Dental plans to smile aboutIndividuals and families

Alaska

Plans available Jan. 1, 2015, through Dec. 31, 2015

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Hello. Welcome to Moda Health and Delta Dental of Alaska, the place you go for great dental care — because good oral health is good for the whole body.

Since 1955, we’ve offered quality dental plans to folks in the Northwest. Today, partnering with Delta Dental of Alaska, we continue to help make dental care affordable and accessible for all Alaskans.

As a member, you’ll find useful online tools, resources and special programs that provide a little extra attention for your pearly whites. When you need a dentist, just tap into the extensive Delta Dental Network for care, near or far.

We’re excited to support you on your journey to better health. Because together, we can be more. We can be better.

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Together, we can find a way to better health.

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Dental plans

Dental coverage for your total health

Healthy teeth are happy teeth. With our individual and family dental coverage, you’ll have access to Delta Dental of Alaska, the nation’s largest dental network. Your smile will thank you, wherever you roam.

Individual dental plan highlightsDelta Dental plans have participating providers who will not charge more than Delta Dental of Alaska's allowed amount. However, on the PPO plan, you will pay less by seeing participating, in-network PPO providers.

> Freedom to choose your dentist > No waiting periods for Class 1 services > Filed-fee savings from

participating dentists > Predetermination of benefits if

requested in a pretreatment plan > No claim forms > Fast and accurate claims payment > Superior customer service

Delta Dental Premier NetworkWherever you go, your Delta Dental of Alaska benefits go with you. The Delta Dental Premier Network includes the largest dental network in Alaska and the country. Three out of every four dentists participate nationwide, serving 50 states, the District of Columbia and Puerto Rico.

Delta Dental PPO NetworkThe preferred provider option (PPO) gives Anchorage members access to the largest PPO network in Alaska and across the country. You’ll enjoy better benefits by seeing dentists in the PPO network.

Protecting more than your smileThrough our Oral Health, Total Health program, we offer additional oral health benefits to members diagnosed with diabetes and pregnant in their third trimester.

Questions about this program? Just call us toll-free at 855-718-1767 for more information. TTY users, please call 711.

Is my dentist in the network?To find out, visit modahealth.com and use our Find Care tool. Just choose a dental network and search for participating dentists in your area.

An option including the Alaska-mandated dental plan is also available.

This is a benefit summary only. For a complete description of benefits, limitations and exclusions, refer to your policy.

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Delta Dental PremierCalendar year costs

Deductible per person None

Out-of-pocket max per person (under age 19) $350 for one member; $700 for two or more members

Annual benefit max (ages 19+) $1,000

Under age 19 Ages 19+

Class 1

Exams and X-rays 20% 20%

Cleanings 20% 20%

Periodontal maintenance 20% 20%

Sealants 20% 20%

Topical fluoride 20% 20%2

Class 2

Space maintainers 30% Not covered

Restorative fillings 30% 30%3

Class 3

Oral surgery 50% 50%4

Endodontics 50% 50%4

Periodontics 50% 50%4

Restorative crowns 50% 50%4

Bridges 50% 50%4

Partial and complete dentures 50% 50%4

Anesthesia 50% 50%4

Orthodontia 50%5 Not covered

Features

Provider network Delta Dental Premier Network

Balance bill Delta Dental Premier Network: No Nonparticipating: Yes

Cost

Monthly rate per person6 $43 $38

1 No deductible on this plan2 Covered once in a 12-month period for high-risk patients only3 Six-month exclusion period applies4 12-month exclusion period applies5 This benefit is available only to dependent children; a two-year exclusion period applies. 6 Rates effective Jan. 1, 2015, through Dec. 31, 2015. If you have more than three

dependent children under age 21, only three need to be calculated into your rate.

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Calendar year costs

Deductible per person None

Out-of-pocket max per person Not applicable

Annual benefit max $1,000

In-network, you pay Out-of-network, you pay

Class 1

Exams and X-rays 10% 50%

Cleanings 10% 50%

Periodontal maintenance 10% 50%

Sealants 10% 50%

Topical fluoride 10%2 50%2

Class 2

Space maintainers Not covered Not covered

Restorative fillings 30%3 50%3

Class 3

Oral surgery 50%4 50%4

Endodontics 50%4 50%4

Periodontics 50%4 50%4

Restorative crowns 50%4 50%4

Bridges 50%4 50%4

Partial and complete dentures 50%4 50%4

Anesthesia 50%4 50%4

Orthodontia Not covered Not covered

Features

Provider network Delta Dental PPO Network All other providers

Balance bill No Delta Dental Premier Network: No Nonparticipating: Yes

Cost

Monthly rate per person5 $30

1 No deductible on this plan2 Covered once in a 12-month period for high-risk patients only3 Six-month exclusion period applies4 12-month exclusion period applies 5 Rates effective Jan. 1, 2015, through Dec. 31, 2015. If you have more than three

dependent children under age 21, only three need to be calculated into your rate.

