Dental Benefit Summary:

Under the DeltaPremier program, you may choose any licensed dentist. However, it is to your advantage to select a participating dentist. Here's why:

• Participating dentists will complete claim forms for you at no charge. If you visit a non-participating dentist, you may be required to complete the forms yourself.
• If you go to a participating dentist, payment will be based on the lowest of (1) DDPV participating dentists' usual, customary, and reasonable fees, (2) the fee the dentist bills for the covered service, or (3) the participating dentist's most recent filed fee with DDPV. You will only have to pay the amount of your copayment, plus any deductibles that may apply.
• Since participating dentists are reimbursed directly, they agree to charge you no more than the amount of your copayment and deductible in advance, so you don't have to pay the whole bill and then wait for reimbursement.
• If you go to a non-participating dentist, payment is made directly to you unless an assignment of benefits is made to the dentist. DDPV's payment is based on the lower of (1) the usual, customary, and reasonable fee amount that is less than DDPV would pay a participating dentist, or (2) the fee the dentist bills for the covered service. You will be responsible for paying the difference between the non-participating dentist's charge and DDPV's payment. You may also have to pay the non-participating dentist in advance for the entire bill.

The following table outlines your Dental Benefits. All Out-of-Network benefits are based on Reasonable and Customary.