website* makes it easy for you to manage your dental plan. Tools, services, information, forms – you’ll find everything you need just a click away.

Log in to:

• Check benefits, eligibility and claims status

• Print your ID card

• Find the average cost of a dental procedure in your area

Find a dentist:

• Select your plan

• Enter options such as state and ZIP code

• Search for a dentist and link to a map with driving directions

* The website deltadentalins.com is the home of the Delta Dental companies listed on the reverse side and their subsidiaries and affiliates. For other Delta Dental companies, visit the Delta Dental Plans Association website at deltadental.com.

Oral health informationRead articles, watch videos, find a glossary of dental terms and subscribe to Dental Wire, our free dental health newsletter

Just for kidsSee our kids’ website also available at MySmileKids.com

Oral Health Quizzes Assess your risk for cavities and gum disease and learn how to prevent them

Why do 54 million enrollees trust their smiles to Delta Dental?

• More dentists • Simpler process • Less out-of-pocket

WE KEEP YOU SMILING®

Q: How do I log in to the website?A: Simply enter your user name and

password in the designated boxes and submit. If you don’t already have a user name or password, click the “Register Today” link to complete the quick three-step registration process: 1. Select “Enrollee” for your user type.

2. Enter your name and other information in the form.

3. Choose a user name and password to complete your registration.

Q: What if I have trouble logging in to the website?

A: If you have problems, use the Online Services Login Customer Service Form to contact us for assistance. You can find the form on the “Individuals & Enrollees” page of the website. Scroll down the “Individuals & Enrollees” page to find the Forms box on the right-hand side of the page. You can find the Online Services Login Service Form link at the end of the Customer Service Forms section.

Q: What if I don’t have Internet access?

A: You can check your benefits, eligibility and claim information on our interactive voice response telephone line or speak to a Customer Service agent Monday through Friday by calling Delta Dental toll-free. For DeltaCare® USA enrollees, please call 800-422-4234. For Delta Dental PPOSM and Delta

Dental Premier® enrollees, please use the appropriate number listed at the left to call your local Customer Service.

Q: Can I contact Delta Dental through the website?

A: Yes. You don’t have to log in to contact us from the website. Simply click on “Contact us” at the top of the home page and follow the appropriate links for your plan. You’ll be presented with a number of contact options, including Online Customer Service Request Forms for specific issues.

Q: How can I check on the average cost of a dental procedure in my area?

A: Log in by entering your user name and password and click on “Fee Finder” in the main navigation menu.

Q: How current is the information in the online dentist directory?

A: The “Find a Dentist” directory is updated daily.

Q: What if I have more questions?A: For detailed instructions on checking

your benefits and eligibility, finding a dentist, printing an ID card and submitting a claim form, visit the “Use Your Dental Plan” page of our website for these and other helpful topics.

Page 2 of 2E EF30 #62916 (rev. 3/11)

Other tools and information:

Visit the “Use Your Dental Plan” page for a helpful plan support guide and answers to frequently asked questions.

• Download and print a claim form

• Find general information about how your plan works

• Get instructions for using our website

Forms and support:

• Find quick links to claim, grievance and customer service request forms

Delta Dental en Español:

• Visit a Spanish version of our website

Get the latest in oral health with Dental Wire, our bi-monthly e-mail newsletter. Sign up at: deltadentalins.com/oral_health

Free Newsletter

Delta Dental Customer Service

DeltaCare® USA800-422-4234

Delta Dental PPOSM andDelta Dental Premier®

Delta Dental of California800-765-6003

Delta Dental of DelawareDelta Dental of the District of ColumbiaDelta Dental of New YorkDelta Dental of Pennsylvania (and Maryland)Delta Dental of West Virginia800-932-0783

Delta Dental Insurance Company(Alabama, Florida, Georgia, Louisiana, Mississippi, Montana, Nevada, Texas, Utah)800-521-2651

California School District Employees866-499-3001

deltadentalins.com

Delta Dental includes these companies in these states: Delta Dental of California – CA • Delta Dental of Pennsylvania – PA & MD • Delta Dental of West Virginia – WV • Delta Dental of Delaware – DE • Delta Dental of the District of Columbia – DC • Delta Dental of New York – NY • Delta Dental Insurance Company – AL, FL, GA, LA, MS, MT, NV, TX, UT

Go paperless!

We make it easy, so you don’t need an ID card to receive services.

When visiting your Delta Dental (DPO) or DeltaCare® USA (DHMO) dentist, simply provide your name, date of birth and social security or enrollee identifi cation number. The dental offi ce can use that information to verify your eligibility and benefi ts.

1. Go to www.deltadentalins.com

2. Log in to Online Services with your username and password. (If you don’t already have a username or password, click the “Register Today” link to complete the quick registration process.)

3. Once you’ve logged in, click the “Eligibility & Benefi ts” tab.

4. Select “Print ID Card” on the left-hand side of the page. (If you do not see this option, in some instances you may also need to click on the “Eligibility & Benefi ts” link on the left-hand side of the page before you have the option to select “Print an ID Card.”)

5. Click “Print.”

How to print an ID card

EF11 #56417 (rev. 5/10)

Delta Dental’s Mission: To advance dental health and access through exceptional dental benefits service, technology and professional support.

Delta Dental PPOSM is underwritten by Delta Dental Insurance Company in AL, DC. FL, GA, LA, MS, MT, NV and UT and by not-for-profit dental service companies in these states: CA – Delta Dental of California, PA, MD – Delta Dental of Pennsylvania, NY – Delta Dental of New York, DE – Delta Dental of Delaware, WV – Delta Dental of West Virginia. In Texas, Delta Dental Insurance Company provides a Dental Provider Organization (DPO) plan.

DeltaCare® USA is underwritten in these states by these entities: AL — Alpha Dental of Alabama, Inc.; AZ — Alpha Dental of Arizona, Inc.; CA — Delta Dental of California; AR, CO, IA, ME, MI, NC, OK, OR, RI, SC, SD, WA, WI, WY — Dentegra Insurance Company; NH and VT — Dentegra Insurance Company of New England; AK, CT, DE, FL, GA, KS, LA, MS, MT, TN, WV and Washington, D.C. — Delta Dental Insurance Company; HI, ID, IL, IN, KY, MD, MO, NJ, OH, TX — Alpha Dental Programs, Inc.; NV — Alpha Dental of Nevada, Inc.; UT — Alpha Dental of Utah, Inc.; NM — Alpha Dental of New Mexico, Inc.; NY — Delta Dental of New York; PA — Delta Dental of Pennsylvania. Delta Dental Insurance Company acts as the DeltaCare USA administrator in all these states, except CA. These companies are financially responsible for their own products. In some states, DeltaCare USA is offered as an open access plan where enrollees can obtain treatment from any licensed dentist; however, deductibles and maximums may be applied for services provided by an out-of-network dentist.

Visit our Delta Dental website at:

www.deltadentalins.com