Dental insurance isimportant.

It’s a fact...

deltadentalco.com

Your oral health is connected to your overall health. Researchers have uncovered links between gum disease and systemic health, including associations with heart disease and strokes. That’s why it’s so important to make dental care a priority — it can help you and your family live healthier.

• 23% of all adults have untreated tooth decay.

• More than half of U.S. children ages 5 to 9 have at least one cavity or

filling.

• One out of every two American adults age 30 or older has periodontal disease.

• Dental disease causes employed adults to lose more than 164 million hours of work a year.

• In Colorado, dental disease costs taxpayers an estimated $1 billion annually.

Fact: Your overall health will benefit.

• Tooth decay is the single most common chronic childhood disease.

• If you have cavity-causing germs in your mouth, you can pass them to your baby.

• More than 120 diseases can cause specific signs and symptoms in and around the mouth and jaw. A dentist doing regular check-ups can help spot these potential problems.

People with dental insurance are more likely to visit the dentist regularly.

Patients receiving regular preventive care have better oral health.

Dental insurance often covers 100% of preventive care.

Facts...

...and Figures

People with dental insurance are more likely to visit the dentist regularly. Routine exams allow your dentist to get to know you and follow your health history. Dentists are more able to catch and treat potential problems early when they see their patients on a routine basis. Invest in your future — make dental care a priority.

What does “healthy living” really mean? Diet, exercise, and plenty of rest are major components of a healthy lifestyle, but other healthy habits include:

• Regular dentist visits.

• Brushing and flossing at least twice a day.

• Making nutritious food choices.

• Sharing your medical conditions with your dentist.

Fact: Finding a provider is easy!

Use the Find a Dentist search tool at deltadentalco.com

Call 1-800-610-0201 8 a.m. to 6 p.m. MT Monday–Friday

Download the free Delta Dental mobile app for iPhone and Android

1 2 3

Fact: Nearly 100% of oral disease is preventable.

Fact: Healthy habits lead to healthy smiles.

By choosing a Delta Dental PPOSM provider, you will save

the most money on out-of-pocket expenses!

Dental Plans to Keep You Healthy and SmilingDelta Dental of Colorado is the state’s leading dental benefits company and the only one based in Colorado. Unlike most carriers, we focus on just one thing — dental insurance. We provide our more than one million members with the convenience of local customer service backed by a national network of dental providers. In addition, we are a nonprofit company with a mission to improve oral health in Colorado.

Since 1958, we have offered high-quality, cost-effective dental plans to help you stay healthy and smiling. We are committed to:

• Expanding access to oral health care.

• Using our dental benefits expertise to provide access to the best dental care in the most extensive network.

• Providing world-class customer service.

Contact Us Delta Dental of ColoradoPO Box 5468Denver, Colorado 80217-5468

Customer RelationsToll-free: 1-800-610-0201 Monday–Friday 8 a.m. to 6 p.m. Mountain TimeEmail: customer_service@ddpco.com

Visit us at deltadentalco.com to:

• Find a provider• View benefits• Print ID cards

• Check claim status• Assess your oral health

risk

• View wellness resources• And much more

Fact: Delta Dental is the champion of your smile!

Delta Dental PPO plus Premier

GRAND COUNTY – Group # W2330 MAXIMUM BENEFIT Calendar Year Maximum

$2,500 per member, per calendar year

CALENDAR YEAR DEDUCTIBLE Applies to Basic and Major Services

Individual Deductible – $50.00 Combination of in and out-of-network

Family Deductible – $150.00 Combination of in and out-of-network

PPO

Dentist

PREMIER

Dentist

NON-PAR

Dentist COVERED SERVICES BENEFIT INFORMATION (subject to Delta Dental guidelines)

DIAGNOSTIC AND PREVENTIVE SERVICES

100% 80% 80%

Oral Exams Two in a calendar year

Cleanings Three in a calendar year

Sealants Once per tooth in a 36-month period for unrestored permanent molars, through age 14

Bitewing X-Rays Twice in a calendar year

Full Mouth X-Rays Once in a 36-month period

Fluoride Twice in a calendar year, through age 15

Space Maintainers One per quadrant, per lifetime to maintain space for eruption of permanent posterior teeth, through age 13

BASIC SERVICES

80% 80% 80%

Fillings Once per tooth in a 12-month period; amalgam fillings on back teeth; composite (white) fillings limited to front teeth

Simple Extractions

Oral Surgery

Endodontics / Periodontics

MAJOR SERVICES

50% 50% 50%

Crowns Once per tooth in a 60-month period. Not a benefit under age 12

Dentures, Bridges Once in a 60-month period, only when existing prosthesis cannot be made serviceable. Fixed bridges or removable partials are not a benefit under age 16

