0 DELTA DENTAL

The Most Affordable Dental Care Your Teeth

Could Ask For

VyStar Financial Group LLC

DeltaCare USA With the DeltaCare USA Plan members pay a low

monthly premium then reduced fees for services

based on rates that Delta Dental negotiates in advance

Plan Highlights bull No claim forms

bullNo deductibles

bullNo annual dollar maximums

bullAccess to specialty care

bullProfessional treatment standards

bullOrthodontic discounts available to covered

dependents and adults

Limitations and Exclusions bullYou must receive treatment from your assigned

network facility in order to receive benefits Your

facility may refer you to a network specialist for

specialty care treatment

bullOnce you are eligible on the plan you will receive

an identification card and a Certificate of

Coverage booklet describing your benefits

bullYou can make an appointment once you have

received confirmation of your enrollment

bullYou will be assigned to a facility based on your

zip code

bullDelta Dental must receive the DeltaCare USA

enrollment materials andor the facility change

request by the 15th day of the month for

coverage to be effective the 1st day of the

following month

For a full listing of plan benefits limitations

and exclusions and for the availability of a DeltaCare

USA network facility in your city visit our website at

wwwvysta re u orgho meproductsdental

For additional information or assistance

please call 904-777-6000 option 9 Outside of

Jacksonville please call 1-800-445-6289 option 9

Or visit one of our convenient branches to speak

with a Member Relationship Specialist

DeltaCare USA Sample Benefits

Service You Pay Waiting Period

Cleaning [111 OJ $000 None

Filling [2140] $4400 None

Crown [2750] $48500 None

Root Canal [3330] $47000 None

Plan Maximum None

Office Co-Pay $500

Deductible None

FAQ - DeltaCare USA

bull How many cleanings a year are covered with this plan Three cleaning s per 12 month period

Are cosmetic procedures covered This plan does not cover cosmetic procedures

bull Is orthodontia covered Ye s orthodonti c discounts are available under thi s plan

bull Is there a waiting period No there is no waiting period with thi s plan

bull Is this insurance Ye s

bull Can I change my Contract Dentist once I am in the plan Ye s after your effective date you may change your Contract Denti st by contacting customer servi ce or by visiting wwwdeltadentalinscom Changes must be reque sted by the 21 st day of the month to be effective on the 1st day of the following month

bull Is there a deadline for enrollments There is no deadline to enroll However appli cations must be submitted by the 15th of the month to become effecti ve on the 1st of the following month Any appli cations re ceived after the 15th can become effecti ve on the 1st of the second month

bull When will I receive my enrollment package and what will it include You will receive your enrollment package upon completion of enrollment and payment of appli cable premium senrollment fee s or a few days prior to the selected effective date The enrollment package will include your Certifi cate of Coverage and lD cards

bull What should I expect to see on my VyStar StatementCredit Card Statement for my premium payments DENTAL 1800-800-1397 will appear on your statement as the charge for your premiums

bull Can I change my payment type from monthly to another available option once I am in the plan Ye s

bull When will my account be debiteddrafted Your account will be debiteddrafted between the 18th and 23rd of each month

bull What if I need to make changes to my coverage (example add or remove a dependentspouse) You can call your plan administratorMorgan-White at 1-888-859-3795

bull Who is eligible for coverage under this plan Generally any individuals who are 18 years of age or older their spouse and their eligible dependents

Eligible dependents include

1I Spou se [unless legally separated or divorced]

2] Unmarried children from birth to age 19 and dependent grand children

to age 18 months

3] Unmarried children from age 19 to the end of the calendar year in

which they turn age 25 if

a] they are supported by the Eligible PersonPrimary Enrollee and

bl they either live in the Enrolleemiddots household or

c] they are enrolled as full-time or part-time students in an acc redited

sc hool

What are my options for selecting an Effective Date Plan effective dates are always the 1st of the month Incomplete enrollment form s or failure to submit the required initial premium amount may cause an initial delay in iss uance of in suran ce

Will I be able to cancel the dental plan after I have enrolled Yes your coverage may be cancelled with 30 days written notice

Delta Dental PPO The Delta Dental PPO Plan allows you the

freedom to visit any licensed dentist It is to your

advantage however to use a Delta Dental PPO

dentist because heshe will

bullProvide treatment to you at reduced fees which

means your share of the bill will usually be lower

bullNot bill you above Delta Dentals approved

amount

bullSubmit all claims directly to Delta Dental

bullOnly charge you the patients share at the time

of treatment [Many non-Delta Dental dentists

require you to pay all of the costs up front and

wait for reimbursement]

