attachment-2-rfp-490-27.pdf

State of New Hampshire Group Number: 1776

Outline of Coverage Delta Dental PPO plus Premier Network

Read Your Dental Plan Description Carefully—This Outline of Coverage provides a very brief description of the important features of your dental benefits plan. This is not the insurance contract, and only the actual policy provisions will control. The Dental Plan Description itself sets forth in detail the rights and obligations of both you and your insurance company. It is therefore important that you READ YOUR Dental Plan Description CAREFULLY! Not all time limitations and exclusions are shown herein. Benefit percentages shown are based on the actual charges submitted up to the Maximum Allowable Charge for participating dentists, or Delta Dental’s allowance for non-participating dentists.

Office Visit Copayment: None

Diagnostic / Preventive (Coverage A)

Basic Restorative (Coverage B)

Major Restorative (Coverage C)

Orthodontics (Coverage D)

No Deductible No Deductible Calendar Year Deductible: $25 per Person* No Deductible

DIAGNOSTIC:

Evaluations twice in a calendar year.

X-rays (comprehensive (full-mouth) series or panoramic film) once in a 3-year period

Bitewing x-rays twice in a calendar year

X-rays of individual teeth as necessary

Brush biopsy once in a 12-month period

PREVENTIVE:

Three cleanings in a calendar year

Fluoride twice in a calendar year to age 19

Space maintainers

Sealant application to permanent molars, once in a 3-year period per tooth

RESTORATIVE:

Amalgam (silver) fillings;

Composite (white) fillings (for all teeth)

ORAL SURGERY:

Surgical and routine extractions

ENDODONTICS:

Root canal therapy

PERIODONTICS:

Periodontal maintenance (cleaning)

Note: Cleanings are limited to three in a calendar year; these may be routine (Coverage A) or periodontal (Coverage B), or a combination of both.

Treatment of gum disease

Clinical crown lengthening once per tooth per lifetime

DENTURE REPAIR:

Repair of a removable denture to its original condition

Rebase and reline (dentures)

EMERGENCY PALLIATIVE TREATMENT

PROSTHODONTICS:

Removable and fixed partial dentures (bridge); complete dentures

Crowns

Onlays

Implants

*Any expense incurred during the last 3 months of the calendar year which is applied against an individual’s deductible will also reduce the deductible for the next calendar year.

ORTHODONTICS:

Correction of malposed (crooked) teeth for children and adults

Delta Dental Pays: 100% No Waiting Period

Delta Dental Pays: 80% No Waiting Period

Delta Dental Pays: 50% No Waiting Period

Delta Dental Pays: 50% No Waiting Period

Calendar Year Maximum: $2,000 per Person Lifetime Maximum:

$1,200 per Person

Eff. 1/1/2026

Delta Dental PPO plus Premier Network You will get the best value from your Delta Dental Plan when you receive your dental care from one of our PPO (greatest savings) or Premier network participating dentists:

No Balance Billing: Because participating dentists accept Northeast Delta Dental’s allowed fees for services, you will typically pay less when you visit a participating dentist.

No Claims Paperwork: Participating dentists will prepare and submit claims for you.

Direct Payment: Northeast Delta Dental pays participating dentists directly, so you don’t have to pay the covered amount up front and wait for a reimbursement check.

To find out if your dentist participates in our PPO or Premier network, you can: call your dentist, visit our website at nedelta.com, or call Customer Service at 1-800-832-5700.

Claim Process for Participating Dentists Your participating dentist will submit your claim to Northeast Delta Dental (claims for any of your covered dependents should be submitted under your Subscriber ID number).

Northeast Delta Dental will produce an Explanation of Benefits (available through our Benefit Lookup site at nedelta.com) detailing what has been processed under your plan’s coverage. You are responsible to pay any outstanding balance directly to the dentist.

Non-Participating Dentists If you visit a non-participating dentist, you may be required to submit your own claim and pay for services at the time they are provided. Claim forms are available by visiting nedelta.com or by calling Northeast Delta Dental. Payment will be made to you, the Subscriber, unless the state in which the services are rendered requires that assignment of benefits be honored and Northeast Delta Dental receives written notice of such assignment. Payment for treatment performed by a non-participating dentist will be limited to the lesser of the dentist’s actual submitted charge or Delta Dental’s allowance for non-participating dentists in the geographic area in which services are provided. It is your responsibility to make full payment to the dentist.

Predetermination of Benefits Northeast Delta Dental recommends that you ask your dentist to submit a pre-treatment estimate for any dental work involving costly or extensive treatment plans.

Predeterminations helps avoid any potential confusion and enable us to help you estimate any out-of-pocket expenses you may incur.

Coordination of Benefits The State of New Hampshire does not allow dual State of New Hampshire dental coverage.

When an individual covered under this plan has additional group coverage, the Coordination of Benefits (COB) provision described in your Dental Plan Description booklet will determine the sequence and extent of payment. If you have any questions about COB, please contact Customer Service Department at 1-800-832-5700.

Identification Cards Identification cards will be produced and distributed shortly after your initial enrollment. Any future cards will be issued electronically via our Benefit Lookup site accessible through nedelta.com. You can also use the Delta Dental mobile app and enjoy access to dentist search, claims and coverage, and your ID card.

Dental Plan Description Booklet You will receive a Dental Plan Description booklet shortly after your enrollment. This benefit booklet describes your dental benefits and explains how to use them. Please read it carefully to understand the benefits and provisions of your Northeast Delta Dental plan.

Who is Eligible?

Please refer to your Dental Plan Description booklet for further details on who is eligible.

Claims Information All claims must be submitted within two years.

Ask your dentist to submit a pre-treatment estimate to Northeast Delta Dental for any procedure involving costly or extensive treatment plans, this will enable us to help you estimate any out-of-pocket expenses you may incur.

If a claim is denied, you can request an appeal by writing to Northeast Delta Dental within six months of the claim processing. Send appeals to Northeast Delta Dental, PO Box 2002, Concord, NH 03302-2002. Consult your Dental Plan Description Booklet for further details.

Where to Get More Information If you have further questions, please contact the Northeast Delta Dental Customer Service department at 800.832.5700 or 603.223.1234. This information should be used only as a guideline for your dental benefits program. For detailed information on your group’s terms, conditions, limitations, exclusions, and guarantees, please refer to your Dental Plan Description Booklet.

THIS INFORMATION SHOULD BE USED ONLY AS A GUIDELINE. FOR

DETAILED INFORMATION ON THE TERMS, CONDITIONS, LIMITATIONS AND

EXCLUSIONS, PLEASE REFER TO THE APPROPRIATE DENTAL PLAN DESCRIPTION.

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