Delta Dental PPOThis plan is only available to Anchorage residents age 19 and older.

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How to enroll

Eligibility requirements > You and any dependents applying

for coverage must be Alaska residents and live in Alaska at least six months out of the calendar year.

> Eligible members include you, your legal spouse or domestic partner, and any children up to age 26.

Easy steps to calculate your premium1 Jot down the rate for each

person age 21+

2 Jot down the rate for each person (up to three*) under age 21

3 Add all of these rates together to get your family’s total rate

Terminating your planIf you terminate this coverage, you must wait two years before you may re-apply for individual dental coverage through us, unless you qualify for special enrollment.

Special enrollmentCertain life events might qualify you for special enrollment. For example, having a baby or moving to a new state could make you or those you cover eligible.

Ready to enroll?

You can enroll in our dental coverage year-round. To get started, visit choosemoda.com to pick the dental plan for you. Questions? Our friendly staff is here to help. Call us toll-free at 855-718-1767, Monday through Friday, 6:30 a.m. to 4:30 p.m. Alaska time. TTY users, please call 711.

* If you have more than three dependent children under age 21, only three need to be calculated into your rate — this helps keep your healthcare affordable.

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Glossary of terms

Healthcare lingo explained

Balance billing Charges for out-of-network care beyond what your health plan allows. Out-of-network providers may bill you the difference between the reimbursement amount and their billed charges. In-network providers can’t do this.

CoinsuranceThe percentage of allowable charges for which the patient is responsible.

CopayThe fixed amount you pay for a specific covered healthcare service, product or treatment, usually at the time of receiving it.

DeductibleThe amount you pay for covered healthcare services in a calendar year before the health plan starts paying for treatment.

Out-of-pocket maximumThe most an individual pays in a calendar year for covered healthcare services before benefits are paid in full. Once members meet their out-of-pocket maximum, the plan covers eligible expenses at 100 percent. The out-of-pocket maximum includes deductibles, coinsurance and copayments. It does not include disallowed charges or balance billing amounts for out-of-network providers.

Preferred provider option (PPO) A preferred provider option (PPO) is a type of dental Delta Dental of Alaska or Moda Health medical plan. PPO members have in-network coverage when receiving care from a provider contracted on a PPO Network panel. Providers contracted under this panel cannot balance bill.

Preferred provider organization (PPO) A PPO can also refer to "preferred provider organization." This is a panel of medical or dental providers contracted under Moda Health or Delta Dental of Alaska to provide in-network coverage at agreed-upon rates, with no balance billing. Members maximize their benefits by seeing in-network PPO providers.

We realize that the words used in health plan brochures can be confusing, so we’ve made you a cheat sheet of sorts. To find even more definitions, including a printable uniform glossary, visit the Learning center at choosemoda.com. For free print copies of the uniform glossary please contact us.

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LimitationsDiagnostic and preventive

> Exam once in a six-month period > Bitewing X-rays once in a six-month

period under age 19 and once in a 12-month period age 19 and over

> Full-mouth or panoramic X-rays once in a five-year period

> Cleaning (prophylaxis or periodontal maintenance) once in a six-month period

> Flouride covered once in six-month period under age 19 and once in a 12-month period age 19 and over if there is recent history of periodontal surgery or high risk of decay because of medical disease or chemotherapy or similar type of treatment

> Sealants limited to unrestored occlusal surface of permanent molars once per tooth in a three-year period under age 19 and once in a five-year period age 19 and over.

Basic and major > Bridges and dentures once in a five-

year period under age 19 and once in a seven-year period age 19 and over.

> Crowns and other cast restorations once in a five-year period under age 19 and once in a seven-year period age 19 and over.

> IV sedation or general anesthesia only with surgical procedures

> Scaling and root planing once in a two-year period > Tooth-colored filings or crowns on back teeth

limited to amount allowed for metallic restoration

Exclusions > Anesthetics, analgesics, hypnosis and

medications, including nitrous oxide > Charges above the reimbursement amount > Charting (including periodontal, gnathologic) > Congenital or developmental malformations > Cosmetic services > Duplication and interpretation of X-rays > Experimental or investigational treatment > Hospital costs or other fees for

facility or home care > Implants > Instructions or training (including plaque control

and oral hygiene or dietary instruction) > Occlusal guard (nightguard) covered once

in a 12-month period between ages 13 and 19 > Orthodontia covered only for

dependent children under age 19 > Precision attachments > Rebuilding or maintaining chewing surfaces

(misalignment or malocclusion) or stabilizing teeth > Services or supplies available under any city,

county, state or federal law, except Medicaid > Temporomandibular joint syndrome (TMJ) > Treatment not dentally necessary

Limitations and exclusions for dental plans

7463004 (10/14) SS-1451-AK

modahealth.com

Questions? We’re here to help. Contact a Moda Health-appointed agent,

or call us toll-free at 888-374-8910. TTY users, please call 711.

Dental plans in Alaska provided by Delta Dental of Alaska..