This represents a summary of benefits

More information is available on our website

wwwvystarcuorghomeprod uctsdenta l Complete

information regarding limitations and exclusions will

be included in the contract and member booklets

You will usually pay the lowest amount for services

when you visit a Delta Dental dentist

PPO dentists agree to accept a reduced fee and

your out of pocket charges are usually lowest when

visiting a Delta Dental PPO dentist You are charged

only the patients share at the time of treatment

Delta Dental pays its portion directly to the dentist

Delta Dental dentists will complete claim forms and

submit them for you at no charge

You are responsible for the difference between

the amount Delta Dental pays and the amount of your

out-of-pocket costs when visiting an out-of-network

dentist Your dentist may require you to pay the

entire amount of the bill in advance and wait for

reimbursement

You may have to complete and submit your own

claim forms or pay your non-Delta Dental dentist a

service fee to submit them for you

Limitations may apply for some benefits Please refer to your

Evidence of Coverage for a list of benefit limitations and exclusions

FAQ - Delta Dental PPO

bull How many cleanings a year are covered with this plan Two cleanings are covered in a 12-month period

bull Are cosmetic procedures covered This plan does not cover cosmetic procedures

bull Is orthodontia covered No orthodontia is not covered under this plan

bull Do I need to obtain claim forms One of the advantages of visiting a Delta Dental network dentist is that he will file the claim on your behalf However if services are provided by an out-of-network dentist you may be required to file a claim yourself

bull Is there a waiting period No there are no waiting periods with this plan

bull Is this insurance Yes

bull Can I change my dentist once I am in the plan Yes you may change your dentist at any time

bull If my dentist isnt currently in the directory what can I do You may want to call your dentist to confirm whether he is a Delta Dental dentist If he does not participate in Delta Dentals network he can charge potentially higher rates than a Delta Dental dentist This may likely affect how much more you pay out of pocket for procedures To reduce your out of pocket expenses you can select a dentist that is in the directory

bull What is the deadline for enrollments There is no deadline to enroll Applications submitted by the 20th of the month can become effective on the 1st of the following month Any applications received after the 20th can become effective on the 1st of the second month

bull When will I receive my enrollment package and what will it include You will receive your enrollment package upon completion of enrollment and payment of applicable premiumsenrollment fees or a few days prior to the selected effective date The enrollment package will include your Certificate of Coverage and lD cards

bull What should I expect to see on my VyStar StatementCredit Card Statement for my premium payments DENTAL 1800-800-1397 will appear on your statement as the charge for your premiums

bull Can I change my payment type from monthly to another available option once I am in the plan Yes

bull When will my account be debiteddrafted Your account will be debiteddrafted between the 18th and 23rd of each month

bull What if I need to make changes to my coverage (example add or remove a dependentspouse) You can call your plan administratorMorgan-White at 1-888-859-3795

bull Who is eligible for coverage under this plan Generally any individuals who are 18 years of age or older their spouse and their eligible dependents

Eligible Dependents include

1 Spouse [unless legally separated or divorced I 2 Children from birth to the end of the calendar year in which

occurs their 25th birthday if a the child is dependent on the eligible personPrimary Enrollee

for support and bthe child lives in the Enrollees household or c the child is a full-time or part-time student

3 Children include natural children step-children adopted children foster children custodial children and newborn children including a newborn child of a covered dependent child until the grandchild is 19 months old

bull What are my options for selecting an Effective Date Plan effective dates are always the 1st of the month Incomplete enrollment forms or failure to submit the required initial premium amount may cause an initial delay in issuance of insurance

bull Will I be able to cancel the dental plan after I have enrolled Yes your coverage may be canceled within 30 days with written notification however once you have terminated coverage you will not be allowed to re-enroll in the dental plan

bull Does this plan have any limitations or exclusions Yes There are some limitations and exclusions with this plan as with most group insurance policies

bull Can my coverage be cancelled Yes if

a you do not pay your premiums on time b you are no longer a member of the Association or c the Group Dental Insurance Policy with VyStar Financial Group

LLC is terminatedcancelled for any reason

Delta Dental PPO Sample Benefits

Service Categories

Plan Pays

Year 1

Plan Pays

Year 2

Plan Pays

Year3

Type 1 - Diagnostic and Preventative Procedures

Diagnostic Routine periodic examinations once in a 6 month period

Preventative Dental prophylaxis [teeth cleaning once in a 6 month period

Radiography Bitewing and full mouth x-rays

Type 2 - Basic Procedures

Restorative Amalgam fillings Other Space maintainers recementation of crowns

Type 3 - Major Procedures

Endondontics Pulpal therapy and root canals

Periodontics Treatment of diseases of the gums

Oral Surgery Extractions and other oral surgery including pre and post operative care

80

60

25

90

70

30

100

80

50

Prosthetics Gold restorations crowns bridges partials and complete dentures

Other Pontics repair of crowns and bridges repair of full and partial dentures

Type 4 - Orthodontia This plan does not have any benefits for orthodontia

0

0

0

Deductible $50 per person per calendar year Diagnostic and Preventative Benefits are not subject to the deductible

Office Co-Pay NA