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, 2015 Administered by Delta Dental of New Mexico We do dental. Better.

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 1,800 of access in New Mexico Over 234,000 dentist locations nationally Over 315,000 dentist locations nationally Almost 2,100 points of access in New Mexico Log on 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. Discounts do not apply to out-of-network providers. 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 (Crown—Full 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 Maximum apply to Orthodontic Services Calendar Year Deductible $50 per enrolled person $150 aggregate per family Does not apply to Diagnostic, Preventive, or Orthodontic Services Calendar Year Maximum $1,200 per enrolled person

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 PRE-TREATMENT ESTIMATE when more costly procedures are anticipated. Patient Disclosure – You’re 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 Website Resources View / Print Coverage Documents & Provider Directories 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 Member Information Available 24/7 Contact us at

UNM Hospitals Dental Plan Customer Service We do dental. Better. Experienced Customer Service Representatives Available Monday – Friday 8:00 AM - 4:30 PM (MST) or Toll Free Mobile Application To download the new mobile app, visit the App Store (Apple) or Google Play (Android) and search for “Delta Dental” Contact Us Automated voice response benefit information available all hours

UNM Hospitals Rates Per Pay Period (24/Year) COVERAGE TYPEEmployee COST Full Time Employee COST Part Time Employee $0.00 $6.10 Employee + 1 $17.50$23.60 Employee + 2 or more $33.50$39.60