Kaiser Permanente and Delta Dental

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1 Kaiser Permanente and Delta Dental Dental Program for Kaiser Permanente FEHBP Enrollees You must be a Kaiser Permanente FEHBP enrollee to participate in the dental plan. Kaiser Permanente and Delta Dental of Colorado recognize that good oral care is an important part of your general health. Your enrollment in a Kaiser Permanente FEHBP plan option gives you and your family two ways to maintain good oral health: a preventive dental benefit administered by Delta Dental included as part of your High Option or Standard Option benefits and a separate optional plan, which you may be eligible to purchase for an additional premium.

2 Preventive Dental Care (Delta Dental PPO SM plus Premier) With your FEHBP medical coverage through Kaiser Permanente, you receive dental coverage for preventive services. With Delta Dental PPO plus Premier, you may visit the dentist of your choice, but you will pay nothing for covered procedures when you visit a participating Delta Dental dentist. * Your preventive dental coverage covers 100% of charges for the following procedures (refer to your preventive procedure list to view all covered services): Oral exams Full-mouth and bitewing X-rays Cleanings Fluoride (child and adult) Delta Dental Buy Up Plan If you would like more inclusive coverage for you and your family, you may purchase separate coverage through Delta Dental s Buy Up Plan for an additional monthly premium. Coverage includes the following types of services (refer to your Buy Up procedure list to view all covered services): Fillings Crowns Implants Periodontal cleanings Extractions Root canals Dentures Buy Up Plan Monthly Cost Employee: $17.12 Family: $48.56 Rates are effective 1/1/14 12/31/14 How to Enroll No enrollment form is necessary for the Preventive Dental Care Plan. You will be automatically signed up for that plan with your enrollment in Kaiser Permanente s medical plan. If you wish to purchase the additional coverage, please complete the enclosed Delta Dental enrollment and payment authorization form. *This is a brief description of the features of Kaiser Foundation Health Plan Inc. s Buy Up and Preventive Dental Care plans. Before making a final decision, please read the Plan s Federal brochure. All benefits are subject to the definitions, limitations and exclusions set forth in the Federal (RI ) brochure. How Coverage Works Your Preventive Dental Care Plan and the Buy Up Plan work differently. To help you choose the right coverage for your needs, this chart provides helpful information on how your benefits work. You must be a Kaiser Permanente FEHBP enrollee to participate in the dental plan. Premium Cost to Patient Calendar-year Maximum Calendar-year Deductible Preventive Dental Care Plan Coverage included with your medical plan premium No annual maximum for diagnostic and preventive services None Covered Services PREVENTIVE SERVICES Buy Up Plan Monthly premium applies $1,000 $50 for individual $150 for family Oral Exams Cleanings 100% covered X-rays BASIC SERVICES Fillings Simple Extractions Endodontics Not covered under the Preventive (Root Canals) Dental Care Plan Periodontics (Gum Disease Treatment) MAJOR SERVICES (12-month waiting period for new enrollees) Implants Not covered under the Preventive 50% covered Dental Care Plan Crowns Dentures This is a brief description of the features of the Kaiser Foundation Health Plan. Before making a final decision, please read the Plan s Federal brochure (RI ). All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochure. Contact Delta Dental of Colorado Customer Service (toll-free) Dentist Search & Eligibility deltadentalco.com Claims Submission PO Box Denver, CO % covered under Preventive Dental Care Plan 80% covered when treated by Delta Dental PPO dentist 50% covered when treated by Delta Dental Premier or out-of-network dentist

3 Delta Dental PPO SM plus Premier With the Delta Dental PPO plus Premier plan, you and your family may visit any licensed dentist but will receive the greatest out-of-pocket savings if you see a Delta Dental PPO dentist. Participating dentists 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 up to Delta Dental s approved amount. If you choose to see an out-of-network dentist, you will incur additional out-of-pocket expenses, and you will be billed the total amount the dentist charges (called balancebilling). When you see a Delta Dental PPO or Premier dentist, you are protected from balance-billing. Advantages of the Delta Dental PPO plus Premier plan Savings: Delta Dental PPO dentists offer subscribers the greatest savings. And you will still save money if you need a service that is not covered. Non-covered services will be billed at a discounted rate if you go to a PPO dentist. Choice: If you choose to visit a Premier dentist, you will still save money because Premier dentists also accept discounted fees (however, discounts are not as great as if you see a PPO dentist). Network: Delta Dental s dual network has nearly 84,000 PPO providers and 142,000 Premier providers nationwide. Looking for a dentist? Concerned about costs? PPO dentists offer you the greatest savings. Service: Porcelain Crown (Benefit illustration only. Example assumes deductible has been met.) Network Greatest Patient Savings Protected from balance-billing Delta Dental PPO Dentist Delta Dental Premier Dentist Least Patient Savings Not protected from balance-billing Out-of-Network Dentist Procedure Cost $1,000 $1,000 $1,000 Maximum Dentist Can Charge Patient Maximum Dentist Can Charge Insurance (MPA)* $710 $950 Unlimited $710 $950 $660 Benefit Percentage 50% 50% 50% Delta Dental Pays $355 $475 $330 You Pay $355 $475 $670 To find a participating dentist or to see if your current dentist is in the network, visit deltadentalco.com and click on the Find a Dentist search tool. You can also contact our customer relations department, Monday Friday 8 a.m. to 6 p.m. MST, at (toll-free) or customer_service@ddpco.com. *The maximum a dentist can charge your insurance company is called the Maximum Plan Allowance (MPA). The MPA for an out-of-network dentist is always lower than in-network MPA. Delta Dental pays a portion of the MPA only, which exposes you to balance-billing from an out-of-network dentist.

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11 Today s Date: Enrollment Form & Payment Authorization Kaiser Permanente FEHBP Enrollees Subscriber Information (complete for all enrollments/changes/updates) Subscriber Name (Last) (First) (Middle Initial) Subscriber Social Security Number Subscriber Date of Birth (MM-DD-YYYY) Mailing Address City State Zip Code Male Female Subscriber Phone Number (including area code) Subscriber Address Select Coverage: Employee Only Employee and Family Please list all dependents. All fields are required. Add Delete Last Name First Name SSN Date of Birth M F Plan Enrollment To enroll, complete this form, including premium payment information and authorization. Return the completed form to: Delta Dental of Colorado, PO Box 5468, Denver, CO Or fax it to: Automatic Premium Payment (APP) Authorization Your payment will be automatically deducted from your bank account on the 27th of each month. Complete this form and be sure to sign it before you submit it. If this form is received by the 20th, your plan effective date will be the first of the month following receipt. Name on Account Name of Bank Account Type: Checking Savings Routing Number (first nine digits on check) Account Number Automatic Premium Payment (APP) Agreement I hereby authorize Delta Dental of Colorado or its agent to initiate debit entries to my checking or savings account as indicated. I acknowledge that payment for the upcoming period will be deducted from my account on the 27th of the previous month (initial payment will be deducted upon receipt of enrollment form). If the charge is declined for any reason, Delta Dental will attempt to charge me again on the 27th of the following month. If the charge is still declined, they will immediately terminate my contract for nonpayment of premium, effective as of the last day of the grace period. This authorization is to remain in full force and effect until Delta Dental of Colorado or its agent receives thirty (30) days notice from me of its cancellation. The notification must be sent to Delta Dental of Colorado, PO Box 5468, Denver, CO Signature of Authorized Account Holder Requested Effective Date (Must be first of the month) KP_FEHBP_EnrollForm_