Simply Blue SM  - Dental - (April 1, 2010 through March 31, 2011.)

Benefits and Rates - (Effective April 1, 2010)

Additional Coverage Details Coverage begins following premium payment. coverage will take effect on the first day of the month following the date Delta Dental of Minnesota receives your application and initial premium. The initial coverage period is for 12 months, regardless of the terms, conditions and coverage period of your medical plan. Delta Dental guarantees not to change your premiums during those 12 months, and you agree to pay premiums on time for those 12 months. Your effective dental coverage date may or may not coincide with your medical coverage date. Only dental treatments begun and completed while coverage is in force are eligible for benefits. Cancellation. You may only purchase the dental plan within 60 days of purchasing or renewing the Simply Blue medical plan. You may cancel the Delta Dental plan at its renewal date without cancelling the medical plan; however, once dental coverage is cancelled, you cannot re-enroll for two years. You’ll find complete details in the Delta Dental Benefit Plan Summary. This brochure is intended to provide a convenient overview of coverage and is not intended to be a complete description. Only those services and supplies specifically listed in the Delta Dental Benefit Plan Summary are covered under the plan, regardless of dental necessity. Please note that treatment for a missing tooth is not immediately covered under this plan. The Delta Dental Benefit Plan Summary is your source for complete information, including the specific dental treatments that are covered, the frequency with which those treatments are covered, benefit amounts, limitations, exclusions and conditions under which coverage may remain in force. Exclusions and limitations are also available at www.deltadentalmn.org.

A dental plan for your way of life You’re on your own. You’re in charge. And getting health care coverage to protect you was priority one. That’s why you chose Simply Blue. Now, you can take charge of your oral health by purchasing a dental plan designed to complement your Simply Blue plan. It’s a smart move, especially as a growing body of evidence links oral health to overall health. Plus, you have a choice of coverage options and prices to fit your needs and budget. These plans are available for Simply Blue members through an arrangement with Delta Dental of Minnesota — the state’s largest dental benefits administrator. Get coverage you can count on When you choose this dental plan, you can be sure that you’ll get the kind of coverage you expect, including: Coverage for a broad spectrum of dental care No waiting periods for routine exams, fillings and some more involved procedures Freedom to see any dentist More savings if you use a dentist within the Delta Dental Premier® network Access to the Delta Dental Premier network, the largest dental network in the state and nation. It’s likely you’re already seeing a participating provider. To find out, call (651) 406-5995 or toll free at 1-888-223-2954, or visit www.deltadentalmn.org and click “Dentist Search.” Service you can trust It’s easy to get started Enrolling in this dental plan is fast and simple. Use the "Dental for SimplyBlue Members Application" form under the "Dental Applications" section on the "APPLICATIONS / FORMS" page.