ORTHODONTICS – NOT COVERED

0% 0% 0% Not covered

You are enrolled in a Delta Dental PPO plus Premier plan. You and your family members may visit any licensed dentist, but will enjoy the greatest out-of-pocket savings if you see a Delta Dental PPO dentist. There are three levels of dentists to choose from. PPO Dentist - Payment is based on the PPO dentist's allowable fee, or the actual fee charged, whichever is less. Premier Dentist - Payment is based on the Premier Maximum Plan Allowance (MPA), or the fee actually charged, whichever is less. Non-Participating Dentist - Payment is based on the non-participating Maximum Plan Allowance. Members are responsible for the difference between the non-participating MPA and the full fee charged by the dentist. You will receive the best benefit by choosing a PPO dentist. Open Enrollment applies. Members may add coverage once per year. This is a brief description of services covered under your dental plan. Please refer to the Employee Benefit Booklet for full plan details. If differences exist between this summary and the Employee Benefit Booklet, the Employee Benefit Booklet will govern. Delta Dental of Colorado Customer Service: 1-800-610-0201 | customer_service@ddpco.com. Find us online at deltadentalco.com.

Delta Dental PPOSM plus Premier

With the Delta Dental PPO plus Premier plan, you and your family members may visit any licensed dentist. You will receive the greatest out-of-pocket savings if you see a Delta Dental PPO provider. PP0 and Premier providers file claims directly with Delta Dental and accept Delta Dental’s reimbursement in full. You are responsible only for your deductible and coinsurance (as determined by your plan), as well as any charges for non-covered services. If you choose to see an out-of-network provider, you will incur additional out-of-pocket expenses, and you will be billed the total amount the provider charges beyond what Delta Dental pays (called balance-billing). When you see a Delta Dental PPO or Premier® provider, you are protected from balance-billing for covered services. Advantages of the Delta Dental PPO plus Premier plan:

SAVINGS: Delta Dental PPO providers offer our members the greatest savings.

CHOICE: If you choose to visit a Premier provider, you will still save money because Premier providers also accept discounted fees (however, discounts are not as great as if you see a PPO provider).

NETWORK: Delta Dental’s dual network has nearly 102,000 PPO providers and an additional 50,000 Premier providers, for a total of 152,000 participating providers nationwide.

To find a participating provider or to see if your current provider is in the network, visit our website at deltadentalco.com and click on the Find a Dentist search tool. Or use our free mobile app for iPhone and Android. You may even be able to schedule an appointment online or on the app if your provider has Brighter Schedule.

You can also contact our customer relations department, Monday–Friday 8 a.m. to 6 p.m. Mountain Time, at 1-800-610-0201 (toll-free) or customer_service@ddpco.com.

Looking for a dentist? Concerned about costs?PPO providers offer you the greatest savings.

Service: Porcelain Crown (Benefit illustration only.Example assumes deductible has been met.)

Greatest Savings Least Savings

Protected from balance-billing (for covered services)

Not protected from balance-billing

Network Delta Dental PPO Provider

Delta Dental Premier Provider

Out-of-Network Provider

Procedure Cost $1,000 $1,000 $1,000

Maximum Provider Can Charge Patient $700 $850 $1,000+*

Benefit Percentage 50% 50% 50%**

Delta Dental Pays $350 $425 $500

You Pay $350 $425 $500+

* Please note that an out-of-network provider is not bound by Delta Dental’s in-network contractual obligations and may bill patients for the remaining balance, called balance-billing. The practice of balance-billing refers to a provider’s ability to bill patients for outstanding balances after the insurance company pays the required portion of the bill (coinsurance percentage).

** Check your specific plan to see what the coinsurance rate is as they differ from plan to plan.

deltadentalco.com

Dear Delta Dental of Colorado Member:

Welcome to Delta Dental! You are enrolled in our Delta Dental PPOSM plus Premier plan.

As Colorado’s largest dental benefits provider, we can help you get the dental care you and your family need, when and where you need it. Delta Dental members can easily access high-quality dental care from our extensive network of PPO providers across the state.

Please take some time to review your benefit booklet. It has important information about your benefits, as well as information about PPO providers in the Delta Dental network.

