Delta Dental of New Mexico Oral Health is Our Passion Quality Benefits, Quality Dentists … administering the dental program for State of New Mexico General Services Department Risk Management Division Delta Dental of New Mexico Oral Health is Our Passion Quality Benefits, Quality Dentists … administering the dental program for State of New Mexico General Services Department Risk Management Division Delta Dental of New Mexico Oral Health is Our Passion Quality Benefits, Quality Dentists … administering the dental program for State of New Mexico General Services Department Risk Management Division Delta Dental of New Mexico Oral Health is Our Passion Quality Benefits, Quality Dentists … administering the dental program for State of New Mexico General Services Department Risk Management Division Dental Plan Benefits August, 2012 Administered by Delta Dental of New Mexico

Delta Dental PPO SM Delta Dental Premier ® Select a Delta Dental PPO dentist to help reduce patient out-of-pocket costs. Select a Delta Dental Premier dentist if you prefer or if specialty care is needed and not available in Delta Dental PPO. Find a Dentist UNM Hospitals Dental Plan Provider Network Overview – Point-of-Service Plan One Plan, two network choices! Plan Participants can select any dentist in either the Delta Dental Premier ® or Delta Dental PPO SM network at the time dental services are received. Over 900 points of access in New Mexico Over 155,500 dentist locations nationally Over 236,500 dentist locations nationally Over 1,270 points of access in New Mexico Log on to DeltaDentalNM.com to search for a dentist. Pre-selection of a dentist is not required and every member of your family may visit a different dentist. There is no need to contact Delta Dental to change your dentist; you may change as often as you like. Whenever possible, use in-network dentists. Lower out-of-pocket costs, and important member protections apply when services are received in-network!

UNM Hospitals Dental Plan Provider Network Overview – Point-of-Service Plan The illustration below shows how the reduced Maximum Approved Fees for Delta Dental PPO can result in significant patient savings Example assumes Procedure Code 2790 (CrownFull Cast High Noble Metal) Delta Dental PPO Provider Delta Dental Premier Provider Dentist Submitted Charge $1,142 Delta Dental Maximum Approved Fee (network- specific) $809$1,025 Participant Pays (50% Co-payment for Major Services) $ (50% of $809) $ (50% of $1,025) Savings of over $100!

UNM Hospitals Dental Plan Dental Plan Benefits Overview Separate Lifetime Maximums apply to Orthodontic Services Calendar Year Deductibles $50 per enrolled person $150 aggregate per family Does not apply to Diagnostic, Preventive, or Orthodontic Services Calendar Year Maximums $1,200 per enrolled person per calendar period

Out-of-network dentists may balance bill patients for amounts over Maximum Approved Fees. Delta Dental PPO SM Delta Dental Premier ® Diagnostic and Preventive Services – No Deductible Covered Oral Exams & Cleanings (2 per Calendar Year), X-rays, Fluoride Application, Emergency Treatment, Sealants, Space Maintainers, and Diagnostic Casts Delta Dental Pays 100% You Pay 0% Delta Dental Pays 100% You Pay 0% Basic Services Fillings, Stainless steel crowns, Extractions, Oral Surgery, Root canals, Periodontics (surgical or non-surgical), and General Anesthesia Delta Dental Pays 80% You Pay 20% Delta Dental Pays 80% You Pay 20% Major Services Onlays, Crowns, Bridges, Partials or Complete dentures, Specified Implant Procedures Delta Dental Pays 50% You Pay 50% Delta Dental Pays 50% You Pay 50% UNM Hospitals Dental Plan Dental Plan Benefits Overview

Out-of-network dentists may balance bill patients for amounts over Maximum Approved Fees. UNM Hospitals Dental Plan Orthodontic Benefit Overview ORTHODONTIC SERVICES (child and adult) No deductible Delta Dental Pays 50% up to $1,000 lifetime maximum Enrollees Pay 50% plus balance of cost up to the applicable Delta Dental Maximum Approved Fee

UNM Hospitals Dental Plan Predetermination of Benefits ASK YOUR DENTIST FOR A PREDETERMINATION OF BENEFITS when more costly procedures are anticipated. Patient Disclosure – Youre entitled to it! An advance estimate of benefits before dental care services are received Not required, but strongly recommended No charge for this service.

UNM Hospitals Dental Plan Special Eligibility Provisions UNM Hospitals Special Eligibility Provisions If you enroll one dependent (spouse/domestic partner/child), all dependents must be enrolled (except children younger than 3 years of age) unless you can provide UNMH HR with proof of other coverage. Children are covered to age 26 regardless of employment, marital, or student status.

UNM Hospitals Dental Plan Information Available 24/7! Subscriber Information Available 24/7! Featured Plan Information Available in the Member Section View and print: Summary of Benefits Dental Benefit Plan Provisions Provider Directory Consumer Toolkit Verify eligibility of subscriber and dependents Confirm status of deductibles and plan maximums Review how a specific claim was processed Print a personalized subscriber ID card Oral Health Links Oral Health Assessment Oral Health and Wellness Portal DeltaDentalNM.com

UNM Hospitals Dental Plan Customer Service Experienced Benefit Representatives No frustrating menu of options from which to choose Talk to a local representative with 45 seconds of calling Hours of Operation: Monday – Friday 8:00am-4:30pm Albuquerque: Toll free: We do dental. Better. Questions?

UNM Hospitals Rates COVERAGE TYPE Employee COST Full Time Employee COST Part Time Employee $ 0.00$ 6.10 Employee + 1 $ 17.50$ Employee + 2 or more $ 33.50$ Per Pay Period (24/Year)