To get more information about your dental benefits, you can visit our website at www.deltadentalco.com or download our free mobile app for:

• Benefit information including coverage, deductibles and maximums used to date, and claim status• Copies of your Explanation of Benefit (EOB) statements • Benefit maximums used to date • An ID card that you can print out, email to your provider, or pull up on your smart phone• Help in finding a provider

Our customer service department is here to assist you:Monday – Friday, 8 a.m. – 6 p.m. (Mountain Time)1-800-610-0201 or customer_service@ddpco.com

Thank you for choosing Delta Dental. Remember that your oral health is important to your overall health, so use your benefits. We look forward to serving you.

Best Regards,

Helen Drexler

Type your information in the fields below, then print the PDF. Cut out the card and carry in your wallet.

Delta Dental PPOSM plus Premier

Employee Name

Group Name Group Number

This card does not guarantee eligibility.Customer Relations: 1-800-610-0201 | www.deltadentalco.com

Mail claims to:Delta Dental of Colorado — Claims Processing

P.O. Box 173803Denver, CO 80217-3803

Customer Relations: 1-800-610-0201www.deltadentalco.com

deltadentalco.com

Using Your Dental Benefits Online or On The Go, Delta Dental Makes Taking Careof Your Teeth Easy

GO TO OUR WEBSITE OR MOBILE APP AND FIND A DENTISTNEAR YOU. Choose either a Delta Dental PPOSM or a Delta Dental Premier® provider based on the plan you have. A Delta Dental PPO providerwill always cost you less out of pocket, so search for one near you to get the greatest savings.

Congratulations! You have a dental plan from Delta Dental of Colorado. It’s so important touse your dental benefits because your oral health is connected to your overall health. Your dentist can spot the early signs of systemic diseases and can help you avoid painful and costly dental procedures in the future. So make dental care a priority.

MAKE AN APPOINTMENT...AND SMILE! You’re taking steps to protect your oral health and your overall health! Plus, preventive services — like cleanings and exams — are usually at no cost to you, so there’s no reason to wait.**

CREATE A SUBSCRIBER ACCOUNT ON DELTADENTALCO.COM. You can check the specifics of your plan, the status of claims, and much more. To create a secure account, go to our homepage and click on the Members link and follow the prompts. If you need help setting this up, you can contact our customer service team.

CONTACT USToll-free: 1-800-610-0201 | Monday–Friday 8 a.m. to 6 p.m.Email: customer_service@ddpco.com

DOWNLOAD OUR FREE MOBILE APP. Once you’ve created an account online, you can access all of the same information AND make an appointment with your dentist within the app.* To download and install the app on your device, visit the App Store (Apple) or Google Play (Android) and search for Delta Dental.

*Dentist participation in the mobile scheduling tool varies. If your dentist does not currently participate, ask them to sign up for that option.

ADDITIONAL RESOURCESOur website has additional resources to help you understandyour benefits and the importance of your oral health:

• www.deltadentalco.com/using-your-benefits.aspx• www.deltadentalco.com/wellness.aspx• www.deltadentalco.com/mobile-app.aspx

**Frequencies and limitations apply. Be sure to check your specific plan benefits and eligibility.

See better – live betterDelta Dental Vision provided by EyeMed Vision CareYour eyes say a lot about you – from your emotions to vision and your overall health. And, when you’re proactive about protecting your eyes, the impact is clear.

Regular eye exams not only correct vision problems, they also can reveal early warning signs of more serious health conditions such as hypertension, cardiovascular disease and diabetes. So, schedule exams annually and you’ll be set on a path to better health.

Keep on savingYou can use your EyeMed discount as often as you like, all year long, on nearly all your vision care purchases at EyeMed’s participating providers.

Visit eyemed.com to learn moreNeed to locate a provider? Want to learn about vision wellness? Visit eyemedvisioncare.com/deltadental.

Locate a providerYou love choices - and so do we. That’s why our network has thousands of independent doctors and retail providers.

Schedule an appointmentCall ahead or stop by one of the many providers that offer walk-ins. Most also have evening and weekend hours to fit any schedule.

Show your ID cardWhen you arrive, let the provider know you have an EyeMed discount through Delta Dental.

Please note your discount cannot be combined with any other dis-counts, coupons or promotional offers.

Member/Patient Services: 1.866.723.0391ACCESS DISCOUNT PLAN

DELTA DENTALDiscount Plan#: 9231093

Signature:

This is not insurance.Dependents are eligible.

Please detach carefully at perforation and keep card in your wallet.

Delta DentalDiscount plan Access networkDiscounted exam and a defined materials discount

THIS IS NOT INSURANCE

*Items purchased separately will be discounted 20% off of the retail price.**Since LASIK and PRK vision corrections are elective procedures, performed by specially trained providers, this discount may not always

be available from a provider in your location. For a location near you and the discount authorization, please call 1.877.5LASER6.Member will receive a 20% discount on those items purchased at participating providers that are not specifically covered by this discount. The 20% off discount does not apply to EyeMed providers' professional services or contact lenses. Retail prices may vary by location. All discounts cannot be combined with any other discounts or promotional offers. This discount design is offered with the EyeMed Access panel of providers.

Limitations/Exclusions:• Orthoptic or vision training, subnormal vision aids and any

associated supplemental testing• Medical and/or surgical treatment of the eye, eyes or

supporting structures• Corrective eyewear required by an employer as a condition

of employment and safety eyewear unless specifically covered under plan

• Services provided as a result of any Worker’s Compensation law• Discount is not available on those frames where the manufacturer

prohibits a discount

Visit eyemedvisioncare.com/deltadental for more information or to locate a provider near you.

EyeMed Member/Patient Services: Visit eyemed.com or call the number on the frontof this card.

EyeMed Doctors/Providers Only: Visit eyemed.com to receive plan information or authorization online or call 1.800.521.3605.

Vision care services Member costExam and dilation as necessary ……………………………………………………………………………………………………………… $5 off routine exam $5 off contact lens exam

Complete pair of glasses purchase*:Frame, lenses and lens options must be purchased in the same transaction to receive full discount.

Standard plastic lenses:Single Vision …………………………………………………………………………………………………………………………………………………… $50Bifocal ……………………………………………………………………………………………………………………………………………………………… $70Trifocal ……………………………………………………………………………………………………………………………………………………………… $105

Frames ……………………………………………………………………………………………………………………………………………………………… 35% off retail price

Lens options:UV treatment ………………………………………………………………………………………………………………………………………………… $15Tint (solid and gradient) …………………………………………………………………………………………………………………………… $15Standard plastic scratch coating …………………………………………………………………………………………………………… $15Standard polycarbonate ………………………………………………………………………………………………………………………… $40Standard progressive lens (Add-on to bifocal) ………………………………………………………………………………… $65Standard anti-reflective coating …………………………………………………………………………………………………………… $45Other add-ons and services …………………………………………………………………………………………………………………… 20% off retail price

Contact lens materials: (Discount applied to materials only)Disposable ……………………………………………………………………………………………………………………………………………………… 0% off retail priceConventional …………………………………………………………………………………………………………………………………………………… 15% off retail price

Laser vision correction**: LASIK or PRK ………………………………………………………………………………………………………………………………………………… 15% off retail price or 5% off promotional price

Frequency:Examination …………………………………………………………………………………………………………………………………………………… UnlimitedFrame ……………………………………………………………………………………………………………………………………………………………… UnlimitedLenses ……………………………………………………………………………………………………………………………………………………………… UnlimitedContact lenses ……………………………………………………………………………………………………………………………………………… Unlimited

2. Patient Direct Provider Number:

Select Coverage: q Employee Only q Employee and Spouse q Employee and Children q Employee, Spouse, and Children

Please list all dependents. All fields are required.Add Delete Last Name First Name SSN Date of Birth M F

q q q q

q q q q

q q q q

q q q q

q q q q

If you need more space to list additional dependents, please use a second enrollment form.

Employee’s Signature Date

It is unlawful to knowingly provide false, incomplete, or misleading information to Delta Dental of Colorado to defraud or attempt to defraud Delta Dental. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Report any insurance company or agent thereof, who knowingly provides false, incomplete, or misleading facts to Delta Dental participants for the purpose of defrauding the participants regarding their insurance benefits, to the Colorado Division of Insurance.

1. Patient Direct Provider Name:

q Delta Dental Patient Direct® (for Patient Direct, the following fields are mandatory):

Delta Dental of ColoradoPO Box 5468 Denver, CO 80217-5468

Phone: 303-741-9300, ext. 3900Toll-free: 1-800-233-0860, ext. 3900

q New Enrollment q Waive Coverage q Change Coverage q Active q Retired q COBRA/State Continuation

Employee Information (please print clearly or type)

StandardEnrollmentForm_0515

Employer: Group #: Subgroup #:

SSN: Date of Birth: Date of Hire: Effective Date:

Last Name: First Name: M / F

Street Address: City: State: Zip:

Contact Email Address: Cell Phone:

Would you like to receive communications from Delta Dental of Colorado by email and text message? q Yes q NoYour email address and cell phone will not be used for any purpose other than communications from Delta Dental of Colorado.

I understand that the terms of the contract between Delta Dental and my company may not allow for late enrollment for my dependents. The contract may allow for late enrollments but may require waiting periods or additional limitations.

Enrollment Form

Changes to Existing EligibilityDate change is effective (mm/dd/yyyy):

Reason for change/explanation: List effective date for checked boxes below.

q Name Change (list above)q Cancel Coverageq Employment Terminatedq Reinstatement of Coverage (see reverse)q Address Change (list above)q COBRA/State Continuation (list start date above)q Late Enrollment (if applicable)q Family Status Change q Add Dependent q Delete Dependentq Other Reason for Change: ___________________

q Marriage q Birth/Adoption* q Divorceq Deathq No Longer Eligibleq Part-time to Full-timeq Retireeq Add Disabled Child*q Transfer to Group/Subgroup: ________________________

Date: Date: Date: Date: Date: Date: Date: Date: Date:

q Delta Dental Premier® q Delta Dental PPOSM q Delta Dental PPOSM Plus Premier

q Exclusive Panel Option (EPO) q Delta Dental MAC PPOSM

Applicant: Select an insurance plan or Patient Direct discount plan (below).

Please read the following information carefully before completing the other side of this form. You should fill out this form if you are enrolling in coverage or changing any information from an earlier enrollment. If you have any questions about filling out this form, your human resources department representative can help you. Status Definitions Status definitions appear near the top of the enrollment form. Please check the appropriate box in each section.

New Enrollment: Check for first-time enrollment for you or your dependents.

Waive Coverage: Check if you do not want to take dental coverage. Please note that not all plans allow waiving of coverage.

Change Coverage: If you are making changes to your existing enrollment information, please check this box and complete the appropriate information under Changes to Existing Eligibility near the bottom of the form. Also complete the following: Active: You are a current employee. Retired: You are retired, and your group continues to provide you with dental benefits. COBRA: You are no longer an active employee, but you have continued self-paid coverage under COBRA.

Group Number/Subgroup Number Please enter the Delta Dental group number for the program you are enrolling in. If your employer uses subgroup numbers, please include the appropriate subgroup number. If you are unsure of your group and/or subgroup number, please contact your human resources department. Employee Information This section must be completed to process your enrollment or update your records. All information should apply to you, the primary subscriber. Please print clearly or type. Effective Date The date that Delta Dental coverage takes effect for you and/or your dependents.

List of Dependents This section should be completed when: 1.) Enrolling dependents and/or 2.) You have checked Change Coverage and are changing information that was previously submitted to Delta Dental. Please include both first and last names, date of birth, and Social Security numbers for any individuals for whom you are enrolling or submitting a change or correction.

Standard Dependent Definitions (May Vary) Spouse: Your legal spouse. Child(ren): Includes unmarried and married child(ren), step-child(ren), legally adopted child(ren), and court-ordered foster child(ren) in a parent/child relationship who meet the age limits specified between your employer and Delta Dental. Common Law: If you add a common-law spouse and later cancel coverage for this individual, you will be required to provide legal documentation before another common-law can be added to the plan. List Common Law as spouse. Civil Union: Civil Union is included in all fully insured employer group contracts with Delta Dental. Fully insured groups offer this as a dependent option; therefore, please list partner as a spouse and provide all information requested. Domestic Partner: May not be included in all employer group contracts with Delta Dental. If your group offers this as a dependent option, please list partner as a spouse and provide all information requested. Disabled or Full-time Student: If you have a disabled child or a full-time college student, please provide supporting documentation.

Changes to Existing Eligibility Information This section should be completed only if you are making changes to your existing enrollment information.

Reinstatement: Check for reinstatement coverage for yourself or your dependents. Please provide reason for reinstatement (divorce, loss of coverage, etc.) under Other Reason for Change. Cancel Coverage: Check only if you are terminating Delta Dental coverage for yourself or a family member. This is not the same as Employment Termination. Group Transfers: When transferring from one group to another, all dependents will transfer unless otherwise indicated. This section should also be completed when transferring to COBRA.

When reporting a change or correction, please include an effective date of change and clearly state the reason for the change. *Please attach supporting documentation to the enrollment form and submit to your HR office.

Privacy Policy Statement It is unlawful to knowingly provide false, incomplete, or misleading facts to Delta Dental of Colorado to defraud or attempt to defraud Delta Dental. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Report any insurance company or agent thereof who knowingly provides false, incomplete, or misleading facts to Delta Dental participants for the purpose of defrauding the participants regarding their insurance benefits to the Colorado Division of Insurance. Enrollment forms, changes, and those items requiring supporting documentation should be submitted to your human resources department office so they can make changes to your plan through Delta Dental of Colorado’s employer portal. Delta Dental of Colorado PO Box 5468 Denver, CO 80217-5468 Phone: 303-741-9300, ext. 3900